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Keratoameloblastoma: A Case Report
Poster Session
POSTER 33 Autofluorescence Visualization Detection for Oral Epithelial Dysplasia N. Yamamoto: Tsurumi University, School of Dental Medicine, K. Kawaguchi, H. Fujihara, M. Yasukawa, Y. Kishi, M. Hasebe, K. Kumagai, Y. Hamada To detect oral epithelial dysplasia, iodine staining method is generally used. However, iodine staining has weak points of mucosal irritation and no adaptation in the keratinized mucosa. Recently, autofluorescence visualization (AV) method has been noticed instead of conventional iodine staining (IS) method. To carry out the method, an autofluorescence visualization device, which emits a cone of light in the blue spectrum between 400460 nm wavelength into the oral mucosa, is used. Normal epithelium emits a green autofluorescence, but oral epithelial dysplasia reveals dark due to fluorescence visualization loss (FVL). AV method detects oral epithelial dysplasia, according to the relative luminance difference. The purpose of this study is to evaluate the clinical usefulness of AV method with VELscopeÒ to detect oral epithelial dysplasia. The subjects were 31 oral mucosal lesions in the 19 patients (12 men and 7 women, mean age 64.1 y/o) referred to the department of Oral and Maxillofacial Surgery, Tsurumi University Dental Hospital, between February and September in 2014. All subjective lesions were evaluated by AV method, iodine staining method and biopsy. The digital photo documents of VELscopeÒ were analyzed to quantize the relative luminance difference between the blackest point of FVL and the average of three whitest points from the surrounding areas by using Image JÒ software. The cut-off value of the relative luminance difference was calculated area under receiver operating characteristic curve. Oneway analysis of variance and Mann-Whitney U test were used for statistical analysis, and probability value less than 0.05 was considered as statistical significance. Subsequently, the cut-off value of the relative luminance difference has been set to 43.9 for determination of a possibility of oral epithelial dysplasia. The accuracy of AV method was assessed and compared to that of IS method. Histopathological diagnosis was set as the gold standard of this study. Histopathologically, the 13 lesions were diagnosed as squamous cell carcinoma (SCC), 11 lesions as leukoplakia with dysplasia (LD), 5 lesions as leukoplakia without dysplasia (LND), and 2 lesions as lichen planus (LP). The mean relative luminance differences of SCC, LD, LND and LP were 87.0, 64.1, 11.7 and 61.4, respectively. In the examination with AV method, epithelial dysplasia was detected in the 23 of 31 lesions, and remaining 8 lesions had no dysplasia. The accuracy of AV method was 90.3%, sensitivity was 91.7%, and specificity was 85.7%. Meanwhile, 24 lesions had dysplasia and 7 lesions had no dysplasia when IS method. Consequently, the accuracy of iodine staining method was 74.2%, sensitivity was 83.3%, and specificity was 42.9%. Moreover, the AAOMS 2015
grade of epithelial dysplasia is approximately proportional to the level of relative luminance differences. Based on the mentioned results, the accuracy of AV method was higher than that of IS method, and it is suggested that AV method is more appropriate to detect oral epithelial dysplasia. Although the sensitivity of AV method was almost as same as that of IS method, its specificity was much higher than that of IS method. Therefore, AV method was suggested to have a low risk for overdiagnosis, comparing to IS method, and it has possibility to expect the grade of dysplasia by the relative luminance difference. In conclusion, AV method seems to be useful modality for detecting oral epithelial dysplasia instead of conventional IS method. References: 1. Farah CS. Head Neck. 2012;34(6):856-62. 2. Awan KH. Oral Oncol. 2011;47(4):274-7.
POSTER 34 Keratoameloblastoma: A Case Report A. P. Fagin: Oregon Health & Science University, D. Petrisor, J. C. Stewart Introduction: Keratoameloblastoma is an extremely rare odontogenic tumor characterized loosely by keratinization formation in an ameloblastomatous epithelium. Since then there have been sixteen cases described in the English literature. However, debate remains whether this is a unique lesion or an extreme variant of acanthomatous ameloblastoma, a well-described variant defined by squamous metaplasia in the stellate reticulum with or without keratinization.1 Here we present a case of a keratoameloblastoma that we feel supports that this represents a unique lesion. Case Report: A 23-year-old white male was referred from his community dentist for diagnosis and management of pain in the right maxilla associated with a large radioluscent lesion on CBCT without appreciable swelling or expansion on physical exam. Incisional biopsy obtained revealed a lesion with features of both keratocystic odontogenic tumor (KOT) and ameloblastoma. MRI and CT obtained for pre-surgical work-up revealed an enhancing, lytic, lobulated soft tissue mass measuring 3.0 x 2.3 x 2.0 cm, associated with unerupted #1’ with evidence of penetration into the lateral wall of the maxilla. The patient underwent right hemimaxillecatomy and reconstruction with radial forearm free flap. On histological section, the resected lesion demonstrated areas of classic KOT morphology with flat connective tissue epithelial interface, parakeratinized corrugated surface, and hyperchromatic palisaded basal cells. These areas immediately abutted columnar cells with reverse nuclear polarization surrounding a loose stellate reticulum, classically associated with ameloblastoma. e-69
Poster Session Discussion: The authors intend to report additional immunohistochemical staining data, including calretenin staining which is known to be specific for ameloblastoma.2 The presence, absence, and pattern of the staining observed in this lesion and its comparison to prior reports in the literature may help to shed some light onto the identity and origins of this rare odontogenic lesion. References: 1. Sisto J, Olsen, G. Histogenetic relations between keratoameloblastoma and solid variant of odontogenic keratocyst. J Oral Maxillofac Surg 70:860-864, 2012. 2. DeVilliers P, Liu H, Suggs C, Simmons D. Calretinin expression in the differential diagnosis of human ameloblastoma and keratocystic odontogenic tumor. Am J Surg Pathol 32:256–260, 2008.
POSTER 35 Unusual Presentation of a Sarcoma of the Mandible R. M. Calvi: Christiana Care Health System, J. Vorrasi, A. Shihabi A 24 year old female presents with complaints of pain and swelling to the right mandible. A panorex radiograph was obtained that demonstrated a radiolucent trabeculated lesion extending from tooth #32 to the condylar neck. Buccal and lingual soft tissue bony expansion was evident on clinical exam. Two biopsies were obtained; the first was inconclusive and the second demonstrated a giant cell reparative granuloma. Upon composite resection of the right mandible and reconstruction with a vascularized free fibula flap, final pathology resulted in a diagnosis a low grade fibrohistiocytic sarcoma. The incidence of a sarcoma of the mandible is extremely rare, with 32 confirmed cases reported in the literature. We present the misdiagnosis from a benign pathological case of a giant cell reparative granuloma to a malignant fibrohistiocytic sarcoma.
POSTER 36 Risk Factors That Prolong Length of Stay After Oral Cancer Surgery L. E. Lunday: Broward Health Medical Center, Nova Southeastern University College of Dental Medicine, A. M. Weyh, S. McClure
spective review of patient charts from July 2007 to January 2014. Lip and oral cavity tumor sites were included, while patients with previous head and neck surgery, adjunctive therapy, or recurrence were excluded to reduce confounders. The outcome variable, LOS, was defined as the time interval between the day of surgery until discharge or death. The study predictor variables included patient age, gender, social history, cancer stage, co-morbidities, and presence of postoperative complications. The Carlson comorbidity index was used to standardize and quantify comorbidities.2 Data was collected as binary data, either present or not present, regardless of magnitude. Patients were classified as either prolonged LOS or standard LOS. Prolonged LOS was defined as greater than or equal to the 75th percentile for each index operation, for consistency with other studies3. Data was analyzed with IBMÒ SPSSÒ statistical package to find the odds ratio and perform Fisher’s exact test to determine significance. P values <0.05 were considered statistically significant. This study consisted of 89 surgically treated patients. The mean age was 63.613.3 years, with 63 males and 26 females. Stratifying for stage, 4 patients had carcinoma in situ, 23 were stage I, 19 were stage II, 14 were stage III, and 29 were stage IV. Preoperative variables statistically significant for increase in risk of prolonged LOS were advanced age of 65+ years (OR=3.6; CI95% 1.4-9.2), and an advanced stage of III-IV (OR=2.5; CI95% 1.0-6.2). Postoperative complications significant for increased risk of prolonged LOS were delirium (OR=8.7; CI95% 1.7-45.0), cardiovascular complication (arrhythmia, myocardial infarction, cerebrovascular accident, deep vein thrombosis, and/or hypoxemia) (OR=5.7; CI95% 1.0-31.4), systemic bacterial infection (pneumonia, septicemia) (OR=5.0; CI95% 1.7-14.5), PEG tube placement (OR=2.7; CI95% 1.0-7.0), and respiratory failure (OR=2.5; CI95% 1.0-6.1). Increase risk was seen with males, alcohol and tobacco users, a co-morbidity index $3, and poor wound healing, however, these results were not statistically significant. A positive association was found between both preand postoperative variables and an increased risk for prolonged LOS in this study population. Although findings were statistically significant for our 89 patients, a multicenter study would be indicated to further assess risk to this patient population and possible solutions to lowering this complication. References:
Postoperative length of stay (LOS) is associated with increased complications, mortality, and delay in adjuvant therapies. It also reflects upon patients’ co-morbidities, postoperative status, and stability of housing.1 The purpose of this study was to determine the independent association of pre/postoperative variables and LOS, through a retrospective cross sectional study. An exempt classification was granted by participating hospitals’ institutional review boards, to perform a retroe-70
1. Lee MK, Nalliah RP, Kim MK, et al. Prevalence and impact of complications on outcomes in patients hospitalized for oral and oropharyngeal cancer treatment. Oral surg Oral Med Oral Pathol Oral Radiol Endod. 2011. 112(5):581-591. 2. Carlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in logitudinal studies:development and validation. J Chronic Dis. 1987. 40(5):373-83. 3. Collins TC, Daley J, Henderson WH, et al. Risk factors for prolonged length of stay after major elective surgery. Ann Surg. 1999.230(2):251-9.
AAOMS 2015
POSTER 33 Autofluorescence Visualization Detection for Oral Epithelial Dysplasia N. Yamamoto: Tsurumi University, School of Dental Medicine, K. Kawaguchi, H. Fujihara, M. Yasukawa, Y. Kishi, M. Hasebe, K. Kumagai, Y. Hamada To detect oral epithelial dysplasia, iodine staining method is generally used. However, iodine staining has weak points of mucosal irritation and no adaptation in the keratinized mucosa. Recently, autofluorescence visualization (AV) method has been noticed instead of conventional iodine staining (IS) method. To carry out the method, an autofluorescence visualization device, which emits a cone of light in the blue spectrum between 400460 nm wavelength into the oral mucosa, is used. Normal epithelium emits a green autofluorescence, but oral epithelial dysplasia reveals dark due to fluorescence visualization loss (FVL). AV method detects oral epithelial dysplasia, according to the relative luminance difference. The purpose of this study is to evaluate the clinical usefulness of AV method with VELscopeÒ to detect oral epithelial dysplasia. The subjects were 31 oral mucosal lesions in the 19 patients (12 men and 7 women, mean age 64.1 y/o) referred to the department of Oral and Maxillofacial Surgery, Tsurumi University Dental Hospital, between February and September in 2014. All subjective lesions were evaluated by AV method, iodine staining method and biopsy. The digital photo documents of VELscopeÒ were analyzed to quantize the relative luminance difference between the blackest point of FVL and the average of three whitest points from the surrounding areas by using Image JÒ software. The cut-off value of the relative luminance difference was calculated area under receiver operating characteristic curve. Oneway analysis of variance and Mann-Whitney U test were used for statistical analysis, and probability value less than 0.05 was considered as statistical significance. Subsequently, the cut-off value of the relative luminance difference has been set to 43.9 for determination of a possibility of oral epithelial dysplasia. The accuracy of AV method was assessed and compared to that of IS method. Histopathological diagnosis was set as the gold standard of this study. Histopathologically, the 13 lesions were diagnosed as squamous cell carcinoma (SCC), 11 lesions as leukoplakia with dysplasia (LD), 5 lesions as leukoplakia without dysplasia (LND), and 2 lesions as lichen planus (LP). The mean relative luminance differences of SCC, LD, LND and LP were 87.0, 64.1, 11.7 and 61.4, respectively. In the examination with AV method, epithelial dysplasia was detected in the 23 of 31 lesions, and remaining 8 lesions had no dysplasia. The accuracy of AV method was 90.3%, sensitivity was 91.7%, and specificity was 85.7%. Meanwhile, 24 lesions had dysplasia and 7 lesions had no dysplasia when IS method. Consequently, the accuracy of iodine staining method was 74.2%, sensitivity was 83.3%, and specificity was 42.9%. Moreover, the AAOMS 2015
grade of epithelial dysplasia is approximately proportional to the level of relative luminance differences. Based on the mentioned results, the accuracy of AV method was higher than that of IS method, and it is suggested that AV method is more appropriate to detect oral epithelial dysplasia. Although the sensitivity of AV method was almost as same as that of IS method, its specificity was much higher than that of IS method. Therefore, AV method was suggested to have a low risk for overdiagnosis, comparing to IS method, and it has possibility to expect the grade of dysplasia by the relative luminance difference. In conclusion, AV method seems to be useful modality for detecting oral epithelial dysplasia instead of conventional IS method. References: 1. Farah CS. Head Neck. 2012;34(6):856-62. 2. Awan KH. Oral Oncol. 2011;47(4):274-7.
POSTER 34 Keratoameloblastoma: A Case Report A. P. Fagin: Oregon Health & Science University, D. Petrisor, J. C. Stewart Introduction: Keratoameloblastoma is an extremely rare odontogenic tumor characterized loosely by keratinization formation in an ameloblastomatous epithelium. Since then there have been sixteen cases described in the English literature. However, debate remains whether this is a unique lesion or an extreme variant of acanthomatous ameloblastoma, a well-described variant defined by squamous metaplasia in the stellate reticulum with or without keratinization.1 Here we present a case of a keratoameloblastoma that we feel supports that this represents a unique lesion. Case Report: A 23-year-old white male was referred from his community dentist for diagnosis and management of pain in the right maxilla associated with a large radioluscent lesion on CBCT without appreciable swelling or expansion on physical exam. Incisional biopsy obtained revealed a lesion with features of both keratocystic odontogenic tumor (KOT) and ameloblastoma. MRI and CT obtained for pre-surgical work-up revealed an enhancing, lytic, lobulated soft tissue mass measuring 3.0 x 2.3 x 2.0 cm, associated with unerupted #1’ with evidence of penetration into the lateral wall of the maxilla. The patient underwent right hemimaxillecatomy and reconstruction with radial forearm free flap. On histological section, the resected lesion demonstrated areas of classic KOT morphology with flat connective tissue epithelial interface, parakeratinized corrugated surface, and hyperchromatic palisaded basal cells. These areas immediately abutted columnar cells with reverse nuclear polarization surrounding a loose stellate reticulum, classically associated with ameloblastoma. e-69
Poster Session Discussion: The authors intend to report additional immunohistochemical staining data, including calretenin staining which is known to be specific for ameloblastoma.2 The presence, absence, and pattern of the staining observed in this lesion and its comparison to prior reports in the literature may help to shed some light onto the identity and origins of this rare odontogenic lesion. References: 1. Sisto J, Olsen, G. Histogenetic relations between keratoameloblastoma and solid variant of odontogenic keratocyst. J Oral Maxillofac Surg 70:860-864, 2012. 2. DeVilliers P, Liu H, Suggs C, Simmons D. Calretinin expression in the differential diagnosis of human ameloblastoma and keratocystic odontogenic tumor. Am J Surg Pathol 32:256–260, 2008.
POSTER 35 Unusual Presentation of a Sarcoma of the Mandible R. M. Calvi: Christiana Care Health System, J. Vorrasi, A. Shihabi A 24 year old female presents with complaints of pain and swelling to the right mandible. A panorex radiograph was obtained that demonstrated a radiolucent trabeculated lesion extending from tooth #32 to the condylar neck. Buccal and lingual soft tissue bony expansion was evident on clinical exam. Two biopsies were obtained; the first was inconclusive and the second demonstrated a giant cell reparative granuloma. Upon composite resection of the right mandible and reconstruction with a vascularized free fibula flap, final pathology resulted in a diagnosis a low grade fibrohistiocytic sarcoma. The incidence of a sarcoma of the mandible is extremely rare, with 32 confirmed cases reported in the literature. We present the misdiagnosis from a benign pathological case of a giant cell reparative granuloma to a malignant fibrohistiocytic sarcoma.
POSTER 36 Risk Factors That Prolong Length of Stay After Oral Cancer Surgery L. E. Lunday: Broward Health Medical Center, Nova Southeastern University College of Dental Medicine, A. M. Weyh, S. McClure
spective review of patient charts from July 2007 to January 2014. Lip and oral cavity tumor sites were included, while patients with previous head and neck surgery, adjunctive therapy, or recurrence were excluded to reduce confounders. The outcome variable, LOS, was defined as the time interval between the day of surgery until discharge or death. The study predictor variables included patient age, gender, social history, cancer stage, co-morbidities, and presence of postoperative complications. The Carlson comorbidity index was used to standardize and quantify comorbidities.2 Data was collected as binary data, either present or not present, regardless of magnitude. Patients were classified as either prolonged LOS or standard LOS. Prolonged LOS was defined as greater than or equal to the 75th percentile for each index operation, for consistency with other studies3. Data was analyzed with IBMÒ SPSSÒ statistical package to find the odds ratio and perform Fisher’s exact test to determine significance. P values <0.05 were considered statistically significant. This study consisted of 89 surgically treated patients. The mean age was 63.613.3 years, with 63 males and 26 females. Stratifying for stage, 4 patients had carcinoma in situ, 23 were stage I, 19 were stage II, 14 were stage III, and 29 were stage IV. Preoperative variables statistically significant for increase in risk of prolonged LOS were advanced age of 65+ years (OR=3.6; CI95% 1.4-9.2), and an advanced stage of III-IV (OR=2.5; CI95% 1.0-6.2). Postoperative complications significant for increased risk of prolonged LOS were delirium (OR=8.7; CI95% 1.7-45.0), cardiovascular complication (arrhythmia, myocardial infarction, cerebrovascular accident, deep vein thrombosis, and/or hypoxemia) (OR=5.7; CI95% 1.0-31.4), systemic bacterial infection (pneumonia, septicemia) (OR=5.0; CI95% 1.7-14.5), PEG tube placement (OR=2.7; CI95% 1.0-7.0), and respiratory failure (OR=2.5; CI95% 1.0-6.1). Increase risk was seen with males, alcohol and tobacco users, a co-morbidity index $3, and poor wound healing, however, these results were not statistically significant. A positive association was found between both preand postoperative variables and an increased risk for prolonged LOS in this study population. Although findings were statistically significant for our 89 patients, a multicenter study would be indicated to further assess risk to this patient population and possible solutions to lowering this complication. References:
Postoperative length of stay (LOS) is associated with increased complications, mortality, and delay in adjuvant therapies. It also reflects upon patients’ co-morbidities, postoperative status, and stability of housing.1 The purpose of this study was to determine the independent association of pre/postoperative variables and LOS, through a retrospective cross sectional study. An exempt classification was granted by participating hospitals’ institutional review boards, to perform a retroe-70
1. Lee MK, Nalliah RP, Kim MK, et al. Prevalence and impact of complications on outcomes in patients hospitalized for oral and oropharyngeal cancer treatment. Oral surg Oral Med Oral Pathol Oral Radiol Endod. 2011. 112(5):581-591. 2. Carlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in logitudinal studies:development and validation. J Chronic Dis. 1987. 40(5):373-83. 3. Collins TC, Daley J, Henderson WH, et al. Risk factors for prolonged length of stay after major elective surgery. Ann Surg. 1999.230(2):251-9.
AAOMS 2015