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Case No. 47. Cystic adamantinoma
Case Reports CASE NO. 47 CYSTIC
ADAMANTINOMA
MAX H. JACOBS,M.D., D.M.D.,
F.I.C.A.,
BOSTON,MASS.
T
HE patient, Mrs. A. K., a white woman, complained of a progressively growing mass in the right side of the mandible. Hi&?-Y.-Eighteen years previously she had an impacted mandibular cuspid and cyst removed. One year ago she developed discomfort and occasional pain in the right side of the mandible. She noticed an increase in the size of the jaw in the cuspid area. This increased to such an extent that it was visible externally. Examina.tion.-In the right mandibular canine area was a bulging mass extending from the right lateral incisor to the first molar. The mass was firm, The mass nonfluctuant,, and in places, crepitus could be heard on pressure. was nodular and somewhat tender to palpation. X-Ray Ezanzination.-X-ray examination disclosed a large circumscribed area extending from the right second premolar to below the right central incisor (Fig. 1). The inferior margin of this area in places penetrated into the lower border of the mandible. There were several small calcified areas within the radiolucent mass. The mandibular right lateral and first premolar appeared to penetrate the area.
Fig. l.-Cystic
adamantinoma. Note the finger-like projection extending illto the bone at the border of the mandible.
Differential Diagnosis.-Radicular cyst, recurrent dentigerous cyst, and cystic adamantinoma had to be considered. There was sufficient bone structure between the radiolucent area and the apex of the deciduous cuspid to rule out radicular cyst, the other teeth being vital. Recurrent dentigerous cyst occurs very infrequently. Because of the fingerlike projection extending from the lower border of the radiolucent area into the 157
158
Max H. Jacobs
bone structure and because the mass was nodular to palpation, the diagnosis of cystic adamantinoma was made. Operatiolz.--Under gas oxygen-ether anesthesia, a vertical incision was made from the gingival margin of the mandibular left central incisor to the mucolahial fold. The interdental papillae as far as the lower right first molar were in&cd and the mucoperiostcum was reflected. In places a bluish gray wit,h the periosteum. The rest of the membrane was found to bc in contact bnccal boric was parchment-like and thin in character. No teeth were extracted.
Fig.
Z.-Low-power
microscopic within which
Fig.
3.-High-power
section through can be seen many
microscol)ic
the cystic star cells
section
through
membrane showing and ameloblasts.
the
epithelial
epithelial
bud
bud.
The cyst was enuclcatcd and several nodules were found to have penetrated into the lower border of the mandible. The walls of the bony cavity were cauterized with phenol and washed with alcohol. The cavity was packed with iodoform exit of the gauze. The mucoperiosteum was laid back and sutured, permitting
Cgstic Adanmntin~oma gauze through the lower part of the incision in the mucolabial fold. When the cyst was collapsed, the membrane was found to be filled with tiny palpable nodules. Microscopic Exnmination.-Microscopic examination reveals sections of a cyst. Lining the cyst in most areas is a flattened layer of a stratified squamous type of epithelium without any rete pegs. Surrounding this stratified squamous layer is a moderately thick band of collagenous and elastic fibrous tissue, which in turn contains within it several spicules of bone. These have the usual lamellat,ed structure and contain the tiny spaces with central nuclei representing the Raversian system. From the cyst lining there extend several buds made up of epithelial cells, some consistin g of masses of these epithelial cells in no typical arrangement but containing wit,hin this mass many star cells and ameloblasts which are readily recognized. Other buds are surrounded by a stratified mass of spinous cells and in the center contain large cells, stellate in shape with centrally placed vesicular nuclei and a pink-staining cytoplasm representing the so-called star cells. Many areas of cystic changes within these buds are also present. Tiny little focal areas of polymorphonuclear leucocytic infiltration are also present throughout the mass. In several areas the cystic degeneration shows cells which are flattened and squamous and in the center consist of large vacuolated cells with pyknotic nuclei (Figs. 2 and 3). Diagnosis.-Cystic Adamantinoma. (81. J. S., Pathologist.) Com~~aent.-The point of interest in this case is the type of cyst that was removed eighteen years previously. Since cystic adamantinomas may arise from epithelial inclusions sometimes found in the dental follicle of an unerupted or impacted t.ooth, it is possible that the original cyst was an adamantinoma. Recurrence may take place any number of years later, if it was not entirely eradicated. 311
COMMONWEALTH
AVENUE.
ADAMANTINOMA
MAX H. JACOBS,M.D., D.M.D.,
F.I.C.A.,
BOSTON,MASS.
T
HE patient, Mrs. A. K., a white woman, complained of a progressively growing mass in the right side of the mandible. Hi&?-Y.-Eighteen years previously she had an impacted mandibular cuspid and cyst removed. One year ago she developed discomfort and occasional pain in the right side of the mandible. She noticed an increase in the size of the jaw in the cuspid area. This increased to such an extent that it was visible externally. Examina.tion.-In the right mandibular canine area was a bulging mass extending from the right lateral incisor to the first molar. The mass was firm, The mass nonfluctuant,, and in places, crepitus could be heard on pressure. was nodular and somewhat tender to palpation. X-Ray Ezanzination.-X-ray examination disclosed a large circumscribed area extending from the right second premolar to below the right central incisor (Fig. 1). The inferior margin of this area in places penetrated into the lower border of the mandible. There were several small calcified areas within the radiolucent mass. The mandibular right lateral and first premolar appeared to penetrate the area.
Fig. l.-Cystic
adamantinoma. Note the finger-like projection extending illto the bone at the border of the mandible.
Differential Diagnosis.-Radicular cyst, recurrent dentigerous cyst, and cystic adamantinoma had to be considered. There was sufficient bone structure between the radiolucent area and the apex of the deciduous cuspid to rule out radicular cyst, the other teeth being vital. Recurrent dentigerous cyst occurs very infrequently. Because of the fingerlike projection extending from the lower border of the radiolucent area into the 157
158
Max H. Jacobs
bone structure and because the mass was nodular to palpation, the diagnosis of cystic adamantinoma was made. Operatiolz.--Under gas oxygen-ether anesthesia, a vertical incision was made from the gingival margin of the mandibular left central incisor to the mucolahial fold. The interdental papillae as far as the lower right first molar were in&cd and the mucoperiostcum was reflected. In places a bluish gray wit,h the periosteum. The rest of the membrane was found to bc in contact bnccal boric was parchment-like and thin in character. No teeth were extracted.
Fig.
Z.-Low-power
microscopic within which
Fig.
3.-High-power
section through can be seen many
microscol)ic
the cystic star cells
section
through
membrane showing and ameloblasts.
the
epithelial
epithelial
bud
bud.
The cyst was enuclcatcd and several nodules were found to have penetrated into the lower border of the mandible. The walls of the bony cavity were cauterized with phenol and washed with alcohol. The cavity was packed with iodoform exit of the gauze. The mucoperiosteum was laid back and sutured, permitting
Cgstic Adanmntin~oma gauze through the lower part of the incision in the mucolabial fold. When the cyst was collapsed, the membrane was found to be filled with tiny palpable nodules. Microscopic Exnmination.-Microscopic examination reveals sections of a cyst. Lining the cyst in most areas is a flattened layer of a stratified squamous type of epithelium without any rete pegs. Surrounding this stratified squamous layer is a moderately thick band of collagenous and elastic fibrous tissue, which in turn contains within it several spicules of bone. These have the usual lamellat,ed structure and contain the tiny spaces with central nuclei representing the Raversian system. From the cyst lining there extend several buds made up of epithelial cells, some consistin g of masses of these epithelial cells in no typical arrangement but containing wit,hin this mass many star cells and ameloblasts which are readily recognized. Other buds are surrounded by a stratified mass of spinous cells and in the center contain large cells, stellate in shape with centrally placed vesicular nuclei and a pink-staining cytoplasm representing the so-called star cells. Many areas of cystic changes within these buds are also present. Tiny little focal areas of polymorphonuclear leucocytic infiltration are also present throughout the mass. In several areas the cystic degeneration shows cells which are flattened and squamous and in the center consist of large vacuolated cells with pyknotic nuclei (Figs. 2 and 3). Diagnosis.-Cystic Adamantinoma. (81. J. S., Pathologist.) Com~~aent.-The point of interest in this case is the type of cyst that was removed eighteen years previously. Since cystic adamantinomas may arise from epithelial inclusions sometimes found in the dental follicle of an unerupted or impacted t.ooth, it is possible that the original cyst was an adamantinoma. Recurrence may take place any number of years later, if it was not entirely eradicated. 311
COMMONWEALTH
AVENUE.