Mandibular metastasis as the first clinical indication of occult lung adenocarcinoma with multiple metastases: A case report

RATIONALE

Although metastases to the oral and maxillofacial region (OMR) are rare, the lung is the most common primary site metastasizing to the OMR.

PATIENT CONCERNS

An 83-year-old woman presented with reports of trismus, occlusal discomfort, swelling, and spontaneous pain in the right buccal region. Despite the absence of abnormal chest imaging findings, immunohistochemical analysis of biopsy specimens of the mandible and the thyroid indicated that the patient had multiple metastases from a lung poorly differentiated adenocarcinoma.

DIAGNOSES

Metastases to the OMR and the thyroid from an undiscovered lung adenocarcinoma.

INTERVENTIONS

Gefitinib was started as first-line chemotherapy, and zoledronic acid was administered for bone metastases.

OUTCOMES

Follow-up imaging examinations showed ossification and deformation of the right mandibular ramus and the condylar process. Although 2 years have passed since the first visit to our hospital, lung lesions have not been confirmed by imaging examinations.

LESSONS

Clinicians should consider the possibility that symptoms in the OMR may be the first clinical sign of an undiscovered distant primary tumor, and the primary tumors may not be detected by imaging examinations even when metastases to the OMR are revealed.

The Role of Sonic Hedgehog Signaling in Osteoclastogenesis and Jaw Bone Destruction

Sonic hedgehog (SHH) and its signaling have been identified in several human cancers, and increased levels of its expression appear to correlate with disease progression and metastasis. However, the role of SHH in bone destruction associated with oral squamous cell carcinomas is still unclear. In this study we analyzed SHH expression and the role played by SHH signaling in gingival carcinoma-induced jawbone destruction. From an analysis of surgically resected lower gingival squamous cell carcinoma mandible samples, we found that SHH was highly expressed in tumor cells that had invaded the bone matrix. On the other hand, the hedgehog receptor Patched and the signaling molecule Gli-2 were highly expressed in the osteoclasts and the progenitor cells. SHH stimulated osteoclast formation and pit formation in the presence of the receptor activator for nuclear factor-κB ligand (RANKL) in CD11b⁺ mouse bone marrow cells. SHH upregulated phosphorylation of ERK1/2 and p38 MAPK, NFATc1, tartrate-resistant acid phosphatase (TRAP), and Cathepsin K expression in RAW264.7 cells. Our results suggest that tumor-derived SHH stimulated the osteoclast formation and bone resorption in the tumor jawbone microenvironment.

Spontaneous regeneration of bone after resection of central giant cell lesion: a case report

There are several treatment modalities to date for central giant cell granuloma including conservative treatment and surgical treatment with often planned reconstruction of the bony defect. Spontaneous bone regeneration of mandibular defects following complete resection of mandible has rarely been reported in the literature. We report a case of spontaneous bone formation after resection of a central giant cell granuloma in the anterior mandible of a pediatric patient and the importance of maintaining the periosteum during surgical resection as a rare case report.

Diverse growth patterns in an intraosseous ameloblastoma: a case report

Desmoplastic ameloblastoma (DA) is a benign but locally invasive variant of the solid/multicystic ameloblastoma (SMA). In the recent World Health Organization classification of odontogenic tumours, DA has been characterised as a variant, with specific clinical, radiographic and histopathological features. A possible 'transitional' form of DA, showing microscopic features of the desmoplastic variant together with areas typical of classic follicular or plexiform ameloblastoma, has been described as a 'hybrid' lesion of ameloblastoma (HLA). A unique case with synchronous emergence of desmoplastic and unicystic ameloblastoma (different growth patterns) in the mandible of a 50-year-old male is reported.

Adamantinoma of the spine: case report

OBJECTIVE

We report a patient with a cervicothoracic spinal and a mandibular adamantinoma. Adamantinoma is a rare malignant neoplasm of bone and, to our knowledge, there have been only five cases of spinal adamantinoma reported. The pathogenesis of the adamantinoma, as well as the management of this extremely rare spinal tumor, is reviewed.

CLINICAL PRESENTATION

A 55-year-old man was admitted to our service with cervical pain and signs of C8 and T1 radiculopathy. On physical examination, cervical spine deformity, swelling in the left mandible region, and signs of C8 and T1 radiculopathy were observed. Neuroradiology examinations showed an osteolytic mass of the C6, C7, and T1 vertebral bodies, extending into the lateral masses and transverse processes. After surgical procedures, the patient had clinical improvement.

INTERVENTION

Corpectomy of C6, C7, and T1 was performed through a cervicothoracic anterior approach. Anterior stabilization of the spine was obtained using an autologous iliac crest graft and osteosynthesis with an anterior plate. On a second procedure, posterior tumor resection and spinal stabilization were performed. After the 1-year follow-up examination, a new anterior procedure was performed because of tumor recidivity and spine instability.

CONCLUSION

Adamantinoma, an extremely rare lesion, is a locally aggressive tumor with slow growth and the potential to metastasize. Although it is an extremely rare occurrence in the spine, adamantinoma should be considered on the diagnosis of tumors of the vertebrae. Neuroradiological examinations are not specific in the differentiation of this tumor from other conditions. This fact, coupled with the limited experience that most physicians in general have in dealing with this tumor, makes the diagnosis and treatment of adamantinoma challenging.

[Functional recovery with prosthetic management for segmental resection of the mandible without reconstruction]

PATIENT

The patient, a 54-year-old male, consulted the Oral Surgery Department of Iwate Medical University Hospital with a complaint of a mass in the left oral base in June 1992. In September 1992, the patient was diagnosed as having cancer in the left mandibular base, and the tumor was excised by resection of the entire cervical region on the left side. Since radiation osteonecrosis in the left mandible and mandibular fracture were detected, segmental excision of the left mandible was performed in March 1993. Although the postoperative course was good without reconstruction, the patient consulted the Second Prosthetic Department to achieve functional recovery in February 1996. This patient had no occlusal contact between the maxilla and mandible because the mandible shifted to the affected side. After fixation of a mandibular prosthetic appliance for the defective mandible, a palatal plate for the maxilla in occlusal contact with the mandibular dentition and mandibular prosthetic appliance were fixed in November 1997. After fixation of a new mandibular prosthetic appliance and dentures for the maxilla with palatal ramp in April 2001, masticatory function was observed to have improved with control of the mandible.

DISCUSSION

To prevent the mandibular shift and improvement of the masticatory function, a palatal plate with a palatal ramp in the occlusal contact region was fixed, and a balance of the masticatory muscles could be maintained. An evaluation of the level of improvement in the masticatory function and the pronunciation function indicated that the mandibular prosthetic appliance and palatal plate with a palatal ramp in the occlusal contact region increased the kind of food that the patient could take. Moreover, by enlarging the narrow Donders space, the pronunciation was improved.

CONCLUSIONS

Fixation of a palatal plate with a palatal ramp in the occlusal contact region without reconstruction of the mandibular bone was useful for the control of mandibular deviation to the affected side and improvement of the masticatory function.

Evaluation of quality of life among patients after extirpation of mandibular ameloblastoma

OBJECTIVE

To evaluate the quality of life (QOL) based on the functional, aesthetic and personal satisfaction among patients with ameloblastoma who underwent either partial or total mandibulectomy without reconstruction.

DESIGN

Cross-sectional study.

SETTING

The Department of Oral Surgery and Oral Pathology, School of Dentistry; Muhimbili University College of Health Sciences, Tanzania.

SUBJECTS

Patients surgically treated for ameloblastoma without reconstruction. RESULTS. The postoperative problems were mostly associated with eating of solid foods, appearance and speech. All patients treated by total mandibulectomy had moderately severe problems with eating of solid foods and were dissatisfied with their appearance.

CONCLUSION

The relatively small tumours resulted in a much better QOL. Public awareness programmes to avoid late referral and treatment is the most effective way to reduce the number of patients who after treatment suffer a poor QOL.

Osteoma of the mandibular condyle: report of a case with 5-year follow-up

Osteomas of the mandibular condyle are rare. An unusual case of an osteoma occurring in the mandibular condyle of a 22-year-old man with mandibular deviation and malocclusion is reported; this represents the 14th documented case in the English language literature. The tumor was resected with condylectomy. Postoperatively, mandibular deviation was minimized.

Mechanisms of cancer invasion of the mandible

There is little evidence that the tumor enters the mandible preferentially through the occlusal surface, the periodontal membrane, or named foramina. Tumor enters the mandible at the point of contact, which is often at the junction of the attached and reflected mucosa, which lies below the crest of the ridge in all but grossly resorbed mandibles. Angulation of the bone cut in rim or marginal resection of the mandible is advised. The erosive pattern of disease is associated with shallow mandibular invasion and smaller tumors in the soft tissue. This finding supports the principle of marginal resection in such cases. There is little evidence to support the principle that the tumor spreads preferentially along the inferior alveolar nerve or the bone marrow. The inclusion of the neurovascular bundle in marginal resections of the mandible is not necessary. Preoperative assessment should include plain radiography combined with a sensitive scan (bone scintigraphy, single photon emission computerized tomography, or MRI) and inspection of the bone surface after periosteal stripping at the time of the resection.

Ameloblastoma: a clinical, radiographic, and histopathologic analysis of 71 cases

OBJECTIVES

The purpose of this study was to compare the clinical, radiologic, and histopathologic features of 71 intraosseous ameloblastomas.

STUDY DESIGN

Data with respect to the patients' ages, sex, tumor locations, and surgical treatment history, as well as the radiographic findings and number of recurrences, were analyzed. The histologic types of and radiologic findings regarding tumors with higher recurrence rates were also investigated.

RESULTS

The patients' ages at biopsy ranged from 11 to 70 years (mean, 30.4 years). Thirty-nine (54.9%) of the 71 subjects were males, and 32 (45.1%) were females. Sixty-two (87.3%) of the 71 ameloblastomas were located in the mandible. Swelling was the most common symptom and was experienced by 27 (38.0%) patients. Radiographically, 42 (59.2%) of the 71 tumors were unilocular with a well-demarcated border. Of the remaining 29 cases, 14 were multilocular, 2 were of soap-bubble shape, and 13 were unknown in appearance. The most common histologic pattern was plexiform, rather than follicular or acanthomatous. Sixteen cases of ameloblastoma had developed in a cyst. The overall recurrence rate was 21.1%, and the average age of the patient at recurrence was 26.4 years.

CONCLUSIONS

When the diagnosis of ameloblastoma in young people remains in doubt after clinical and radiologic examination, a biopsy is necessary. Long-term follow-up at regular intervals after surgery is also recommended.

Peripheral ossifying fibroma--a clinical evaluation of 134 pediatric cases

PURPOSE

Reported clinicopathologic studies on the peripheral ossifying fibroma (POF), a reactive gingival lesion, have not addressed the pediatric population in specific detail. This study, the first devoted to children, investigated the clinical features of a large number of POFs and compared the findings to cases reported in the English language literature.

METHODS

Detailed clinical and historical information of 134 surgically removed POFs in patients aged 1-19 formed the basis of this study. Clinical manifestations, histogenesis, treatment rationale with pediatric considerations, and biologic behavior were emphasized.

RESULTS

The POF was found more frequently in females (60%). It had a predilection for the maxillary gingiva (60%) and for the incisor/cuspid region. The average patient age was 14 years. Only 2 (1%) POFs were found to be unequivocally associated with primary teeth. The clinician seldom included the POF in the differential diagnosis. The recurrence rate after surgical excision was 8%.

CONCLUSIONS

This study revealed that a POF arising from the periodontal ligament of a primary tooth is most likely a rare event. However, the pediatric patient with a POF has special management considerations compared to the adult. Because of the POF behavior pattern, a proper treatment protocol is warranted with close postoperative follow-up.

Functional criteria for mandibular implant placement post resection and reconstruction for cancer

STATEMENT OF PROBLEM

Osseointegrated implants used in the mandible post resection and reconstruction for cancer represents a treatment option with the potential for functional improvement and enhanced quality of life. Unfortunately, protocols for their use in this patient population have been empirical and technique-driven with the assumption that they will overcome most, if not all, functional deficits encountered.

PURPOSE

The article reviews the salient oral physiologic factors for this group of patients and presents a rational approach and functional criteria for patient selection and implant placement. Other considerations discussed include: timing of implant placement, irradiated and compromised tissues, patient motivation, and tumor prognosis.

CONCLUSION

These principles, if followed, may enhance realistic functional outcomes for this patient population.

Osseointegrated implants in the head and neck cancer patient

BACKGROUND

Osseointegrated implants allow patients with oromandibular defects to obtain complete or partial dentition via implant-assisted or implant-borne prostheses. Implants restore masticatory and occlusal function, improving oral intake and articulation. However, use of implants in head and neck cancer patients has been discouraged due to lack of data supporting their utility in these patients. This study attempts to establish the validity of using osseointegrated implants for dental restoration in head and neck cancer patients.

METHODS

Six patients who underwent resection/reconstruction for head and neck cancer received osseointegrated implants. Integration was assessed clinically, radiographically, and mechanically at 4-8 months; oral intake, mastication, and articulation were evaluated 6-12 months after receiving the dental prosthesis.

RESULTS

Osseointegration occurred in 92% (24/26) of the implants: 100% (14/14) in neomandibles and 83% (10/12) in native mandibles. One patient had implants (2/5) that failed to integrate. The remaining patients' implants were immobile, free of infection, with no osteoradionecrosis. These patients tolerated a regular diet and experienced weight gain and improved articulation.

CONCLUSIONS

The advent of osseointegrated implants and their compatibility with native and neomandible allows the restoration of functional dentition in patients undergoing ablative surgery for head and neck cancer.

Oral rehabilitation with implant-retained prostheses following ablative surgery and reconstruction with free flaps

Ablative surgery of the oral tissues may result in significant facial deformity, poor oral function, and psychologic detriment. Immediate surgical reconstruction with vascularized free flaps has become increasingly popular, but the oral rehabilitation of these patients with conventional dental prostheses is usually unsuccessful. The results and clinical experiences of treating a group of 17 patients with ablative surgery, immediate reconstruction with free flaps, and restoration with mandibular implant-retained prostheses are presented after follow-up periods of 6 months to 7 years. Most patients expressed a high degree of satisfaction with their prostheses. General principles and guidelines for the provision of this effective treatment modality are discussed.

Features of odontogenesis and expression of cytokeratins and tenascin-C in three cases of extraosseous and intraosseous calcifying odontogenic cyst

To characterize further the nature of calcifying odontogenic cyst (COC), we studied histologically and immunohistochemically an extraosseous and two intraosseous lesions. The extraosseous COC was in continuity with the stratified squamous epithelium of the alveolar mucosa. Immunostaining with monoclonal antibodies showed reactivity of both low- and high-molecular-weight cytokeratins, the degree of coexpression decreasing with the increasing morphological diversity of the cyst/tumour epithelium. Staining for the matrix glycoprotein tenascin-C was seen not only in the connective tissue, where its distribution patterns corresponded to the stage of hard tissue formation, but also in epithelial elements. The staining patterns were analogous to those described during normal tooth formation. Both the morphological characteristics and expression patterns of the various cytokeratin types and tenascin-C implied that COC represents a pathological counterpart of normal odontogenesis. In the case of the extraosseous COC, the correspondence could be traced back to early stages of tooth development.

[Study for searching equilibrium point in dentulous hemimandibulectomy patients]

Occlusal registration for prosthodontic rehabilitation in dentulous hemimandibulectomy patient has various difficulties due to mandibular instability. The purpose of this study was to find the occlusal contact position for remaining dentition to stabilize the hemiresected mandible during clenching. Three hemimandibulectomized subjects without surgical bony construction were selected and custom-made Gothic-arch typed apparatus was fabricated. Mandibular movements during clenching were recorded with jaw movement tracking device with six degrees of freedom. The results were as follows: 1. The direction of the mandibular rotation around each coordinate axis in 3-dimensional space during clenching was constant in each subject, regardless of stylus position. 2. The most stable points on the hemimandibules during clenching did not necessarily correspond to the mid-portion of the remaining dentition of the mandible. 3. When referred to the maxillary arch, the point was lined up within the distal half of the second premolar and the mesial third of the first molar in mid-sagittal plane along the long axis of the remaining dentition. 4. Rotational axis during clenching existed on the horizontal plane. 5. It was assumed that the most stable point of the mandible in a hemimandibulectomy patient may be useful in interocclusal registration in clinical dental practice.

Paget's sarcoma of the mandible

BACKGROUND

Sarcomatous change occurs in less than 1% of patients with Paget's disease. It has been reported in only 9 patients in the mandible, and has been uniformly fatal. Comparison of Paget's sarcoma of the mandible to osteosarcoma of the mandible and to osteosarcoma in other locations was made to attempt to explain and improve the outcome of patients with these tumors.

METHODS

Two 78-year-old women with Paget's sarcoma of the mandible treated with radical resection are reported. The literature is reviewed to compare the clinical presentation and prognosis of patients with mandibular Paget's sarcoma to patients with osteosarcoma in non-Pagetoid mandibles and with osteosarcoma outside of the head and neck.

RESULTS

Both patients died within 2 years of lung metastases. The patients with mandibular Paget's sarcoma were markedly older, with an average age of 65.6 years, compared to 32.5 years for mandibular osteosarcoma. Paget's sarcoma of the mandible was uniformly rapidly fatal; in non-Pagetoid mandibles the 5-year survival is 40%. There have been reports of only 7 patients who have survived with Paget's sarcoma in other locations. In osteosarcoma of the extremities 5-year disease-free survival exceeds 75% with multimodality therapy.

CONCLUSIONS

Paget's sarcoma of the mandible is a rare tumor which affects elderly patients. It progresses rapidly and has a much poorer prognosis than osteosarcoma occurring in a non-Pagetoid mandible. The prognosis may be improved with early detection and treatment with multimodality therapy.

Pathoses of coronoid process as a cause of mouth-opening restrictions

The mandible coronoid process is another site subject to various pathoses that may result in limited jaw movement. Six different pathoses that prevented the free rotation of the coronoid are presented. Differential diagnosis and treatment approach are emphasized.

A combined anterolateral thigh flap, anteromedial thigh flap, and vascularized iliac bone graft for a full-thickness defect of the mental region

A triple combined anterolateral thigh flap, anteromedial thigh flap, and vascularized iliac bone graft was used for reconstruction of a full-thickness defect of the mental region after wide resection of advanced tongue cancer. The distal end of the pedicle vessels of these double skin flaps, i.e., the lateral circumflex femoral system, was directly anastomosed in tandem to the pedicle of the iliac bone graft, which was enveloped by these flaps. The advantages of this iliac osteocutaneous flap are as follows: It can be transferred within a shorter surgical time because the flaps can be obtained in the supine position simultaneously with tumor resectioning; and its skin components can be separated from the bone because each component has its own pedicle vessels, has a longer vascular pedicle (> 10 cm), and has a thicker crest of the bone graft. This flap is believed to be suitable for reconstruction of large full-thickness defects in various sizes of the mandibular and maxillary regions of the face.

Transforming growth factor beta 2 in epithelial differentiation of developing teeth and odontogenic tumors

Dysregulation of TGF beta 2, a modulator of cell growth and differentiation, can result in uncontrolled growth and tumor formation. Our comparative studies on the expression of TGF beta 2 mRNA and protein indicate that TGF beta 2 may primarily be a regulator of epithelial differentiation during tooth development (between 13 and 20 gestational wk) and tumorigenesis of odontogenic neoplasms. A paracrine mode of action for TGF beta 2 in early human tooth germ (cap/early bell stage) is suggested by location of mRNA in the mesenchyme surrounding the tooth germ, whereas protein is found in the epithelial dental lamina and enamel organ. During the late bell stage, TGF beta 2 gene expression shifted from the mesenchyme to the odontogenic epithelium and was colocalized with protein, suggesting an autocrine role for the terminal differentiation of ameloblasts. In odontogenic tumors of epithelial origin (ameloblastomas) and epithelial-ectomesencymal origin (ameloblastic fibromas), TGF beta 2 mRNA was mostly located in the mesenchymal tumor component and protein in the epithelial tumor component. Odontogenic ectomesenchymal tumors (myxomas) were not associated with TGF beta 2 mRNA and protein expression. The results imply that TGF beta 2 may play an important role in epithelial-mesenchymal interactions in human tooth morphogenesis and development of odontogenic tumors.

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.

Microvascular free-tissue transfer with rigid internal fixation for reconstruction of the mandible following tumor resection

The authors described their experience using rigid internal fixation techniques in combination with free microvascular tissue transfer for the immediate reconstruction of mandibular defects following tumor ablation. The technique allows immediate return of jaw motion and limited function while assuring maintenance of occlusion and reasonable cosmesis.

Aggressive (malignant?) epithelial odontogenic ghost cell tumor

Although the calcifying odontogenic cyst (COC) is a well-established pathologic entity, it has been recognized that there is an odontogenic neoplasm with histologic features similar to the COC that has often been diagnosed as COC. Investigators have applied several terms to this neoplasm, but we prefer the term epithelial odontogenic ghost cell tumor (EOGCT). No reports have appeared previously in the literature describing either carcinoma arising in a COC or malignant EOGCT. Three cases are reported here with aggressive growth and histologic features strongly implying a malignant potential, although none is known to have metastasized. Two occurred in the maxilla and one in the mandible. One was discovered 9 years following removal of a typical COC, and another recurred rapidly after excision.

Osteochondroma of the mandibular condyle. Report of a case and review of the literature

Osteochondroma (osteocartilaginous exostosis) is a rare tumour in the region of the mandibular condyle. Much confusion seems to exist in the literature in differentiating these tumours from condylar chondromas as well as from condylar hyperplasias. A case of condylar osteochondroma with a review of the literature is presented.

Mural odontogenic epithelial proliferations within the wall of a dentigerous cyst: their significance

A case of a dentigerous cyst with proliferating odontogenic epithelium in a 5-year-old black boy is presented. A controversy exists in the histologic diagnosis and surgical treatment of this lesion. The accuracy of the pathologic diagnosis is imperative, as it will determine to a great extent the surgical modality of treatment.