Malignant Tumors PDF

VI. Malignant Tumors Dr. Tarek Abdallah BDS, MSc, PhD, Dip. Lecturer of Oral & Maxillofacial Radiology and LASER  What is Malignant Tumors 1. Uncontrolled growths of tissue. 2. Locally invasive than benign tumors. 3....

VI. Malignant Tumors Dr. Tarek Abdallah BDS, MSc, PhD, Dip. Lecturer of Oral & Maxillofacial Radiology and LASER  What is Malignant Tumors 1. Uncontrolled growths of tissue. 2. Locally invasive than benign tumors. 3. Have a greater degree of anaplasia. 4. Can metastasize regionally to lymph nodes and distantly to other sites. 5. May arise: a. De Novo (Primary Tumor). b. From distant 1ry tumor (2ry Metastatic Malignancy). 3 Tarek Abdallah, 24-25  Clinical Features of Malignancy Clinical Correlation There are some clinical S&S that suggest that a lesion may be malignant: 1. Swelling. 9. Weight loss. 2. Teeth displacement. 10. Dysgeusia. 3. Loosened teeth over a short duration. 11. Dysphonia. 4. Foul smell. 12. Dysphagia. 5. Ulceration. 13. Hemorrhage. 6. Presence of indurated/rolled border. 14. Lack of normal healing. 7. Exposure of underlying bone. 15. Pain with no obvious dental cause. 8. Lymphadenopathy. 16. Neural complaints (motor or sensory). 4 Tarek Abdallah, 24-25  Features Benign Tumors Malignant Tumors 1. Onset Insidious Sudden 2. Duration (Long) Slowly growing (Short) Rapidly growing Benign 3. Shape Regular Irregular Uncoordinated & 4. New Growth Uncoordinated Uncontrolled VS 5. Nature Expansile in nature Destructive in nature Malignant 5. Cells Arrangement Abnormal Abnormal + Pleomorphism (Anaplasia) 6. Way of growth Direct Extension Infiltration & Invasion Not (Stopped growth, once 7. Life-Threatening Yes, & Cause death treated) Tarek Abdallah, 24-25 8. Adjacent structures Direct Invasion from both  Features Benign Tumors Malignant Tumors 9. Radiographic Picture/Features: Anywhere in the jaw Anywhere in the jaw Benign I. Site & Location Tooth-bearing (Od.) SCC: Lip, Tongue, Gingiva, & Floor of the mouth Non-tooth-bearing (Non-Od.) Sarcoma: Post Man. & Max. Well-defined & Ill-defined & II. Shape & Periphery Occasionally Ill-defined Few with Punched-out border VS III. Internal St. RL. RO, or Mixed RL-RO RL & may Mixed Patchy IV. Effect on Surrounding Structures: Malignant A. Periosteum Can stimulate periosteal rx. With Normal new laid bone Can stimulate periosteal rx. Alveolar bone Destruction B. New Bone Loading Normal New bone Destructed (Sunray) B. Cortical bone Expansion (Thin/ Thick) Erosion & Destruction C. Teeth Displacement Floating in Space Irregular widening & D. Roots Resorption, Divergence, flaring Tarek Abdallah, 24-25 Destruction  7 Imaging role in cancer First, aid in the establishment of an initial diagnosis of a tumor. Second, aids in the appropriate staging of disease from early small to large cancers that have spread. Third, assist the surgeon or radiation oncologist to determine the anatomic spread of the tumor so that it can be excised or irradiated adequately. Fourth, can determine the presence of osseous involvement from soft tissue tumors Fifth, help to determine good biopsy sites Sixth, the practitioner should assess the involvement of lymph nodes and the treatment outcome. Finally, a thorough diagnostic imaging examination is part of the management of a patient who has survived cancer, who often is rendered xerostomic; neutropenic; and susceptible to dental caries, periodontal disease, and systemic infection. 7 Tarek Abdallah, 24-25  Outline I. Carcinomas II. Metastatic Tumors III. Sarcomas IV. Malignancies of the Hematopoietic System 1. SCC Arising in Soft Tissue 1. Osteosarcoma 2. SCC Originating in Bone 2. Chondrosarcoma 1. Multiple Myeloma 3. SCC Originating in a Cyst 3. Fibrosarcoma 2. Non-Hodgkin’s Lymphoma 4. SCC Originating in the Max. Sinus 4. Ewing’s Sarcoma 3. Burkitt’s Lymphoma 5. Central Mucoepidermoid Carcinoma 4. Leukemia 6. Malignant AB and AB Carcinoma V. Dental Radiology for Cancer Survivors 8 Tarek Abdallah, 24-25  IMAGING FEATURES Of Malignant Tumors LOCATION Primary and metastatic malignant tumors may occur anywhere in the oral and maxillofacial region. Primary carcinomas are more commonly seen in the tongue, floor of the mouth, tonsillar area, lip, soft palate, or gingiva. Sarcomas are more common in the mandible and in posterior regions of both jaws. Metastatic tumors are most common in the posterior mandible and maxilla. Some metastatic lesions grow at the apices of teeth or in the follicles of developing teeth. 9 Tarek Abdallah, 24-25  Diagrammatic representation of radiologic features of oral malignancy D, Multifocal lesions located at root apices and in the papilla of a developing tooth destroying the crypt cortex and10displacing the developing tooth in an occlusal direction (arrow). Tarek Abdallah, 24-25  IMAGING FEATURES Of Malignant Tumors PERIPHERY AND SHAPE Ill-defined border with lack of cortication and absence of encapsulation. This border usually extends from an area of bone destruction (radiolucent) to a region of normal bone with uneven extensions and is referred to as an infiltrating pattern. This border is produced by finger-like extension of the tumor in many directions. 11 Tarek Abdallah, 24-25  IMAGING FEATURES Of Malignant Tumors PERIPHERY AND SHAPE In contrast, some malignancies, especially squamous carcinomas arising in adjacent soft tissues and invading the mandible, may have well-defined borders. Evidence of destruction of a cortical boundary with adjacent soft tissue mass is highly suggestive of malignancy. Such a mass may exhibit a smooth or ulcerated peripheral border if cast against a radiolucent background, such as the air within the maxillary sinus. The shape of a malignant tumor of the jaw is commonly irregular. 12 Tarek Abdallah, 24-25  Diagrammatic representation of radiologic features of oral malignancy Ill-defined invasive borders followed by bone destruction. Destruction of the cortical boundary (floor of 13 maxillary Tarek Abdallah, 24-25 antrum) with an adjacent soft tissue mass (arrows).  IMAGING FEATURES Of Malignant Tumors INTERNAL STRUCTURE The internal aspect is typically radiolucent in most instances. Occasionally, residual islands of bone are present, resulting in a pattern of patchy destruction with some scattered residual internal osseous structure. Some tumors, such as metastatic prostate or breast lesions, can induce bone formation, resulting in an abnormal- appearing internal sclerotic osseous architecture, Whereas others, such as osteogenic sarcomas, can produce abnormal bone giving the involved bone a sclerotic (radiopaque) appearance. 14 Tarek Abdallah, 24-25  IMAGING FEATURES Of Malignant Tumors EFFECTS ON SURROUNDING STRUCTURES Malignancy is destructive, often rapidly so. The effect on surrounding structures mirrors this behavior. Slower growing benign tumors or cysts may resorb tooth roots or displace teeth in a bodily fashion without causing loose teeth. In contrast, rapidly growing malignant lesions generally destroy supporting alveolar bone so that teeth may appear to be floating in space. 15 Tarek Abdallah, 24-25  Diagrammatic representation of radiologic features of oral malignancy Tarek Abdallah, 24-25 16 Bone destruction around existing teeth, producing an appearance of teeth floating in space. hemangioma with phleboliths (arrows).  IMAGING FEATURES Of Malignant Tumors EFFECTS ON SURROUNDING STRUCTURES Because malignant tumors tend to grow rapidly, they invade via the easiest routes, such as through the maxillary antrum or through the periodontal ligament space around teeth, resulting in irregular widening with destruction of the lamina dura they also may spread through the inferior alveolar neurovascular canal, causing similar widening. 17 Tarek Abdallah, 24-25  Diagrammatic representation of radiologic features of oral malignancy Tarek Abdallah, 24-25 18 C, Tumor invasion along the periodontal membrane space causing irregular thickening of this space.  IMAGING FEATURES Of Malignant Tumors EFFECTS ON SURROUNDING STRUCTURES Usually no periosteal reaction occurs where the tumor has destroyed the outer cortex of bone; however, some tumors stimulate unusual periosteal new bone formation. Lesions such as osteosarcoma and metastatic prostate lesions as well as other tumors can stimulate the formation of thin straight spicules of bone, giving a “hair-on-end” or “sunburst” appearance. If there is a secondary inflammatory lesion coexisting with the malignancy, a periosteal reaction normally associated with an inflammatory lesion (e.g. onion skin–like) may be seen. 19 Tarek Abdallah, 24-25  Diagrammatic representation of radiologic features of oral malignancy Cortical bone destruction without periosteal reaction Four types of effects on cortical bone and periosteal reaction, from top to bottom: Laminated periosteal reaction with destruction of the cortical bone and the new periosteal bone Destruction of cortical bone with periosteal reaction at the periphery forming Codman’s triangles 20 Spiculated or sunray type of periosteal reaction Tarek Abdallah, 24-25 I. Carcinomas Tarek Abdallah, 24-25  Carcinomas 1. Squamous Cell Carcinoma SCC arising in Soft tissue 2. Squamous Cell Carcinoma SCC arising in bone 3. Malignant Ameloblastoma / Ameloblastic Carcinoma Tarek Abdallah, 24-25 I. Carcinomas Epithelial Origin 1. SCC Arising in Soft Tissue Tarek Abdallah, 24-25  A. Soft tissue SCC / Epidermoid Carcinoma Def: R/P It originates within the surface epithelium & 1. Location: Post Mand. (Lateral border of the Tongue). characterized by the invasion of malignant cells Ant Mand. (Lip & Floor of the Mouth) into underlying CT with a spread into deeper 2. Periphery: RL, Irregular border. soft tissues & bone. Can be smooth without cortex (Erosion rather than Invasion) 3. Internal St: Totally RL. C/p: 4. Effect on surroundings: 1. PDLs Widened 1. White/Red irregular patchy lesion 2. Loss of Adjacent LD 2. Central Ulceration 3. Teeth float in a mass of RL soft tissue without alveolar support. 3. Rolled/Indurated Borders 5. D.D. Osteomyelitis 4. Lymphadenopathy Tarek Abdallah, 24-25  SCC Periapical image reveals bone destruction similar to The tooth socket from an extracted second molar has enlarged instead periodontal disease around the lateral incisor from a of healing because of the presence of a squamous cell carcinoma. squamous cell carcinoma originating in the soft tissues of the alveolar process. 25 Note the lack of a sclerotic bone reaction at the periphery. Tarek Abdallah, 24-25  Mucoepidermoid Carcinoma Multilocular radiolucency is characteristic of central mucoepidermoid carcinoma. This lesion has displaced the mandibular canal and destroyed the superior crest of the alveolar process and the distal supporting bone of the second molar. 26 Tarek Abdallah, 24-25  Mucoepidermoid Carcinoma Axial CT image reveals multiple cyst like growths, some surrounded by sclerotic bone and expansion of the mandible with extension into the surrounding soft tissue (arrow). 27 Tarek Abdallah, 24-25  Mucoepidermoid Carcinoma Coronal CT image of a maxillary mucoepidermoid carcinoma with a multilocular internal structure. Tarek Abdallah, 24-25 I. Carcinomas Epithelial Origin 2. SCC Arising in Bone Tarek Abdallah, 24-25  2. Central SCC / Primary Intraosseous Carcinoma / SCC originating in Bone Def: R/P 1. Location: More in Mand. (Molar tooth bearing areas). It arises from intra-osseous remnants of Od. 2. Periphery: Ill def. periphery (degree of raggedness of the epithelium without any connection with the border may reflect the aggressiveness of the lesion) & surface epithelium. rounded / oval in shape. C/p: 3. Internal St: Wholly RL. Rare, remain silent till reach large. 4. Effect on surroundings: 1. Destruction of the antral or nasal floors 2. Destruction of LD 30 3. Teeth Tarekfloat in a24-25 Abdallah, space. 2 Squamous Cell Carcinoma arising in bone Tarek Abdallah, 24-25  Intra-osseous SCC Primary intraosseous carcinoma in the left mandible exhibits no internal structure, a poorly defined periphery, and thinning of the overlying mandibular bone. 32 Tarek Abdallah, 24-25  SCC on Cyst Carcinoma arising in a preexisting dentigerous cyst related to the mandibular left third molar shows absence of a cyst cortex, invasion into adjacent bone, and ill-defined borders. 33 Tarek Abdallah, 24-25  SCC In the occlusal image, the anterior floor of the nasal fossa has been destroyed (note lack of anterior nasal spine). 34 Tarek Abdallah, 24-25  SCC The supporting alveolar bone has been destroyed from around the teeth. 35 Tarek Abdallah, 24-25  SCC In the panoramic image, there is destruction of the right alveolar process and floor of the maxillary sinus and 36the soft tissue mass. Tarek Abdallah, 24-25  SCC Destruction of bone in the mandibular retromolar area by a squamous cell carcinoma. 37 Tarek Abdallah, 24-25  SCC 38 and the Axial and coronal CT images of the tumor displayed in D. Note destruction of the lateral cortical plate in the axial image medial cortical plate in the coronal image andTarek lackAbdallah, of bone24-25 reaction at the margins of the tumor.  SCC Periapical images of an ill-defined SCC invading the alveolar process from the nasal cavity. Note the long transition zone from the bone destruction near the midline to the more normal bone 39 pattern distal to Abdallah, Tarek the cuspid. 24-25  SCC A and B, Periapical images of two cases of carcinoma of the alveolar process. Bone destruction around the tooth roots 40 leaves the teeth bereft ofTarek any Abdallah, bone support. 24-25  SCC Cropped panoramic image of a carcinoma growing Sagittal CT image of another case of a carcinoma destroying down the inferior alveolar canal shows the irregular the mandible in the region of the mental foramen (white width of the canal and destruction of its cortical arrows) and growing down the canal. Note the destruction of borders. the peripheral cortex of the canal (black arrow). Tarek Abdallah, 24-25  SCC Panoramic image of a squamous cell carcinoma originating within the left maxillary sinus. 42 Tarek There is destruction of the tuberosity, posterior floor of the sinus, Abdallah, posterior 24-25 wall of the maxilla, and zygomatic process of the maxilla.  SCC Sagittal CT image shows destruction of bone around the molars and tuberosity region. 43 Tarek Abdallah, 24-25 SCC 44 Another sinus carcinoma with destruction of the left maxilla and presence of a soft tissue mass (arrow). Tarek Abdallah, 24-25  I. Carcinomas 1. Epithelial Origin 3. Malignant AB & Metastatic AB Tarek Abdallah, 24-25  3. Malignant AB & Metastatic Ameloblastoma R/P Ameloblastic carcinoma 1. Location: More in Post. as Benign Ameloblastoma Benign + metastasis. 2. Periphery: Well def. with cortication 3. Internal St: ULRL or ML RL (Honeycomb/Soap bubble with & thick septae). Malignant AB show invasion to surroundings 4. Effect on surroundings: 1. Bodily displacement 2. root Maligant Ameloblastoma resorption 3. may erode and destroy cortical floors of cavities. Malignant + cannot metastasize (Benign Clinical behavior) 50 Tarek Abdallah, 24-25 II. Metastatic Tumors 51 Tarek Abdallah, 24-25  II. Metastatic Tumors Def: R/P They represent the establishment 1. Location: Post areas of the jaws. Mand. Followed by max. sinus, of a new foci of malignant hard palate & condyle. In mand. They are usually bilateral. disease from a distant malignant 2. Periphery: Demarcated without cortication. Ill def., invasive tumor. In jaws, they arise from margins. sites inferior to the clavicle. 3. Internal St: generally RL, may sclerotic metastasis 4. Effect on surroundings: 1. May stimulated periosteal bone reaction, C/p: Loss of LD, PDLs enlargement, Teeth floating in soft tissue space, loss of Dental pain, numbness, & alveolar support, extraction socket fail to heal any may increase in size. paresthesia. 5. D.D: Multiple Myeloma, Periapical inflammatory lesions. 52 Tarek Abdallah, 24-25  Metastatic Carcinomas Metastatic breast carcinoma surrounding the apical half of the second and third molar roots and extending inferiorly. It has destroyed the inferior border of the mandible. 53 Tarek Abdallah, 24-25  Metastatic Carcinomas 54 Bilateral metastatic lesions from the lung destroying the mandibular rami. Tarek Abdallah, 24-25  Metastatic Carcinomas Coronal CT image using soft tissue algorithm of the case shown in B. D, Destruction of the left mandibular condyle (arrows) from a thyroid metastatic lesion. 55 Tarek Abdallah, 24-25 Metastatic Carcinomas 56 Tarek Abdallah, 24-25  Metastatic Carcinomas Axial CT image using soft tissue algorithm of the case shown in D demonstrates invasion into surrounding soft tissue (arrows). 57 Tarek Abdallah, 24-25  Occlusal image of prostate lesions causing sclerosis and a spiculated Metastatic Carcinomas periosteal reaction (arrows). Partial panoramic image of prostate metastatic lesions involving the body and ramus. 58 Note the sclerotic bone reaction (arrows). Tarek Abdallah, 24-25 Metastatic Carcinomas Two periapical images of a metastatic lesion of breast carcinoma. Note the irregular widening of the periodontal membrane spaces and patchy sclerotic bone reaction, especially around the roots of the molars. 59 Tarek Abdallah, 24-25 II. Sarcomas Mesenchymal Origin 68 Tarek Abdallah, 24-25  Sarcomas 1. Osteosarcoma 2. Chondrosarcoma 3. Fibrosarcoma 4. Ewing’s Sarcoma Tarek Abdallah, 24-25  1. Osteosarcoma / Osteogenic Sarcoma  1. Osteosarcoma Def: R/P It produce osteoid directly by malignant stroma 1. Location: More in Mand. (post. Tooth, bearing areas. Angle, as opposed to adjacent reactive bone formation. or ramus). 2. Periphery: Ill def., RL, no sclerosis. (Hair-on-end or C/p: Codman’s triangle) More in males 3. Internal St: May RL, Mixed RL-RO, or RO. (loss of normal Rapid Swelling trabeculae) Pain, tenderness, erythema, ulceration, loose 4. Effect on surroundings: 1. Widening PDLs (suggests teeth, epistaxis, & trismus. osteosarcoma as well as other malignances) 2. Loss of cortices & LD 71 5. D.D: Fibrosarcoma, metastatic carcinoma, & Oss. Fibroma. Tarek Abdallah, 24-25 Periphery and Shape: Tarek Abdallah, 24-25 Tarek Abdallah, 24-25 Tarek Abdallah, 24-25 Effects on Surrounding Structures Tarek Abdallah, 24-25  Osteosarcoma 77 Radiographs of a resected mandible of a 25-year-old man with osteosarcoma, showing sunray spicules. Tarek Abdallah, 24-25  Osteosarcoma Cropped panoramic image shows an osteosarcoma occupying the body of the right mandible. Note the widened ligament spaces (arrows) and that the density of the mandible in the first molar region is greater than normal because of abnormal bone formation from the tumor. Tarek Abdallah, 24-25  Osteosarcoma 79 Periapical images of another case of osteosarcoma show irregular widening of the periodontal membrane space of the teeth of Tarek the left maxilla and extending to the right maxilla where the Abdallah, ligament 24-25of the left central incisor is widened (arrows). space  Osteosarcoma Coronal CT image of an osteosarcoma of the maxilla. Note the spiculated bone formation extending laterally from the maxilla (arrows). 80  2. Chondrosarcoma Def: R/P It produce osteoid directly by malignant stroma 1. Location: Equally in Mand. ( coronoid & condyle) & Max. (Ant. area). as opposed to adjacent reactive bone formation. 1. Periphery: Misleading benign nature. Well def. & sometimes corticated, with round, ovoid or lobulated shape. C/p: 3. Internal St: Mixed RL-RO (moth-eaten bone/ Snow-like appearance/ Ground Glass abnormal bone) with islands with Affect males & females equally unaffected residual bone. Firm, hard mass of relatively long duration. 4. Effect on surroundings: 1.Expand cortices Push the antrum or nasal fossa When large, pain, headache, & deformity. Condylar expansion Tooth displacement Root Resorption 5. D.D: Osteosarcoma & Fibrous Dyspalsia. 81 Tarek Abdallah, 24-25  Chondrosarcoma Chondrosarcoma of the anterior maxilla, with irregular calcification in the internal structure of the tumor (arrows). Tarek Abdallah, 24-25  Chondrosarcoma Coronal CT image using bone algorithm of a chondrosarcoma Axial CT scan using soft tissue algorithm involving the mandibular condyle (note the two areas of bone demonstrating the soft tissue extent of the lesion destruction). Tarek Abdallah, 24-25 (arrows) and sparse calcifications.  Fibrosarcoma Def: R/P It is a neoplasm composed of malignant 1. Location: More in Mand. (premolar-molar area). fibroblasts that produce collagen & elastin. Periphery: Ragged, Ill def., poorly demarcated, non-corticated. C/p: Saucer-like depression + sclerosis in adjacent normal bone. 3. Internal St: RL, long time lesions, reactive bone formation. 1. Affect males & females equally 4. Effect on surroundings: Destruct adjacent structures as 2. Slowly, rapidly enlarging mass presented 1. Inferior Border with usual symptoms. 2. Alveolar Process. 3. Cortical Bone 3. Mass may be centrally (pain) or peripheral 4. Lamina Dura (bulky lesion) 5. Gross Teeth Displacement 6. Teeth Floating in Space 88 4. May cause pathological fracture Tarek Abdallah, 24-25  Fibrosarcoma 89 process, Fibrosarcoma involving the right maxillary sinus has destroyed the cortical boundaries of the sinus, zygomatic hard palate and posterior maxilla, andTarek Abdallah,process alveolar 24-25 in this panoramic film. Destructive effects of Fibrosarcoma: Mandible Maxilla Either Jaw lamina dura and follicular cortices Loss of: Loss of: are obliterated. the alveolar process floor of the Destruction of the outer cortical plate, inferior border maxillary sinus with a protruding soft tissue mass. cortices of the posterior wall of Root resorption is uncommon. neurovascular canal the maxilla Teeth are grossly displaced and lose nasal floor their supporting bone so that they appear to be floating in space Tarek Abdallah, 24-25 IV. Malignancies of Hemopoietic System 99 Tarek Abdallah, 24-25  Malignancies of Hemopoietic System 1. Multiple Myeloma 2. Non-Hodgkin’s Lymphoma 3. Burkitt’s Lymphoma 4. Leukemia Tarek Abdallah, 24-25  1. Multiple Myeloma Def: It is a malignant neoplasm of plasma cells. R/P Common in long bones and rare in the oral cavity 1. Location: More in Mand. (post area) that maxilla. Periphery: Well def., non-corticated, Punched out, may be C/p: ragged & infiltrative or oval or cystic in shape. 1. Fatigue, weight loss, fever, low back pain 3. Internal St: RL, occasionally islands of residual bone and progressive anemia. 4. Effect on surroundings: 2. Hypercalcemia & amyloidosis 1. Teeth appear too opaque 3. Bens jones protein in urine (foamy urine) 2. Lamina Dura & Follicles may loose their cortication 3. Thin lower border of mandible 4. Dental pain, swelling, hemorrhage, 4. All are profound if renal fails 101 paresthesia, & teeth mobility. Tarek Abdallah, 24-25  Multiple Myeloma Multiple myeloma, seen as multiple circular radiolucent lesions in the skull. Tarek Abdallah, 24-25  Multiple Myeloma Cropped panoramic image of a different case shows multiple small lesions of multiple myeloma present through the body and ramus of the mandible.  Multiple Myeloma Cropped panoramic image depicting multiple areas of well-defined bone destruction lacking any cortical boundary. The lesions are multiple, separate, and appear to be “punched out,” typical of changes seen in multiple myeloma. 104 Tarek Abdallah, 24-25  Multiple Myeloma Cropped panoramic image shows a solitary lesion in the condylar neck region and a pathologic fracture (arrow). 105 Tarek Abdallah, 24-25  Malignant Lymphoma Panoramic image revealing a malignant lymphoma invading the right maxilla. Note the ill-defined bone destruction and loss of the anterior aspect of the floor of the maxillary antrum (arrows). Tarek Abdallah, 24-25  Malignant Lymphoma Intraoral radiographs also show ill-defined bone destructionTarek andAbdallah, the lack24-25 of any bone reaction or formation.  Malignant Lymphoma Cropped panoramic image reveals an ill-defined lymphoma invading the left body of the mandible. Note the irregular widening of the periodontal ligament spaces (arrows). 108 Tarek Abdallah, 24-25  Malignant Lymphoma Intraoral films of the same case demonstrate widened periodontal ligament spaces (white arrows) compared with the normal periodontal ligament space of the right Tarek mandibular Abdallah,cuspid 24-25 (black arrow).  2. Malignant Lymphoma / Non-Hodgkin’s lymphoma Def: It is a malignant tumor of cells normally R/P resident in the lymphatic system. 1. Location: More in Mand. (premolar-molar area). Occur within lymph nodes, however extra nodal sites as bone, skin, and tonsils can be Periphery: Poorly def., similar appearance to periodontal involved. diseases (rounded without defining outer cortex). C/p: 3. Internal St: MLRL destructions. Some times patchy Ro 1. Affect middle and older age groups. present. 2. Common sites are; max. sinus, palate, 4. Effect on surroundings: tonsillar area and bone. 1. Loss of Lamina Dura 3. Night sweats, fever, puritis, painless enlargement, weight loss, anemia, 2. Teeth Displacement & mobility anoreoxia & generalized weakness. 3. Loss of tooth crypts 110 Tarek Abdallah, 24-25 2 Non-Hodgkin’s Lymphoma Tarek Abdallah, 24-25  3. Burkitt's Lymphoma / Def: African Jaw Lymphoma It is a characteristic form of Non-Hodgkin’s lymphoma that is a primarily a tumor of R/P childhood. 1. Location: More in Mand. (premolar-molar area). 2. Periphery: Ill def., non-corticated. No definite shape that C/p: cause ballooning 1. Affect males more than females, Childs or 3. Internal St: Non corticated RL, young adults & Max>Mad 4. Effect on surroundings: 2. Rapidly growing, facial deformity, nasal 1. Thinning of the adjacent structures blockage, displacing orbital contents, 2. Production of soft tissue tumor mass adjacent to the osseous loosened teeth, grossly displaced & lesion 112 paresthesia. Tarek Abdallah, 24-25 3 Burkitt’s Lymphoma Tarek Abdallah, 24-25  LEUKEMIA Periapical radiographs of the left mandible demonstrate multifocal areas of bone destruction and widening of portions of the 114 periodontal ligament space (arrow) characteristic of infiltration of the mandible with leukemia. Tarek Abdallah, 24-25  Differential Diagnosis 1 Multiple Myeloma Tarek Abdallah, 24-25 2 Metastatic Carcinoma Multiple Myeloma Tarek Abdallah, 24-25  3 4 Squamous Cell Carcinoma Langerhan’s Cell Disease Squamous Cell Carcinoma Tarek Abdallah, 24-25 5 Leukemia Tarek Abdallah, 24-25  Differential Diagnosis: 1 2 Osteosarcoma Ewing’s Sarcoma Metastatic Tumor Tarek Abdallah, 24-25  Thank You Dr. Tarek Abdallah BDS, MSc, PhD, Dip. Lecturer of Oral & Maxillofacial Radiology and LASER Ref; Oral Radiology: Principles and Interpretation, 7th Ed. Stuart C. White, Michael J. Pharoah. 129  Methods of Radiographic Interpretation Head of Department Prof: Abdel Wahab Sayed, Prof: » Adel Zein A Abdein, Prof. Zeinab A Salam Prof: Amr Abdel Azeem, » Course Director Prof. Mushira Dahaba Prof: Mohamed El Sorogy, » Prof: Hossam Kandil, » Prof: Hala Zakarya, » Prof: Soad Mahmoud, » Prof: Eman Abdel Aziz, » Prof. Maha Eshak » Prof: Nashwa Salah Ahmed, » Prof: Hoda Abdel Kader, » Prof: Gihan Omar, » Prof: Hany Omar. » Updated, Tarek Abdallah, PhD. 2024-2025 130