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Computed tomographic findings in primary mandibular osteosarcoma
clinicalRadiology (1983) 34,153-155
0009-9260/83/00240153502.00
© 1983 Royal College of Radiologists
Computed Tomographic Findings in Primary Mandibular Osteosarcoma D. B. MENDELSOHN, Y. HERTZANU and R. B. J. GLASS
Department olD,agnostic Radiology, Johannesburg, and Hillbrow Hospitals and University of the Witwatersrand, Johannesburg, South Africa 0steosarcoma of the mandible is a rare tumour. Two cases examined by computed tomography (CT) are presented. The osteolytic, osteoblastic and extra-osseous components are excellently shown by CT. The attenuation coefficient of calcified and non-calcified osteoid is extremely variable, with densities ranging from +19 to +320 EMI units. The extension of lesions into the pterygopalatine fossa, infratemporal fossa and cranial cavity are precisely defined on CT, information which is necessary for surgical and radiotherapy planning.
Osteosarcoma is a highly malignant tumour of bone characterised by the production of tumour osteoid and bone from sarcomatous stroma without passing through a cartilaginous phase. The skeletal incidence is approximately one case per 100 000 of the general population in the United States (Garrington et al., 1967). More than half arise in the long bones of the limbs, particularly about the knee and in the bones of the pelvis. Only 6.5% of all osteosarcomas arise in the jaws; the mandible is more commonly involved than the maxilla (Garrington etaL, 1967). We present two cases of primary osteosarcoma of the mandible. CT was used in both patients particularly to assess the extent of turnout invasion into the pterygopalatine and infratemporal fossae, areas poorly demonstrated by conventional radiological methods.
associated soft tissue mass, involving the right ascending mandibular ramus (Fig. 3). CT scans (Fig. 4a, b) showed a large high density mass (+320 EMI units) w~th an associated non-calcified osteoid component (+19 EMI units) invading the posterior wall of the right maxillary antrum as well as the entire infratemporal fossa. The tumour was considered to be inoperable and the patient was referred for palliative radiotherapy.
DISCUSSION Lesions of the jaw usually occur in the third and fourth decades of life, in contrast to osteosarcoma of long bones, which occurs predominantly in the second decade (High et al., 1978). A slightly increased incidence is noted in males. The aetiology of primary osteosarcoma is unknown, but secondary osteosarcoma may occur in
CASE REPORTS Case 1. A 15-year-old black female presented with a large mass, at the left angle of the mandible, which had been increasingin size over the past few months. Clinical examination revealed extension of the tumour into the oral cavity. Radiography showed a malignant mixed osteolytie and osteoblastic lesion involving the angle and ascending ramus (Fig. 1). CT showed a large, irregular, bony mass replacing the mandibular ramus and extending through the posterior wall of the maxillary antrum. The entire infratemporal fossa was involved by turnout; left parapharyngeal encroachment was noted. The high-density component (new bone formation) measured a maximum of +301 EMI units. The minimum reading of turnout component was +20 EMI units (Fig. 2a, b). Biopsy confirmed the diagnosis of an osteosarcoma. The patient was referred for radiotherapy and chemotherapy but died shortly thereafter. Case 2. A 19-year-old black male presented with a painful mandibular mass which had been enlarging over several weeks This was also found to be fungating into the oral cavity. Radiography demonstrated a malignant tumour, with an 11
Fig. 1 Case 1. Lateral oblique mandibular view. Massive dense and irregular new bone formation is shown in the ascending left ramus. Osteolytic destruction of the angle of the mandible is also present.
154
CLINICAL RADIOLOGY
(a)
(b)
Fig. 2 - Case 1. (a) CT scan at the level of the maxillary antra. A large, expanding, left-sided bony mass is demonstrated, replacing the mandibular ramus (+L0040, W0400). (b) Axial scan taken 6 mm cephalad to (a). The entire infratemporal fossa is involved with turnout. Encroachment on the left parapharyngeal space is shown, with destruction of the posterior wallof the left maxillary antrum (L0040, W0400).
certain circumstances, for example, superimposed on fibrous dysplasia or Paget's disease, following irradia. tion or trauma (Curtis et al., 1974). The commonest presenting symptom of man. dibular osteosarcoma is the presence of an enlarging mass; pain and parasthesiae may follow. Loosening of teeth may be the initial complaint, causing the patient to present initially to the dentist (Caron et al., 1971). The most c o m m o n site of mandibular involvement is the body. In 38 cases of mandibular osteosarcoma, 22 arose in the body, six in the angle, five in the symphysis, and three in the ramus (Garrington et al., 1967). The radiological appearance may be osteolytic, osteoblastic or mixed. Only 25% show the classic 'sunburst' appearance (Foltz and Jackson, 1982). The CT findings of osteosarcoma have been described in the long bones and pelvis (De Santos et Fig. 3 - Case 2. Angled postero-anterior radiograph showing destructive changes with periosteal new bone formation and a partially ossified soft-tissue mass involving the right mandibu" lar ramus.
CT F I N D I N G S IN P R I M A R Y M A N D I B U L A R O S T E O S A R C O M A
155
(a) (b) Fig. 4 - Case 2. (a) Axial CT at the level of the maxillary antra reveals a large, expansile, right-sided mass occupying the entire infratemporal fossa and encroaching on the right parapharyngeal space. Unrelated opacffication of the left maxillary antrum is present (+L0027, W0200). (b) CT scan 2 cm above (a) Thinning of the posterior wall of the right maxillary antrum is demonstrated. In addition, bony destruction of the base of the skull has occurred on the right side (+L0027, W0200).
al., 1979). In our review o f the fiterature we were unable to find references relating to the CT appearances of osteosarcoma in the mandible. Differential diagnoses to be considered include chondrosarcoma, Ewing's sarcoma, fibrosarcoma, dental anlage t u m o u r s and chronic osteomyelitis. The t r e a t m e n t o f choice is radical surgical resection. R a d i o t h e r a p y and c h e m o t h e r a p y m a y be used as adjunctive therapy ( G o e p f e r t et aL, 1979). The prognosis o f osteosarcoma o f the j a w is better than that o f long bones. The 5-year survival rate for the mandible is 34.8% and for the maxilla is 25.8% (High et al., 1978). T u m o u r s arising in the symphysis menti have a b e t t e r prognosis than those arising elsewhere in the mandible. Local recurrence and metastases occur f r e q u e n t l y in patients w i t h osteosarcoma. Metastasis occurs usually via the b l o o d s t r e a m , with the lung being the commonest site.
CONCLUSION Primary osteosarcoma o f the m a n d i b l e is a rare tumour. CT is superior to conventional radiological methods in d e m o n s t r a t i n g the nature and e x t e n t o f the tumour. Axial and coronal CT will accurately
demonstrate the size and anatomic relationships o f the t u m o u r for surgical and radiotherapy evaluation. Acknowledgements. We wish to thank Drs T. Gregor and M. Wainer of the Department of Otolaryngology, Hillbrow Hospital, Johannesburg, for their case referrals. REFERENCES Caron, A. S., Hajdu, S. I. & Strong, E. W. (1971). Osteogenic sarcoma of the facial and cranial bones. A review of 43 cases.American Journal o f Surgery, 122, 719 725. Curtis, M. L., Elmore, J. S. & Sotereanos, G. C. (1974). Osteosarcoma of the jaws: report of a case and review of the literature. Journal of Oral Surgery, 32, 125 - 130. De Santos, A. L., Bernardino, M. & Murray, J. (1979). Computed tomography in the evaluation of osteosarcoma. Experience with 25 cases. American Journal o f Roentgenology, 132, 535-540. Foltz, J. & Jackson, D. (1982). Osteogenic sarcoma of the mandible. A 24 year follow-up study. Journal of Oral and Maxillofacial Surgery, 40, 48-51. Garrington, G. E., Scofield, H. H., Cornyn, J. & Hooker, S. P. (1967). Osteosarcoma of the jaws. Analysis of 56 cases. Cancer, 20, 377-391. Goepfert, H., Ballantyne, A. J., Matalon, V. & McCarthy, E. (1979). Osteogenic sarcoma of the mandible: surgical resection and prosthetic rehabilitation. Otolaryngology and Head and Neck Surgery, 87, 417-419. High, C. L., Frew, A. L. & Glass, R. T. (1978). Osteosarcoma of the mandible - report of a case. Oral Surgery, Oral Medicine and Oral Pathology, 45,678-684.
0009-9260/83/00240153502.00
© 1983 Royal College of Radiologists
Computed Tomographic Findings in Primary Mandibular Osteosarcoma D. B. MENDELSOHN, Y. HERTZANU and R. B. J. GLASS
Department olD,agnostic Radiology, Johannesburg, and Hillbrow Hospitals and University of the Witwatersrand, Johannesburg, South Africa 0steosarcoma of the mandible is a rare tumour. Two cases examined by computed tomography (CT) are presented. The osteolytic, osteoblastic and extra-osseous components are excellently shown by CT. The attenuation coefficient of calcified and non-calcified osteoid is extremely variable, with densities ranging from +19 to +320 EMI units. The extension of lesions into the pterygopalatine fossa, infratemporal fossa and cranial cavity are precisely defined on CT, information which is necessary for surgical and radiotherapy planning.
Osteosarcoma is a highly malignant tumour of bone characterised by the production of tumour osteoid and bone from sarcomatous stroma without passing through a cartilaginous phase. The skeletal incidence is approximately one case per 100 000 of the general population in the United States (Garrington et al., 1967). More than half arise in the long bones of the limbs, particularly about the knee and in the bones of the pelvis. Only 6.5% of all osteosarcomas arise in the jaws; the mandible is more commonly involved than the maxilla (Garrington etaL, 1967). We present two cases of primary osteosarcoma of the mandible. CT was used in both patients particularly to assess the extent of turnout invasion into the pterygopalatine and infratemporal fossae, areas poorly demonstrated by conventional radiological methods.
associated soft tissue mass, involving the right ascending mandibular ramus (Fig. 3). CT scans (Fig. 4a, b) showed a large high density mass (+320 EMI units) w~th an associated non-calcified osteoid component (+19 EMI units) invading the posterior wall of the right maxillary antrum as well as the entire infratemporal fossa. The tumour was considered to be inoperable and the patient was referred for palliative radiotherapy.
DISCUSSION Lesions of the jaw usually occur in the third and fourth decades of life, in contrast to osteosarcoma of long bones, which occurs predominantly in the second decade (High et al., 1978). A slightly increased incidence is noted in males. The aetiology of primary osteosarcoma is unknown, but secondary osteosarcoma may occur in
CASE REPORTS Case 1. A 15-year-old black female presented with a large mass, at the left angle of the mandible, which had been increasingin size over the past few months. Clinical examination revealed extension of the tumour into the oral cavity. Radiography showed a malignant mixed osteolytie and osteoblastic lesion involving the angle and ascending ramus (Fig. 1). CT showed a large, irregular, bony mass replacing the mandibular ramus and extending through the posterior wall of the maxillary antrum. The entire infratemporal fossa was involved by turnout; left parapharyngeal encroachment was noted. The high-density component (new bone formation) measured a maximum of +301 EMI units. The minimum reading of turnout component was +20 EMI units (Fig. 2a, b). Biopsy confirmed the diagnosis of an osteosarcoma. The patient was referred for radiotherapy and chemotherapy but died shortly thereafter. Case 2. A 19-year-old black male presented with a painful mandibular mass which had been enlarging over several weeks This was also found to be fungating into the oral cavity. Radiography demonstrated a malignant tumour, with an 11
Fig. 1 Case 1. Lateral oblique mandibular view. Massive dense and irregular new bone formation is shown in the ascending left ramus. Osteolytic destruction of the angle of the mandible is also present.
154
CLINICAL RADIOLOGY
(a)
(b)
Fig. 2 - Case 1. (a) CT scan at the level of the maxillary antra. A large, expanding, left-sided bony mass is demonstrated, replacing the mandibular ramus (+L0040, W0400). (b) Axial scan taken 6 mm cephalad to (a). The entire infratemporal fossa is involved with turnout. Encroachment on the left parapharyngeal space is shown, with destruction of the posterior wallof the left maxillary antrum (L0040, W0400).
certain circumstances, for example, superimposed on fibrous dysplasia or Paget's disease, following irradia. tion or trauma (Curtis et al., 1974). The commonest presenting symptom of man. dibular osteosarcoma is the presence of an enlarging mass; pain and parasthesiae may follow. Loosening of teeth may be the initial complaint, causing the patient to present initially to the dentist (Caron et al., 1971). The most c o m m o n site of mandibular involvement is the body. In 38 cases of mandibular osteosarcoma, 22 arose in the body, six in the angle, five in the symphysis, and three in the ramus (Garrington et al., 1967). The radiological appearance may be osteolytic, osteoblastic or mixed. Only 25% show the classic 'sunburst' appearance (Foltz and Jackson, 1982). The CT findings of osteosarcoma have been described in the long bones and pelvis (De Santos et Fig. 3 - Case 2. Angled postero-anterior radiograph showing destructive changes with periosteal new bone formation and a partially ossified soft-tissue mass involving the right mandibu" lar ramus.
CT F I N D I N G S IN P R I M A R Y M A N D I B U L A R O S T E O S A R C O M A
155
(a) (b) Fig. 4 - Case 2. (a) Axial CT at the level of the maxillary antra reveals a large, expansile, right-sided mass occupying the entire infratemporal fossa and encroaching on the right parapharyngeal space. Unrelated opacffication of the left maxillary antrum is present (+L0027, W0200). (b) CT scan 2 cm above (a) Thinning of the posterior wall of the right maxillary antrum is demonstrated. In addition, bony destruction of the base of the skull has occurred on the right side (+L0027, W0200).
al., 1979). In our review o f the fiterature we were unable to find references relating to the CT appearances of osteosarcoma in the mandible. Differential diagnoses to be considered include chondrosarcoma, Ewing's sarcoma, fibrosarcoma, dental anlage t u m o u r s and chronic osteomyelitis. The t r e a t m e n t o f choice is radical surgical resection. R a d i o t h e r a p y and c h e m o t h e r a p y m a y be used as adjunctive therapy ( G o e p f e r t et aL, 1979). The prognosis o f osteosarcoma o f the j a w is better than that o f long bones. The 5-year survival rate for the mandible is 34.8% and for the maxilla is 25.8% (High et al., 1978). T u m o u r s arising in the symphysis menti have a b e t t e r prognosis than those arising elsewhere in the mandible. Local recurrence and metastases occur f r e q u e n t l y in patients w i t h osteosarcoma. Metastasis occurs usually via the b l o o d s t r e a m , with the lung being the commonest site.
CONCLUSION Primary osteosarcoma o f the m a n d i b l e is a rare tumour. CT is superior to conventional radiological methods in d e m o n s t r a t i n g the nature and e x t e n t o f the tumour. Axial and coronal CT will accurately
demonstrate the size and anatomic relationships o f the t u m o u r for surgical and radiotherapy evaluation. Acknowledgements. We wish to thank Drs T. Gregor and M. Wainer of the Department of Otolaryngology, Hillbrow Hospital, Johannesburg, for their case referrals. REFERENCES Caron, A. S., Hajdu, S. I. & Strong, E. W. (1971). Osteogenic sarcoma of the facial and cranial bones. A review of 43 cases.American Journal o f Surgery, 122, 719 725. Curtis, M. L., Elmore, J. S. & Sotereanos, G. C. (1974). Osteosarcoma of the jaws: report of a case and review of the literature. Journal of Oral Surgery, 32, 125 - 130. De Santos, A. L., Bernardino, M. & Murray, J. (1979). Computed tomography in the evaluation of osteosarcoma. Experience with 25 cases. American Journal o f Roentgenology, 132, 535-540. Foltz, J. & Jackson, D. (1982). Osteogenic sarcoma of the mandible. A 24 year follow-up study. Journal of Oral and Maxillofacial Surgery, 40, 48-51. Garrington, G. E., Scofield, H. H., Cornyn, J. & Hooker, S. P. (1967). Osteosarcoma of the jaws. Analysis of 56 cases. Cancer, 20, 377-391. Goepfert, H., Ballantyne, A. J., Matalon, V. & McCarthy, E. (1979). Osteogenic sarcoma of the mandible: surgical resection and prosthetic rehabilitation. Otolaryngology and Head and Neck Surgery, 87, 417-419. High, C. L., Frew, A. L. & Glass, R. T. (1978). Osteosarcoma of the mandible - report of a case. Oral Surgery, Oral Medicine and Oral Pathology, 45,678-684.