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Giant ameloblastoma
Clinical Imaging 36 (2012) 146 – 148
Giant ameloblastoma Narindra Rajaonarison Ny Ony a,⁎, Anja Randriamarolahy b , Onimalala Mercia Elise Randrianjanahary b , Ahmad Ahmad b , Jean Noël Bruneton a a
Service d'Imagerie Médicale, Centre Hospitalier Princesse Grace Monaco, 1 Avenue Pasteur, 98012 Monaco Cedex b Service d'Imagerie Médicale CHU-JRA, Antananarivo, Madagascar Received 28 October 2011; accepted 13 December 2011
Abstract Ameloblastoma is the most frequent of the odontogenic tumors. We report a case of a giant ameloblastoma involving the maxillary region and describe its ultrasonography and computed tomography findings. © 2012 Elsevier Inc. All rights reserved. Keywords: Ameloblastoma; Odontogenic neoplasm; CT; US
1. Introduction
2.3
Ameloblastoma is an epithelial neoplasm arising from the enamel elements of the tooth [1]; it is rarely voluminous and malignant [2,3]. 2. Case report The patient was a young woman, aged 23 years, presenting with a voluminous mass in the right maxillary sinus–nasal region; the lesion has been present and growing from the age of 8 years, following the extraction of a right superior incisive tooth. After a long period of stability, the mass has been growing rapidly in the past 5 months associated with pain, nasal, and oral bleeding. The patient is known to have been chewing tobacco for many years. Ultrasonography (US) of the lesion showed the mass to be heterogeneous with multiple cystic formations and calcific deposits; Doppler studies (Fig. 1) showed vascular formations. Unenhanced computed tomography (CT; Figs. 2 and 3) confirmed the presence of the heterogeneous mass located in ⁎ Corresponding author. E-mail address: [email protected] (N. Rajaonarison Ny Ony). 0899-7071/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.clinimag.2011.06.009
-2.3
Fig. 1. Doppler US showing the heterogeneous tissue (arrow) and the intratumoral vascularization (arrowhead).
N. Rajaonarison Ny Ony et al. / Clinical Imaging 36 (2012) 146–148
147
Radiographs of the chest and an US of the abdomen showed no abnormalities. A biopsy of the mass was performed in the right sinonasal region, and the histological findings were of an ameloblastoma. The patient refused any intervention and never returned for a follow-up. 3. Discussion
Fig. 2. CT without enhancement (axial plane) demonstrating the neoplasm invading the right maxillary sinus (arrow).
the right frontal–nasal–maxillary region, of a length slightly more than 13 cm along its major axis, invading the right maxillary sinus, the ethmoid, and the floor of the orbit. There was no invasion of the right cerebral frontal area.
Fig. 3. CT without enhancement, coronal reconstruction, demonstrating the neoplasm passing over the median line, invading the floor of the right orbit (arrow) and the right maxillary sinus (arrowhead).
Ameloblastoma is the more frequent epithelial odontogenic neoplasm, accounting for 35% of all these neoplasms [4]; it involves mainly young women [1], but Mancuso and Hanafee [2] report a greater frequency in males, in particular black, with the more affected ages being between 20 and 30 years. The lesion involves more frequently the ascending ramus of the mandible [4–6], rather than the maxilla, with localization occurring in our case. The lesion in the maxilla usually originates in the premolar–first molar region. Usually, it appears as a well-defined, unilocular expansile osteolytic lesion. However, at times, the mass is multilocular, assuming a soap-bubble appearance [2,4]. The tumor is slow growing; not infrequently, it takes several years to present clinical findings. Rarely does the lesion become malignant (1%), but recurrence is common (33%) and the unilocular form recurs significantly less frequently (15%). Giant ameloblastoma is at times associated with several complications: local regional extension, superimposed infectious process, severe hemorrhage [5,7]. Following removal of the mass, preceded by embolization [5,8], the possible development of a local recurrence cannot be excluded [8–10]. The complex multicystic pattern demonstrated by US in our patient is considered frequent by Lu et al. [6], who in 2009 proposed a sonographic classification based on the cystic components of the neoplasm. Giant ameloblastoma is, in the majority of the cases, highly hypervascular [5], related with an active tumoral proliferation. The sensibility and specificity of the Doppler studies in the prediction of its active proliferation are, respectively, 100% and 94% [6]. The intratumoral calcific deposits, if present, may be produced by osseous or dental debris. Poor hygienic care of the mouth, tobacco chewing, or malnutrition is among the factors favoring the formation of this neoplasm. Standard radiographs and, in particular, CT allow for the characterization of the process, but in particular for the demonstration of its local and regional extension [5]. A supradiaphragmatic or under-the-diaphragm search, and a skeletal examination may be performed looking for a metastatic process, which would signify a possible sarcomatous degeneration. The treatment consists in the complete resection of the tumoral mass with inclusion of significant bony margins, and
148
N. Rajaonarison Ny Ony et al. / Clinical Imaging 36 (2012) 146–148
if the lesion calls for wide resection, a reconstruction of the area may be necessary. The diagnosis is made histologically on the specimen obtained by biopsy or on the removed tumoral mass [7,11].
[4] [5]
4. Conclusion
[6]
Benign histologically, the ameloblastoma is morbid by local aggression and can threaten the patient's life. US and CT can suggest the diagnosis but are especially useful in the staging process.
[7] [8]
References [9] [1] Singer SR, Mupparapu M, Philipone E. Cone beam computed tomography findings in a case of plexiform ameloblastoma. Quintessence Int 2009;40:627–30. [2] Mancuso AA, Hanafee WN. Head and neck radiology, 1. Philadelphia, PA: Lippincott Williams Wilkins; 2011. p. 548–52. [3] Devenney-Cakir B, Subramanian R, Sundarajan D, Mehra P, Spiegel J, Sakai O. Ameloblastic carcinoma of the mandible with metastasis to the skull and lung: advanced imaging and positron emission
[10]
[11]
tomography computed tomography. Dentomaxillofac Radiol 2010;39: 449–53. Harnsberger HR, Glastonbury CM. Diagnostic imaging-head and neck. 2nd ed. Philadelphia, PA: Amyrsis; 2011. p. 1–15, 30–3. Dunn JL, Olan WJ, Bank WO, Narang AK, Schwartz AM. Giant ameloblastoma: radiologic diagnosis and treatment. Radiographics 1997;17:531–6. Lu L, Yang J, Liu JB, Yu Q, Xu Q. Ultrasonographic evaluation of mandibular ameloblastoma: a preliminary observation. Oral Surg, Oral Med, Oral Pathol, Oral Radiol Endod 2009;108:32–8. Fatterpekar GM, Som PM, Naidich TP. The teaching files-head and neck. Philadelphia, PA: Saunders/Elsevier; 2011. p. 296–7. Artés Martinez AM, Prieto Rodriguez M, Navarro Hervás M, PeňasPardo L, CamaňasSanz A, Vaquero de la Hermosa MC, Vera Sempere FJ. Diagnósticocitológico de lasrecidivastumorales de ameloblastoma: presentación de dos casosclinicos. Med Oral Patol Cir Bucal 2005;10:205–9. Gomez CC, Duarte AP, Diniz MG, Gomez RS. Review article: current concepts of ameloblastoma pathogenesis. J Oral Pathol Med 2010;39: 585–91. Chaine A, Pitak-Arnnop P, Dhanuthai K, Rubin-Poncet B, Bertrand JC, Bertolus C. A treatment algorithm for managing giant mandibular ameloblastoma: 5-year experiences in a Paris university hospital. Eur J Surg 2009;35:999–1005. Bachman AM, Linfesty RL. Ameloblastoma solid/multicystic type. Head Neck Pathol 2009;3:307–9.
Giant ameloblastoma Narindra Rajaonarison Ny Ony a,⁎, Anja Randriamarolahy b , Onimalala Mercia Elise Randrianjanahary b , Ahmad Ahmad b , Jean Noël Bruneton a a
Service d'Imagerie Médicale, Centre Hospitalier Princesse Grace Monaco, 1 Avenue Pasteur, 98012 Monaco Cedex b Service d'Imagerie Médicale CHU-JRA, Antananarivo, Madagascar Received 28 October 2011; accepted 13 December 2011
Abstract Ameloblastoma is the most frequent of the odontogenic tumors. We report a case of a giant ameloblastoma involving the maxillary region and describe its ultrasonography and computed tomography findings. © 2012 Elsevier Inc. All rights reserved. Keywords: Ameloblastoma; Odontogenic neoplasm; CT; US
1. Introduction
2.3
Ameloblastoma is an epithelial neoplasm arising from the enamel elements of the tooth [1]; it is rarely voluminous and malignant [2,3]. 2. Case report The patient was a young woman, aged 23 years, presenting with a voluminous mass in the right maxillary sinus–nasal region; the lesion has been present and growing from the age of 8 years, following the extraction of a right superior incisive tooth. After a long period of stability, the mass has been growing rapidly in the past 5 months associated with pain, nasal, and oral bleeding. The patient is known to have been chewing tobacco for many years. Ultrasonography (US) of the lesion showed the mass to be heterogeneous with multiple cystic formations and calcific deposits; Doppler studies (Fig. 1) showed vascular formations. Unenhanced computed tomography (CT; Figs. 2 and 3) confirmed the presence of the heterogeneous mass located in ⁎ Corresponding author. E-mail address: [email protected] (N. Rajaonarison Ny Ony). 0899-7071/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.clinimag.2011.06.009
-2.3
Fig. 1. Doppler US showing the heterogeneous tissue (arrow) and the intratumoral vascularization (arrowhead).
N. Rajaonarison Ny Ony et al. / Clinical Imaging 36 (2012) 146–148
147
Radiographs of the chest and an US of the abdomen showed no abnormalities. A biopsy of the mass was performed in the right sinonasal region, and the histological findings were of an ameloblastoma. The patient refused any intervention and never returned for a follow-up. 3. Discussion
Fig. 2. CT without enhancement (axial plane) demonstrating the neoplasm invading the right maxillary sinus (arrow).
the right frontal–nasal–maxillary region, of a length slightly more than 13 cm along its major axis, invading the right maxillary sinus, the ethmoid, and the floor of the orbit. There was no invasion of the right cerebral frontal area.
Fig. 3. CT without enhancement, coronal reconstruction, demonstrating the neoplasm passing over the median line, invading the floor of the right orbit (arrow) and the right maxillary sinus (arrowhead).
Ameloblastoma is the more frequent epithelial odontogenic neoplasm, accounting for 35% of all these neoplasms [4]; it involves mainly young women [1], but Mancuso and Hanafee [2] report a greater frequency in males, in particular black, with the more affected ages being between 20 and 30 years. The lesion involves more frequently the ascending ramus of the mandible [4–6], rather than the maxilla, with localization occurring in our case. The lesion in the maxilla usually originates in the premolar–first molar region. Usually, it appears as a well-defined, unilocular expansile osteolytic lesion. However, at times, the mass is multilocular, assuming a soap-bubble appearance [2,4]. The tumor is slow growing; not infrequently, it takes several years to present clinical findings. Rarely does the lesion become malignant (1%), but recurrence is common (33%) and the unilocular form recurs significantly less frequently (15%). Giant ameloblastoma is at times associated with several complications: local regional extension, superimposed infectious process, severe hemorrhage [5,7]. Following removal of the mass, preceded by embolization [5,8], the possible development of a local recurrence cannot be excluded [8–10]. The complex multicystic pattern demonstrated by US in our patient is considered frequent by Lu et al. [6], who in 2009 proposed a sonographic classification based on the cystic components of the neoplasm. Giant ameloblastoma is, in the majority of the cases, highly hypervascular [5], related with an active tumoral proliferation. The sensibility and specificity of the Doppler studies in the prediction of its active proliferation are, respectively, 100% and 94% [6]. The intratumoral calcific deposits, if present, may be produced by osseous or dental debris. Poor hygienic care of the mouth, tobacco chewing, or malnutrition is among the factors favoring the formation of this neoplasm. Standard radiographs and, in particular, CT allow for the characterization of the process, but in particular for the demonstration of its local and regional extension [5]. A supradiaphragmatic or under-the-diaphragm search, and a skeletal examination may be performed looking for a metastatic process, which would signify a possible sarcomatous degeneration. The treatment consists in the complete resection of the tumoral mass with inclusion of significant bony margins, and
148
N. Rajaonarison Ny Ony et al. / Clinical Imaging 36 (2012) 146–148
if the lesion calls for wide resection, a reconstruction of the area may be necessary. The diagnosis is made histologically on the specimen obtained by biopsy or on the removed tumoral mass [7,11].
[4] [5]
4. Conclusion
[6]
Benign histologically, the ameloblastoma is morbid by local aggression and can threaten the patient's life. US and CT can suggest the diagnosis but are especially useful in the staging process.
[7] [8]
References [9] [1] Singer SR, Mupparapu M, Philipone E. Cone beam computed tomography findings in a case of plexiform ameloblastoma. Quintessence Int 2009;40:627–30. [2] Mancuso AA, Hanafee WN. Head and neck radiology, 1. Philadelphia, PA: Lippincott Williams Wilkins; 2011. p. 548–52. [3] Devenney-Cakir B, Subramanian R, Sundarajan D, Mehra P, Spiegel J, Sakai O. Ameloblastic carcinoma of the mandible with metastasis to the skull and lung: advanced imaging and positron emission
[10]
[11]
tomography computed tomography. Dentomaxillofac Radiol 2010;39: 449–53. Harnsberger HR, Glastonbury CM. Diagnostic imaging-head and neck. 2nd ed. Philadelphia, PA: Amyrsis; 2011. p. 1–15, 30–3. Dunn JL, Olan WJ, Bank WO, Narang AK, Schwartz AM. Giant ameloblastoma: radiologic diagnosis and treatment. Radiographics 1997;17:531–6. Lu L, Yang J, Liu JB, Yu Q, Xu Q. Ultrasonographic evaluation of mandibular ameloblastoma: a preliminary observation. Oral Surg, Oral Med, Oral Pathol, Oral Radiol Endod 2009;108:32–8. Fatterpekar GM, Som PM, Naidich TP. The teaching files-head and neck. Philadelphia, PA: Saunders/Elsevier; 2011. p. 296–7. Artés Martinez AM, Prieto Rodriguez M, Navarro Hervás M, PeňasPardo L, CamaňasSanz A, Vaquero de la Hermosa MC, Vera Sempere FJ. Diagnósticocitológico de lasrecidivastumorales de ameloblastoma: presentación de dos casosclinicos. Med Oral Patol Cir Bucal 2005;10:205–9. Gomez CC, Duarte AP, Diniz MG, Gomez RS. Review article: current concepts of ameloblastoma pathogenesis. J Oral Pathol Med 2010;39: 585–91. Chaine A, Pitak-Arnnop P, Dhanuthai K, Rubin-Poncet B, Bertrand JC, Bertolus C. A treatment algorithm for managing giant mandibular ameloblastoma: 5-year experiences in a Paris university hospital. Eur J Surg 2009;35:999–1005. Bachman AM, Linfesty RL. Ameloblastoma solid/multicystic type. Head Neck Pathol 2009;3:307–9.