Ameloblastoma of the maxilla with distant metastases and hypercalcemia

Giant Mandibular Ameloblastoma with Rare Hypercalcemia: A Case Report and Literature Review

Ameloblastoma is the most common benign odontogenic tumor with local invasion and high recurrence, which generally occurs in the jaw bones. Hypercalcemia is a common paraneoplastic syndrome that is commonly observed in patients with malignancies but rarely encountered in patients with benign tumors. Thus far, not many cases of ameloblastoma with hypercalcemia have been reported, and the pathogenic mechanism has not been studied in depth. This paper presents a case report of a 26-year-old male diagnosed with giant ameloblastoma of the mandible, accompanied by rare hypercalcemia. Additionally, a review of the relevant literature is conducted. This patient initially underwent marsupialization, yet this treatment was not effective, which indicated that the selection of the appropriate operation is of prime importance for improving the prognosis of patients with ameloblastoma. The tumor not only failed to shrink but gradually increased in size, accompanied by multiple complications including hypercalcemia, renal dysfunction, anemia, and cachexia. Due to the contradiction between the necessity of tumor resection and the patient's poor systemic condition, we implemented a multi-disciplinary team (MDT) meeting to better evaluate this patient's condition and design an individualized treatment strategy. The patient subsequently received a variety of interventions to improve the general conditions until he could tolerate surgery, and finally underwent the successful resection of giant ameloblastoma and reconstruction with vascularized fibular flap. No tumor recurrence or distance metastasis was observed during 5 years of follow-up. Additionally, the absence of hypercalcemia recurrence was also noted.

Peripheral Ameloblastoma of Acanthomatous Variant: A Case Report

Ameloblastoma is an uncommon benign epithelial neoplasm of odontogenic origin that accounts for about 18% of the odontogenic tumour. It is a slow-growing, locally invasive but rarely metastatic tumour. Extraosseously occurring peripheral ameloblastoma is a rare variant that comprises about 2-10% of all ameloblastoma. We report a case of peripheral ameloblastoma in a 43-years old male patient affecting the mandibular canine-premolar region with a histopathological diagnosis of acanthomatous ameloblastoma. This case report emphasises the clinical, radiographic, and histological features of a rare variant that distinguishes it from the other similar appearing lesion on gingiva along with its various treatment modalities.

Keywords

ameloblastoma; case reports; histopathology; odontogenic tumour.

Primary ameloblastic carcinoma of the maxilla: A case report and literature review

Ameloblastic carcinoma (AC) is a rare malignant odontogenic neoplasm that tends to occur in the mandible rather than in the maxilla. This malignancy is classified as a tumor that combines the morphological features of ameloblastoma and carcinoma, regardless of the presence or absence of metastasis. In addition, AC has been classified into two types, primary and secondary. The former develops de novo and the latter develops by malignant transformation of a pre-existing benign ameloblastoma. The present study describes the case of a 22-year-old patient with primary AC of the maxilla. A review of the literature focusing on the clinical details, treatment results and histopathological and phenotypic information available for ameloblastic carcinoma of the maxilla from a 60-year period was also performed. As a result, it was found that primary AC is dominant in the maxilla and does not exhibit an aggressive phenotype compared with secondary AC. In addition, the presence of recurrence was found to correlate with mortality, indicating that early, aggressive and complete removal of the tumor is the best treatment for survival.

Overwhelming hypercalcaemia in mandibular ameloblastoma

Ameloblastoma is considered to be a benign odontogenic tumour of epithelial in origin that is slow growing but recurrent and invasive in nature. Some of its features have been sources of debate among experts regarding its benign or malignant character. We report a case of a 20-year-old Filipino woman with right mandibular ameloblastoma presenting with overwhelming hypercalcaemia. Work ups for hypercalcaemia eventually revealed tumoral hypercalcaemia, which was initially controlled with intravenous bisphosphanate. The patient eventually underwent tumour excision and mandibular reconstruction, which totally corrected hypercalcaemia. This case will highlight the rare association of hypercalcaemia among patients with ameloblastoma.

A case of recurrent metastatic ameloblastoma and hypercalcaemia successfully treated with carboplatin and paclitaxel: long survival and prolonged stable disease

We describe a case of recurrent metastatic malignant ameloblastoma to the lungs with hypercalcaemia in a 47-year-old man. The first lung metastasis was resected nine years after the initial primary, and the tumour recurred with extensive pulmonary metastases 21 years after the primary tumour was resected. This case presented with malignancy-associated hypercalcaemia, likely due to paraneoplastic syndrome, which is exceedingly unusual in association with malignant ameloblastoma. He was successfully treated with carboplatin/paclitaxel and showed the longest survival and stable disease, from the diagnosis of recurrent metastasis, recorded as a case report. This regimen is reasonably well tolerated and can be repeated safely.

Malignant ameloblastoma: concurrent presentation of primary and distant disease and review of the literature

Malignant ameloblastoma is a rare tumor of odontogenic origin with a metastatic focus. Distant metastatic disease is found most commonly in the lungs. A review of the literature shows that most cases of malignant ameloblastoma involve a disease-free period from primary tumor extirpation to the discovery of metastasis. This report describes the case of a 56-year-old man presenting with ameloblastoma of the maxilla and a solitary pulmonary metastasis concurrently. This represents a rare case in which there is a simultaneous diagnosis of primary ameloblastoma and a metastatic lesion. Appropriate workup for ameloblastoma includes surveillance for metastatic disease. Surgical resection of primary and distant disease is recommended. Chemotherapy and radiation may play a role in palliation when resection of metastatic disease is not feasible.

Hypercalcemia caused by metastatic adamantinoma: response to radiotherapy

Purpose. To describe successful palliation of a patient with metastatic adamantinoma presenting with lung metastases and hypercalcemia resulting from a parathormone-like substance released from the tumor.

Methods and materials. The records of a patient with a history of a tibial adamantinoma who presented with symptoms of hypercalcemia 20 years after the original surgery, as well as the literature concerning hypercalcemia and adamantinoma were reviewed and summarized.

Results. After thorough review of the literature we found no prior reports of radiation being used for palliation of hypercalcemia associated with metastatic adamantinoma.We report rapid improvement in symptoms and normalization of serum calcium levels following a course of radiation therapy. The patient remains asymptomatic 15 months following radiotherapy despite a gradual return of elevated serum calcium levels.

Discussion. Radiation therapy should be considered as a palliative option for patients who are not surgical candidates presenting with medically refractory hypercalcemia.

Ameloblastic carcinoma

Ameloblastic carcinoma (AC) is a rare aggressive malignant epithelial odontogenic tumor of the maxillofacial skeleton with a distinct predilection in the mandible. It may appear de novo or originate from a pre-existing ameloblastoma or odontogenic cyst. It exhibits cytological features of ameloblastoma and carcinoma. It may present as a cystic lesion with benign clinical features or as a large tissue mass with ulceration, significant bone resorption and tooth mobility. The clinical course of ameloblastic carcinoma is typically aggressive, with extensive local destruction. Direct extension of the tumour, lymph node involvement and metastasis to various sites has been reported. Wide local excision is the treatment of choice. Regional lymph node dissection should be considered and performed selectively. Radiotherapy and chemotherapy have limited role in the treatment of ameloblastic carcinomas. Close periodic reassessment of the patient is mandatory.

New classification of maxillary ameloblastic carcinoma based on an evidence-based literature review over the last 60 years

Background

The ameloblastic carcinoma is a rare malignant odontogenic tumor which rather occurs in the mandible than in the maxilla. Its rarity and in this context somewhat speculative histopathogenesis may account for diagnostic difficulties. Current classifications do not consider benign histopathological features at the primary and malignant features at the metastatic tumour site. Based on an evidence-based literature review, a recommendation for a novel classification is presented.

Methods

An evidence-based literature review over the last 60 years regarding ameloblastic carcinoma of the maxilla was conducted.

Results

An overall of 26 cases were found (mean age: 54.4 (5-83 years); male to female ratio: 2.7 to 1). In 54% the primary diagnosis was ameloblastic carcinoma, 34.6% revealed pulmonary metastases, however, only in one patient cervical lymph node metastasis could be found. Whereas two cases did not reveal malignant histopathology at the primary, they revealed malignant features at their metastatic sites. Nineteen of 26 patients (73,1%) were controlled during a median follow-up time of 54,3 months (6 to 156 months); 6 patients died of disease after a median time of 62,7 months (7 to 156 months) after initial diagnosis.

Conclusion

It is of utmost importance to be aware of that ameloblastomas may be capable to degenerate into a "malignant" disease with recurrence and metastasis. In addition to local long-term control, special attention should be paid to potential pulmonary involvement.

Parathyroid hormone-related protein (PTHrP) expression in ameloblastoma

OBJECTIVE

Parathyroid hormone-related protein (PTHrP) production has been demonstrated in a variety of tumor subtypes. Local production of PTHrP by metastatic tumor cells in bone has been linked to bone destruction and tumor growth. Ameloblastoma (AB) is a relatively common odontogenic epithelial neoplasm that manifests local infiltrative intraosseous growth. AB recapitulates the developing enamel epithelium, in which PTHrP recently has been demonstrated. Yet PTHrP expression in a series of ABs has not been studied to date. The purpose of this investigation is to assess the expression of PTHrP in ameloblastoma.

STUDY DESIGN

Formalin-fixed, paraffin-embedded tissue sections of ameloblastoma (n = 30; 24 conventional, 4 unicystic, and 2 arising in dentigerous cyst) were immunostained with anti-PTHrP antibody using a multistep streptavidin-peroxidase technique. Semiquantitative scoring of immunoreactivity was assessed as mild, moderate, and intense.

RESULTS

All cases (100%) demonstrated positive immunoreactivity, with mild reaction in 3 conventional ABs, 1 unicystic and 1 AB arising in dentigerous cyst, and with moderate reaction in 12 conventional ABs, 3 unicystic and 1 AB arising in dentigerous cyst. Intense immunoreactivity was seen in 9 cases of conventional AB. This difference in immunostaining was not statistically significant (Sigma2 = 4.41, df = 4, P = .358).

CONCLUSION

The results of this investigation suggest that PTHrP may play a significant role in local bone resorption, offering at least partial explanation for the tumor's infiltrative growth and destructive behavior. The uniformity of PTHrP expression by AB, as detailed in this study, may harbor significant therapeutic implications, particularly through PTHrP-blocking treatment modalities.

Ameloblastic carcinoma of the maxilla

The maxilla is an unusual site for an ameloblastoma, and certainly for an ameloblastic carcinoma. Ameloblastomas are considered as benign, yet locally aggressive neoplasms in the vast majority of cases. However, very rarely, these tumors demonstrate a clinical course of malignancy. Recently, a classification system was published differentiating between malignant odontogenic carcinoma variants. The two such forms include malignant ameloblastoma, and ameloblastic carcinoma. In the differential diagnosis, the designation of malignant ameloblastoma is reserved for lesions that, despite their benign histology, metastasize as well-differentiated cells. The diagnosis of ameloblastic carcinoma is reserved for tumors that demonstrate a malignant morphologic appearance, regardless of whether metastasis is a proven fact at the time of discovery and treatment. We discuss the presentation, pathology, and treatment of the 18th case of a maxillary ameloblastic carcinoma in the literature.

Ameloblastic carcinoma: report of an aggressive case with multiple bony metastases

Ameloblastic carcinoma is a rare primary tumor of the maxillofacial skeleton with a distinct predilection for the mandible. These lesions may initially show histologic features of ameloblastoma that dedifferentiate over time. Other ameloblastic carcinomas initially present with morphologic features suggestive of ameloblastoma with areas of epithelial dedifferentiation. We herein report a rare case of aggressive ameloblastic carcinoma in a 22-year-old white man who developed widespread bony metastases and expired 4 years after initial diagnosis.

Ameloblastic carcinoma ex ameloblastoma of the mandible with malignancy-associated hypercalcemia

Ameloblastoma is a rare, locally destructive, benign neoplasm of the jawbones, which arises from epithelium derived from the epithelial components of the developing tooth. Ameloblastic carcinoma is the term used to designate any ameloblastoma in which there is histologic evidence of malignancy in the primary tumor, regardless of whether it has metastasized. Most ameloblastic carcinomas are presumed to have arisen de novo, with few cases of malignant transformation of ameloblastoma being apparent. Hypercalcemia is the most common metabolic complication of malignancy. Although malignancy-associated hypercalcemia is often reported in association with other malignancies, it is exceedingly unusual in association with ameloblastoma, malignant ameloblastoma, or ameloblastic carcinoma. We describe a patient with multiple recurrences of ameloblastoma, with subsequent malignant transformation presenting with malignancy-associated hypercalcemia.

Recurrent ameloblastoma of the mandible

Ameloblastoma is an agressive locally recurring neoplasm of odentogenic epithelium. Here we describe a case of mandibular ameloblastoma with 12 yrs. history of local recurrences followed with history of excision twice (10 yrs. and 7 years back).

Ameloblastoma of the maxilla. Case report

A basal cell maxillary ameloblastoma became obvious as an asymptomatic swelling of the left buccal sulcus and alveolar process, although a large extension into the maxillary sinus up to the nasal conchae and the orbital floor had already occurred. The painless and slow growth of the lesion, the thin bone of the upper jaws, the adjacent cavities and the vital structures are the main factors for delay in recognition and thus the potentially lethal result of a maxillary ameloblastoma. A review of location, age, sex and race predilection, clinical course, radiographic appearance, histological types and treatment methods in made.

Malignant ameloblastoma revisited

A case of a malignant ameloblastoma in a 49-year old Sri Lankan woman with widespread pulmonary metastases is presented, the diagnosis confirmed by needle biopsy. The current histological classification of odontogenic carcinomas and the management of metastatic pulmonary deposits are discussed.

Pulmonary metastatic disease in ameloblastoma

Ameloblastoma is a rare disease of odontogenic origin with indeterminate metastatic potential. The first site of metastatic disease is usually the lung. We report aggressive surgical treatment of a patient with bilateral disease with five subsequent recurrences. A review of the literature suggests that in the absence of effective chemotherapy or radiation, surgery should be considered the treatment of choice for metastatic ameloblastoma confined to the lung.

Combined chemotherapy and radiotherapy for advanced maxillary ameloblastoma. A case report

A case of advanced maxillary ameloblastoma was successfully treated with combined intra-arterial chemotherapy (Peplomycin, 85 mg) and radiotherapy (Co60, 7080 r). The tumour showed a remarkable shrinkage, and the patient survived. He is still alive and well at the time of this report. Carefully applied chemotherapy combined with radiotherapy has a useful role in the management of ameloblastoma especially in an advanced maxillary tumour. This report presents a typical example, which indicates that the ameloblastoma may not be an inherently radioresistant and chemoresistant tumour.

Hypercalcaemia and the synthesis of interleukin-1 by an ameloblastoma

A case of hypercalcaemia secondary to a long-standing solitary ameloblastoma is presented with evidence to suggest that the raised plasma calcium was the result of the secretion of interleukin-1 and a parathyroid hormone-like substances by the tumour. The aetiology of humoral hypercalcaemia of malignancy is discussed in relation to the role played by these substances.

Maxillary ameloblastoma: case report

Ameloblastoma of the maxilla is an unusual epithelial tumor of odontogenic origin. Although it is considered benign, it can behave in a slowly growing infiltrative fashion, with multiple recurrences and eventual intracranial, or even distant, spread. Information on this tumor consists, to a large extent, of case reports presented in the oral surgery literature. This study is a retrospective review of our combined institutional experience with nasomaxillary tumors from 1980 to 1988. Among these cases were four patients with maxillary ameloblastoma, two males and two females, ranging in age from 16 to 66 years at presentation. Disease extent varied from ameloblastoma localized to a cyst in the maxillary sinus to extensive maxillary and ethmoid involvement. Follow-up ranged from 2 to 13 years, and disease course varied from apparent disease control to persistent intracranial tumor, despite attempts at extirpation. An analysis of this experience and the related literature is presented, along with recommendations for radical therapy, when appropriate, to best ensure control.

Ameloblastic carcinoma of the maxilla metastatic to the mandible. Case report

A case of maxillary ameloblastic carcinoma metastatic to the mandible is presented. Of 33 cases of ameloblastic carcinoma reported in the English literature 10 have occurred in the maxilla. Of these, none produced mandibular metastases. The authors review the literature, describing clinical presentation, histological appearance, and treatment of this rare lesion.

Metastasizing ameloblastoma

A case of malignant ameloblastoma with widespread, indolent metastases is reported and 42 previously published cases of metastasizing ameloblastoma are reviewed. The disease-free interval (DFI) between diagnosis of tumor and appearance of metastasis in 43 patients is 9 years. The median survival time after metastasis is 2 years. Most metastases were in the lung. Although the biologic behavior of ameloblastomas cannot be predicted on the basis of morphology, metastasis appears to follow multiple recurrences. Early adequate resection of the primary to avoid repeated surgical procedures is advocated to prevent tumor spread. Surgical removal is preferred for treating metastasis. Although the response to radiation cannot be predicted, radiation should be used to treat lesions not amenable to surgical removal. Disseminated ameloblastoma does not appear to respond to chemotherapy.

Clear cell odontogenic carcinoma: report of three cases with pulmonary and lymph node metastases

Three cases of a newly described rare odontogenic tumor are reported. One patient died with pulmonary metastases, one had an associated odontogenic cyst and one exhibited regional lymph node metastasis. The cases lend support to the odontogenic origin and metastatic capability of the clear cell odontogenic tumor. The authors recommend aggressive therapy and believe that the tumor should be considered a clear cell odontogenic carcinoma.

Late loco-regional recurrences after radical resection for mandibular ameloblastoma

5 cases of mandibular ameloblastoma are described with multiple recurrences after a long period of time. 4 of them were primarily treated by radical resection. 1 was initially treated by enucleation and extensive resection was performed only after its recurrence. The invasive growth of the recurrent tumor into the soft tissues and the cranial base, necessitating extensive ablative and reconstructive surgery, reflects the potential aggressiveness of this tumor. It is therefore recommended, to plan an adequate resection in cases of multicystic ameloblastoma, which includes a margin of at least 1 cm, of apparently non-invaded bone. If the tumor has eroded through the cortical bone and invaded into the soft tissues, wider margins are necessary to eliminate possible tumor extensions that are left behind. Adequate follow-up on a regular basis should enable the clinician to detect early recurrence so as to avoid major surgery.

Distant skin metastases in a long-term survivor of malignant ameloblastoma

We report a case of distant cutaneous metastases in a 68-year-old patient with malignant ameloblastoma of the mandible. The metastatic lesions were first noted approximately 31 years after resection of the primary tumor. Metastases to lung, pleura, bone, and brain had also occurred. Histochemical findings differ from those described in adamantinoid basal cell carcinoma. Cutaneous metastasis probably resulted from hematogenous dissemination. To our knowledge, this is the first report of such an occurrence in English language literature.

Mandibular ameloblastoma with intracranial extension and distant metastasis

A case of mandibular ameloblastoma which invaded intracranially through the skull base and developed distant metastasis to the femur is reported. The intracranial extension of the tumor was partially removed three times and the metastasis of the femur was curetted. The remaining tumor temporarily responded to chemotherapy, but the patient died of intracranial tumor regrowth. The period from the initial treatment of the mandibular tumor to death was 21 years.

Biology of metastasizing ameloblastoma

The present report of a malignant metastasizing ameloblastoma and a critical review of literature was undertaken in an attempt to better understand the biological potential and behavior of this rare tumor and thus to facilitate its clinical management. Most of the 26 patients with a proven malignant ameloblastoma including the present case had developed multiple recurrences. The lung was the most frequent metastatic site (88%) followed by regional lymph nodes (27%). Furthermore metastases were observed in some cases in the bone, brain, kidney, small intestine and liver. The interval between diagnosis of tumor and manifestation of metastases was long with a median of 11.1 years. The average survival time was 13.1 years. By contrast, the interval between diagnosis of metastatic disease and death was relatively short (median: 2.6 years). The histologic and cytologic pattern of malignant ameloblastoma and of its metastases was not significantly different from that of non-metastatic ameloblastoma. Because of the lack of morphological criteria of malignancy the biological behavior of ameloblastomas cannot be predicted. It is difficult to be certain which factors are important in the delayed induction of metastases. It is suspected that ameloblastomas possess an inherent low grade malignancy which is stimulated by multiple recurrences. It is further assumed that the metastatic tumor cells have a slow growth rate resulting in late clinical manifestation of metastases. When lung metastases occur we recommend their surgical removal in order to prolong live expectancy or even to obtain a curative effect.

Malignant ameloblastoma or ameloblastic carcinoma

The World Health Organization defines malignant ameloblastoma as a lesion exhibiting features of an ameloblastoma in primary and metastatic growths. To cases collected from the literature we have added two of our own cases in which features of an ameloblastoma were coupled with malignant behavior. It was noted that the diagnosis of "malignant ameloblastoma" is at present used in a rather indiscriminate way, resulting in the grouping of lesions that exhibit considerable differences in biological behavior and histomorphology. This might be due to the fact that the WHO classification emphasizes metastasis as a diagnostic criterion but is rather vague in defining histopathologic aspects. It is advocated that the term malignant ameloblastoma be reserved for those lesions that, in spite of a seemingly innocuous histology, have given origin to metastatic growths, while the WHO classification should be modified to include ameloblastic carcinoma as a diagnostic term for lesions that combine features of an ameloblastoma with a less-differentiated histomorphology.