Oncology - L13 Jaw masses.pdf

Dr/ Ahmed Kamel  JAW MASSES I Anatomy of jaw 1 Lower jaw (Mandible) Definition ▪ The mandible is the skeleton of the lower jaw. Consists of ▪ Body and 2 rami (one ramous on each side). ...

Dr/ Ahmed Kamel  JAW MASSES I Anatomy of jaw 1 Lower jaw (Mandible) Definition ▪ The mandible is the skeleton of the lower jaw. Consists of ▪ Body and 2 rami (one ramous on each side).  SURG IV - Oncology Jaw Masses 2 Upper jaw (Maxilla) ⎚ There are 2 maxillary bones (right and left) which together form front of face. ⎚ Each maxillary bone shares in forming part of 3 important cavities: 1. Floor of the orbit. 2. Floor and lateral wall of the nose. 3. Roof of the mouth. 3 Tooth  SURG IV - Oncology Jaw Masses II Teeth Development (Odontogenesis) ▪ The teeth develop from an ectodermal ridge (Dental plate = Dental lamina) which: A. Buried into the mesoderm. ① B. and Segmented to form enamel germs (odontogenic epithelium). ▪ Each germ invaginated by mesodermal papilla, and ▪ All become surrounded by a vascular fibrous tissue giving dental follicles. ②  SURG IV - Oncology Jaw Masses ▪ In each follicle, the enamel germ give: 1. Ameloblasts: lay down the enamel. 2. Odontoblast: gives rise to dentine, cement, and pulp of the tooth. ③ ▪ Between the teeth, fragments of ectoderm may persist as Para dental epithelial cells of Mallesez which may be responsible for odontomes formation later on. ④    TEETH DEVELOPMENT  SURG IV - Oncology Jaw Masses I Etiology 1 From Gum or alveolar margin A. Generalized B. Localized (Epulis) “See pages 6-7” 1. Diffuse hyperplastic gingivitis. Tumor growing from alveolar margin or mucoperiosteum 2. Drug induced: 1. Benign: Fibrous, Granulomatous and Pregnancy. ▪ Phenatoin (antiepileptic) 2. Locally malignant: Giant-cell. ▪ Nifedipine (coronary dilator). 3. Malignant: carcinoma and sarcoma. 2 From Teeth remnants (Odontomes) ⎚ They are: Tumors and cysts derived from dental structures. ① Epithelial ▪ Dental, dentigerous and adamantinoma “See pages 8-10” ② Mesenchymal ▪ Cementome, Fibrous, osseous ③ Mixed (composite) --- 3 From Bony jaw “See pages 11-18” ① Developmental ▪ Solitary bone cyst, keratocyst, nasopalatine & nasolabial cyst ② Traumatic ▪ Malunited fracture mandible, and maxilla ③ Inflammatory ▪ Alveolar abscess, acute osteomyelitis and chronic osteomyelitis ④ Neoplastic II Classification A. Benign B. Locally malignant C. Malignant Upper jaw Lower jaw ▪ Osteoclastoma ▪ Primary. ▪ Osteoma ▪ Osteoma. ▪ Secondary (Bone ▪ Fibrous dysplasia ▪ Chondroma metastases).  SURG IV - Oncology Jaw Masses ⎚ Types: ① Fibrous Epulis “THE COMMONEST FORM” ② Granulomatous (Pyogenic) Epulis ③ Giant-Cell (Myeloid) Epulis Carious tooth which causes True fibroma arising from outer layer Considered as an osteoclastoma of gum ETIOLOGY chronic irritation & unhealthy of mucoperiosteum arising from bone of alveolar margin granulation tissue Arises near neck of incisor SITE Around a carious tooth Usually arises in the lower jaw or premolar teeth of lower jaw Sessile Sessile swelling SHAPE or Pedunculated swelling Pedunculated swelling PATHOLOGY N/E CONSISTENCY Firm Soft Soft CONSISTENCY Pinkish (less vascular) Red (vascular) Purple (vascular) COVERING Intact mucosa Ulcerated mucosa Intact mucosa 1. Multinucleated giant cells in a matrix of Granulation tissue fibrous tissue. M/E Spindle cells (fibroblasts) (capillaries + fibroblasts) 2. It is NOT a malignant giant cell But a F.B. giant cell. FIG.  SURG IV - Oncology Jaw Masses ① Fibrous Epulis “THE COMMONEST FORM” ② Granulomatous (Pyogenic) Epulis ③ Giant-Cell (Myeloid) Epulis 1. It grows between 2 teeth causing 1. It may grow between 2 teeth and 1. It may grow between 2 teeth loosening loosen them. causing loosening COMPLICATION but no wide separation of teeth. & wide separation of teeth. 2. May turn to fibro sarcomatous epulis. 2. It never turns malignant 2. It never turns malignant ▪ Slowly growing. ▪ Slowly growing. ▪ Slowly growing. SWELLING ▪ Painless. ▪ Painful. ▪ Painless. C/P COVERING ▪ Intact ▪ Not intact ▪ Intact MUCOSA BLEEDING ▪ Does not bleed easily ▪ Bleeds easily on touch ▪ Does not bleed easily ▪ Extraction of adjacent tooth or teeth ▪ Extraction of carious tooth + ▪ Wide excision + on both sides + ▪ Curettage of unhealthy ▪ Curettage of underlying TTT ▪ Excision of tumor + granulation tissue bone ▪ Wedge excision of periosteum to prevent recurrence ④ Malignant Epulis ⑤ Pregnancy Epulis ▪ TYPES: 1. Carcinomatous: SCC of mucous membrane of gum. ▪ DEFINITION: It is inflammatory hyperplastic tumor affecting 2. Sarcomatous epulis: Paraosteal fibrosarcoma of gum pregnant female due to hormones of pregnancy (usually on top of fibrous epulis).  SURG IV - Oncology Jaw Masses ③ Adamantinoma ① Dental cyst ② Dentigerous cyst “COMMONEST TUMOR OF MANDIBLE” ▪ Radicular cyst ▪ Follicular odontoma ▪ Ameloblastoma. SYNONYM: ▪ Multilocular cystic disease of the jaw. ▪ Due to proliferation of paradental ▪ Due to cystic degeneration of a ▪ It is locally malignant tumor epithelial debris of malassez by dental follicle. of paradental epithelial ETIOLOGY: chronic irritation of a nearby infected debris of Malessez. tooth → granuloma → cyst. ▪ Common in the upper jaw ▪ Common in lower jaw in relation to ▪ Commonly occurs in lower SITE (Usually around incisor or canine unerupted tooth jaw near the angle. tooth). (Canine, Premolar or 3rd molar) ▪ Small or large unilocular cyst ▪ Large multilocular cyst with ▪ Small unilocular cyst containing a maldeveloped thick trabeculae → Expanding jaw on both maldirected tooth → Expanding jaw → Expanding jaw mainly PATHOLOGY CYST sides (inward & outward) mainly outward → causing thinning outward → Causing thinning N/E out of outer table. out of outer table ▪ Contains mucoid fluid rich ▪ Contains glairy fluid around ▪ Contains brownish mucous CONTENT in cholesterol unerupted tooth fluid ▪ There are ridges in its wall (pseudo ▪ It grows forwards in the NB --- trabeculae) body and upwards in ramus M/E ▪ Lined by squamous epithelium ▪ Lined by squamous epithelium ▪ Lined by basal-cell carcinoma  SURG IV - Oncology Jaw Masses ① Dental cyst ② Dentigerous cyst ③ Adamantinoma (Ameloblastoma) (Radicular cyst) (Follicular odontoma) (Multilocular cystic disease of the jaw) 1. Infection. COMPLICATION --- --- 2. Pathological fracture. SEX Male --- TYPE OF Commonly affects females Common in children & adolescents between 20 - 40 years PATIENTS AGE Around 40 years (7-25 years) ▪ Slowly growing. ▪ Slowly growing. ▪ Slowly growing. ▪ Painless. SWELLING ▪ Painless. ▪ Painless. C/P ▪ In anterior part of upper ▪ In lower jaw near angle. ▪ In lower jaw near angle. jaw. It may give eggshell crackling It may give eggshell crackling Hard in consistency but, it may give eggshell SENSATION sensation (thinned bone). sensation (thinned bone) crackling sensation (thinned bone) There is usually missed (unerupted) No lymph node enlargement except due to OTHERS --- tooth 2ry infection or malignant change FIG.  SURG IV - Oncology Jaw Masses ① Dental cyst ② Dentigerous cyst ③ Adamantinoma (Ameloblastoma) (Radicular cyst) (Follicular odontoma) (Multilocular cystic disease of the jaw) ▪ Expansion of jaw with ▪ Expansion of jaw with cyst dental cyst that is empty containing maldirected tooth ▪ Multilocular cyst with fine honeycomb ▪ Shows soap bubble appearance with equal lobulation appearance due to pseudo trabeculae PLAIN INV. X-RAY X-ray image showing cyst formation around wisdom tooth 1. Extraction of the infected 1. Resection of affected portion of tooth, and mandible with a safety margin at least ½ 2. Opening the cyst through 1. Deroofing of the cyst, and inch, followed later by TREATMENT incision in the gum, and 2. Removing the tooth, and 2. Replacement with: 3. Curettage of its contents, 3. Crushing the alveolus. A. An autogenous bone graft, or Followed by B. Dental prosthesis. 4. Crushing of the alveolus.  SURG IV - Oncology Jaw Masses 1 Developmental Diseases I. Solitary bone cyst ETIOLOGY ▪ Uncertain (? abnormalities during bone growth) ▪ Vascular dysfunction → leading to a local post-hemorrhagic ischemia PATHOGENESIS → inducing an osseous aseptic necrosis CYST Shows fibrous tissue or only bone M/E LINING Devoid of an epithelial lining CONTENT Usually empty or contain blood or a straw-colored fluid ▪ Polymorphic. C/P ▪ Scalloped borders. ▪ Located between the teeth roots INVESTIGATIONS II. Keratocyst ▪ They are rare benign cystic lesions involving the mandible or maxilla DEFINITION and believed to arise from dental lamina. BEHAVIOR ▪ Aggressive clinical behavior. & PROGNOSIS ▪ High recurrence rate. ▪ Nevoid basal cell carcinoma syndrome. ASSOCIATION ▪ Mutation in the Protein Patched Homolog 1 (PTCH) tumor suppressor WITH gene. INVESTIGATIONS  SURG IV - Oncology Jaw Masses III. Nasopalatine cyst EPIDEMIOLOGY The most common epithelial & nonodontogenic cyst of the maxilla ▪ The cyst originates from: epithelial remnants from the nasopalatine duct. ▪ The cells may be: PATHOGENESIS - Activated spontaneously during life, or - Eventually stimulated by the irritating action of various agents (infection, etc.). IV. Nasolabial cyst ▪ A rare developmental soft tissue cyst that develop between the upper DEFINITION lip and nasal vestibule. ▪ Derived from: 1- Epithelial cells retained in the mesenchyme after fusion of medial and DERIVED FROM lateral nasal processes. 2- Epithelial remnants from the nasolacrimal duct extending between the lateral nasal process and maxillary prominence. ▪ The predominant presentation of a nasolabial cyst is a painless localized swelling WITH varying degrees of nasal obstruction C/P  SURG IV - Oncology Jaw Masses 2 Inflammatory Diseases ① Dental abscess: DEFINITION ▪ It is collection of pus in the tooth following any infection. ▪ It can be: A. Within the tooth in the roots. SITE B. Near the gums. C. or in the alveolar bone which surrounds the tooth. 1. Tooth decay. ETIOLOGY 2. Foreign body: like food particles or bacteria which are trapped in tissues. 3. Trauma. 1. Pain on chewing food or sometimes at rest. 2. Redness in the tissue where infection has occurred, and accumulation of pus has occurred. 3. ↑↑ temperature at that particular place. 4. Foul tasting discharge within the mouth from the place where infection has occurred. 5. Foul breath. C/P 1. Removal of the source. 2. Drainage of the pus collected. - If there is pus within the tooth roots → Root canal treatment. TTT - If in the surrounding tissues → incision and drainage of the pus. 3. Antibiotics. 4. Analgesics: for relief of pain.  SURG IV - Oncology Jaw Masses ② Alveolar abscess ③ Acute Osteomyelitis ④ Chronic Osteomyelitis ▪ Predisposing factors: ▪ Non-specific: Chronic after acute. Tooth extraction in presence of an alveolar ▪ Infection spreading through ▪ Specific: abscess. ETIOLOGY cortex of mandible to form - Actinomycosis ▪ Organisms: S. aureus. a subperiosteal abscess. - TB ▪ Route of infection: direct from the mouth - Syphilis. or rarely blood. Marked general Marked general GENERAL --- constitutional manifestations constitutional manifestations 1. Pain 1. Pain. 1. Pain. C/P 2. Swelling: tender, red, 2. Swelling. 2. Thickening of bone. LOCAL hot, edema of cheek. 3. Trismus. 3. Sinus discharging pus & sequestra 3. Enlarged Cx LNs. ⎚ Plain X-Ray: --- ▪ Sequestra and later involucrum. INVESTIGATION --- ▪ Antibiotics, analgesic, GENERAL ▪ Antibiotics, analgesic, tonics & vitamins ▪ Antibiotics and mouth wash tonics & vitamins. TTT ▪ Saucerisation & sequestrectomy ▪ Intra-oral drainage by an ▪ Mouth washes, till resolution or LOCAL when sequestrum separates incision in mucoperiosteum chronicity  SURG IV - Oncology Jaw Masses PATHOGENESIS OF MANDIBULAR OSTEOMYELITIS 3 Traumatic Diseases Mandible fractures ⎚ Types: 1- Alveolar process fracture 2- Lateral (paramedian) mandible fracture. 3- Mandibular angle fracture. 4- Mandibular body fracture. 5- Mandibular fracture. 6- Fracture condyloid process. 7- Fracture cornoid process.  SURG IV - Oncology Jaw Masses 4 Neoplastic Diseases I. Osteoclastoma ⎚ It is a rare tumor of the jaw. ⎚ Similar to adamantinoma with the following differences: Adamantinoma Osteoclastoma SITE Near angle of mandible. Near symphysis menti. Both horizontal & vertical rami. Only in horizontal part. GROWTH It stops short at angle. SHAPE Equal lobulation. Unequal lobulation. EXPANSION More on outer side. Equal on both sides. COLOR Pink or pale. Brownish or bluish. Honeycomb appearance. Soap bubble appearance. X-RAY II. Malignant Neoplasms of Mandible ▪ The most common malignant tumors of the mandible represent SCCs of the INCIDENCE oral cavity, especially carcinoma of the floor of the mouth and gingiva that invade the mandible secondarily. TYPE OF PATIENT ▪ It affects children or young adults ▪ Painful. ▪ Rapidly growing → They grow to large size, encroach on SWELLING buccal cavity C/P ▪ The tumor is hard, or of variable consistency. ▪ Loosening of teeth. ▪ Profuse salivation. IT CAUSES.. ▪ Foulness of mouth. ▪ Ulceration and bleeding. TTT ▪ Treatment is disappointing, Palliative mandibulectomy.  SURG IV - Oncology Jaw Masses III. Cancer Maxilla INCIDENCE ▪ Malignant lesions of the maxilla are rare. ▪ Often result from direct tumor extension from adjacent structures such as ORIGIN gingiva, mucosa of the upper lip, maxillary sinuses, or nasal cavity. ▪ Etiology of Maxillary sinus cancer: ETIOLOGY 1. Multiple polyps. 2. Chronic sinusitis ▪ Carcinoma of maxilla is not a bony tumor. SITE ▪ But a tumor arising from mucous membrane lining maxillary antrum. PATHOLOGY N/E ▪ Rapidly growing cauliflower mass. 1. Squamous cell carcinoma. “Most common type of maxillary sinus cancer” M/E 2. Adenoid cystic carcinoma. “2nd most common type” A. Intrinsic: In the maxilla itself. B. Extrinsic: The cauliflower mass starts to infiltrate: 1. Medial wall: Encroaches on the nose 2. Inferior wall (floor): Encroaches on the hard palate 3. Upper wall (roof): Encroaches on the eye. 4. Anterior wall: Encroaches on the cheek. 5. Posterior wall: Encroaches on the sphenopalatine fossa. DIRECT SPREAD ▪ Relatively late. LYMPHATIC ▪ To either submandibular or upper deep cervical nodes or both. BLOOD ▪ Lung, Liver, and Bones.  SURG IV - Oncology Jaw Masses 1. Pain. 2. Unilateral nasal obstruction. 3. Unilateral epistaxis & foul nasal discharge. 4. Unilateral epiphora: Due to obstruction of C/P nasolacrimal duct. 5. Diplopia or proptosis. 6. Toothache, loosening of the teeth, ballooning of the hard palate. 7. Swelling of the cheek (ballooning of the face). 1. Early: opacification of the maxillary antrum due to involvement of the cavity with the soft tissue of the tumor. 1. X-RAY 2. Later on (erosion, decalcification, absorption of the bone....) due to actual invasion of the bones. 2. ANTERIOR ▪ May show a mass which is friable, ulcerated & bleeds easily on RHINOSCOPY touch. 3. CT SCAN Investigation of choice ▪ Excellent in detecting maxillary cancer with lymph node metastases. ▪ Reliable in detecting: 4. PET/MR A. Bone marrow invasion. INV. B. Intracranial invasion. C. Invasion of deep tongue muscle. D. Perineural spread ▪ T1 axial (a) ▪ T2 axial (b) ▪ STIR axial (c) ▪ FDG PET/MR T1 with fat suppression axial fusion (d) ▪ STIR coronal (e) ▪ FDG PET/MR T1 VIBE with fat suppression axial fusion, at more inferior level (f) ▪ Primary: A or B A. Combined irradiation + Conservative surgery OPERABLE TTT B. Ferguson’s operation (maxillectomy) followed by prosthesis ▪ Secondary: Total block dissection of neck only if LNS are palpable INOPERABLE ▪ Irradiation.