Oral fibromyxosarcoma of the maxilla

Operative

Oral

ORAL FIBROMYXOSARCOMA Report J.

SUNDER THEODORE

E.

Surgery OF THE MAXILLA

of a Case D.D.S., F.I.A.A.,” AND D.D.S., M.S.,“’ CHICAGO,

VAZIRANI,

BOLDEN,

ILL.

T

HE fibrosarcoma is a malignant tumor of mesenchymal origin which, according to Anderson,l may arise in the skin, in scars, in the periosteal coverings of bone, or within the medullary cavity. Oral fibrosarcomas are relatively rare and have been classified as either odontogenic or nonodontogenic3 Grossly, the tumor is single, solid, and well encapsulated. Growth may be slow or rapid, but it is persistent and usually proceeds along lines of least resistance. Microscopically, it is composed of spindle-shaped fibroblasts and collagenous and reticulum fibers. Many are well differentiated and have delicately interlacing patterns of fibrils and mature cells that show few, if any, mitoses. In the rapidly growing sarcoma, mitotic figures may be numerous and abnormal forms may be included.2 From a prognostic point, of view, this is an important distinction to make.

Clinical

Features

Although oral fibrosarcoma is most common in t,he second and third decades, it may occur at any age. The presence of a mass in the maxilla, which may be slowly or rapidly growing, usually produces oral or rhinologic symptoms. The oral symptoms are mobility of the teeth, swelling of the alveolar process, ulcerations of the gingival mucosa, and a neuralgic type of facial pain. The rhinologic features include unilateral nasal obstruction, mucopurulent or serosanguineous discharge, headaches, and ocular disturbances causing exophthalmos or lateral displacement of the eye. Diagnostic procedures should include a careful history, complete oral examination, rhinoscopy and endoscopy of paranasal cavities, transillumination, and Hospitals.

From

the

Division

*Chief Resident **Instructor in

of in Oral Pathology,

Oral

Surgery,

Surgery. Division

University of

Oral

227

Pathology.

of

Illinois

Research

and

Educational

VAZIRANI

228

AND

0. S.. 0. M.. & 0. P.

BOLDEN

March,

1958

roentgen examinat,ion. The roent,gcnologic studies are essential in determining the extent of tumor inva.sion and possible encroachment on t,he bones of the skull. The final diagnosis must be confirmed by microscopic examination. Prognosis should be based upon the cellular act,ivit,y of the neoplasm and the extent of tumor invasion. Wide surgical excision wit,h combined electrosurgery and irradiation constitutes the basic method of treatment.. Radiation therapy, including radium, external irradiation, and radon seed implantation, is recommended for inoperable cases. The major defect can be closed by plastic surgery and an appropriate prosthesis. The present report concerns a case of oral fibrosarcoma which was diagnosed by repeated biopsies and treated successfully by surgical enucleation.

Case Report Chief Complaint.-‘l’. service in the

of Research mouth.

and

K., R Il-year-old white man, was Educational Hospitals for diagnosis

referred and

to the treatment

oral of

surgery a mass

History of Present Illness.-In June, 1956, the patient noted a gradual swelling of right cheek. He thought that it was a tooth abscess and consulted a dentist. Using local anesthesia, the dentist extracted the maxillary right first and second molars. The tooth sockets did not heal after the extractions. The wound was treated for dry socket for two weeks with irrigation and some kind of packs. Meanwhile, the tumor had grown downward from the postextraction sockets, causing a bulge of considerable size in the palate. The patient, was seen in consultation with an oral surgeon. The mass was diagnosed clinically as a malignant neoplasm, and the patient was referred to the hospital for early diagnosis and treatment. the

Past apparent

History-Medical history included diphtheria at the age of fl years and an allergy to penicillin. A review of systems was essentially negative. There W&S no history of previous dental or sinus complaints. There was no record of a maxillary third molar extraction. The family history was noncontributory. face. raised, 1).

Clinical Findings.-Extaroral examination showed asymmetry of the right side of the The skin appeared to be of normal color. Palpation revealed a well-circumscribed. soft, nontender, noninflammatory mass in the substance of the right cheek (Fig. There was no lpmphadenopathy in the neck.

Intraoral examination revealed an obvious bulging of the labial and palatal mucosa in the maxillary right molar region. An ulcerated, reddish, polypoid growth involved the entire alveolus from the second premolar to the tuberosity. It extended laterally to the mueosal reflection of the vestibule and medially to the midline of the hard palate. It measured 3 cm. in length and 2 em. in width and was raised approximately 2 cm. The mass, which was soft, nontender, nonhemorrhagic, and firm, protruded from the postextraetion sockets (Fig. 2). Transillumination demonstrated density of the right maxillary sinus; the left sinus was clear. Examination of the nose and nasopharynx revealed no evidence of tumor invasion. General physical examination showed a well-developed, well-nourished man who did not appear to be in acute distress. The cardiac, respiratory, gastrointestinal, genitourinary, and neuromuscular systems were within normal limits. Complete blood analysis showed hemoglobin, 19.8 grams; white blood count, 13,000; segmentals, 80 per cent; and lymphocytes, 33 per cent. Urinalysis revealed a specific gravity Kahn and Wassermann tests were of 1.020; protein, 2 plus; and a few epithelial cells. negative. Serum studies were within normal range.

Volume Number

II

ORAL

3

FIBROMYXOSARCOMA

OF

229

MAXILLA

Roentgenographic examination of the paranasal sinuses revealed a diffuse clouding of the right antrum with destruction of the inferolateral antral wall (Fig. 3). In addition, there was a polypoidlike thickening of the membrane in the floor of the antrum. The remaining paranasal sinuses showed no evidence of membrane thickening or clouding. The occlusal projection showed an eroded oval osteolytic defect of the right palate (Fig. 4). Films of the skull and chest revealed no evidence of metastasis. The radiographic interpretation was carcinoma of the right maxillary antrum with secondary erosion of the floor and lateral wall of the antrum.

Fig.

l.-Clinical Note August, 1956. Fig. 2.-Intraoral sockets.

Clinical the antrum 9

appearance

of soft tissue swelling view showing

Impression.-Carcinoma, and soft tissue of the

Biopsy.-On Aug. small wedge-shaped

Fig.

1.

Fig.

2.

the

patient when first seen of the right cheek. the fungating mass extending

probably cheek.

adenocarcinoma,

21, 1956, under local anesthesia, section of tissue was removed

at

of

oral

surgery

from

the

the

palate

clinic right

in molar

involving

an intraoral biopsy was performed. for microscopic examination. The

230

Fig,

VAZIRANI

B.-l

Fig.

iad

‘mph

4.-Occlusal

of

view

paranasal destruction

of

the

sinuses of

palate

AND

demonstrating lateral wall

revealing

0. S.. O.T&,;

BOLDEN

of

cloudhwss antrum.

extensive

erosion

of

of

the

rigk

right

ant]

palate.

0. I’. 1956

MAXILLA

231

biopsy report indicated granulation tissue, secondarily infected. suspicion of malignancy, the lesion was rebiopsirtl to include the diagnosed as ( i fihromyxosarroma. ’’

Because of the clinical This was deeper tissues.

Volume Number

II

1

ORAL

FIBROMPXOSARCOMA

OF

Treatment and Course.-The patient was admitted to the hospital on Aug. 36, 1956, He was prepared for surgery following confor wide surgical excision of the right maxilla. sultation with the departments of otolaryngology and medicine. The tumor was removed surgically through a Weber-Ferguson incision after ligation of the external carotid artery. Details of Operation.-The patient was prepared and draped. Endotracheal general The right anesthesia was produced with Pentothal sodium, nitrous oxide, and oxygen. external carotid artery was tied off. An incision measuring approximately 4 cm. was made at the level of the hyoid bone. After blunt and sharp dissection, the internal jugular vein and common carotid artery were identified. At the bifurcation of the internal and external carotid artery, several enlarged lymph nodes were found and removed. Frozen section of these showed the lymph nodes affected by secondary chronic inflammation. The right external carotid artery was identitled and ligated with 0 black silk ligature. The artery was not cut. The wound was closed in layers, and the incision was closed with a running suture of 000 black silk. A pressure dressing was applied. The facial area was then exposed and an initial incision was made from 1 cm. below the inner canthus of the right eye, running downward in the groove between the nasal and the maxillary bones to the right ala of the nose. The incision was then carried to the midline below the ala of the nose and through the lip in the midline of the philtrum. Arterial and venous bleeding was controlled with hemostats, and bleeders were tied with 000 plain ligature. The mucous membrane and a right gingival buccal fold were cut to the tuberosity with scissors. The flap thus created was elevated to the right side of the face. Since the tumor was growing forward and extended into. the muscular structure of the right side of the cheek, these muscles were removed from the flap. Another incision was made which extended from the apex of the first incision at the inner canthus of the right eye to the outer canthus of the right eye along the infraorbital plate. The flap thus formed gave adequate exposure of the anterior surface of the sinus. The right nasal bone was then separated from the right maxillary bone by means of a mallet and gouge. The columella was separated from the maxillary crest and the palate was split along the midline. The soft palate was then separated from the hard palate by means of scissors. The infraorbital plate was separated from the maxillary sinus by use of a gouge and chisel in the infraorbital region. The right xygomatic arch was then removed from its insertion into the maxilla by means of a gouge. The entire right maxilla was brought forward and loosened from the soft tissue of the pterygoid fossa. Loose strands of connective tissue were cut with scissors. Much bleeding was encountered during this procedure. This was adequately controlled. The infraorbital plate was examined and did not appear to be involved with tumor. Electrocautery was used to cauterize the tissues and to stop bleeding. This accomplished, the incision was sutured internally with 000 chromic catgut and externally with 00000 nylon, and the cavity was filled with petrolatum gauze. During tho procedure the patient received 1,000 C.C. of whole blood and 1,000 cc. of dextrose, 5 per cent in water, intravenously. After pressure dressings were applied the patient was returned to the recovery room in good condition. Postoperative Course.-The patient experienced the expected amount of pain, discomfort, and swelling. The liquid diet was fed through a Mead-Johnson tube. Dressings were changed on the fourth and seventh postoperative days. The remaining sutures were removed on the eighth day. Sloughing was seen a.round the canthus and lip region, possibly due to tight suturing. The wound finally healed with slight puckering in those areas. The patient was discharged from the hospital on Sept. 17, 1956. Pathologic Findings.-The specimen was submitted in the fresh state and consisted of a portion of maxilla with four teeth, the gingival margin, and the buccal mucosa and bony structures about the antrum (Fig. 5). The specimen weighed 80 Gm. There was a

0. S.. 0. M.. & 0. P. Much. 195X

232

large fungating mass which came from Ihe molar tooth sockets. The overlying it was rrililisll lwowl in color. This mass meaaurccl was ulcerated and necrotic; length, L’ cm. in width, and was clevatcd al~prosinmtely 1 cm. above the gingival The mass in the antrum was lxrgc, Tt measured apprOximitt,t~ly in appearance. width. The tumor appeared to be eroding antrum. On rut section, the tumor prov(s(l and had some septa.

Fig.

S.-Surgical

specimen

of

the

right

covering 2.3 czar. ill margin.

polypoid, frial)lr, gelatinous, sticky, anrl si1vcr.v 5 cm. in length, 3 cm. in height, and 2.5 cm. in the bone in the palatal and lateral walls of the to l)c of lathrr firm, v*hitc, fibrous myxoid tissue

maxilla showing molar sockets.

fungating

mass

protruding

frolrl

from the antrum showed it to be composelI Microscopic examination of a section In several areas these elements were mdrkedlj predominantly of mesenchymal elements cellular and were arranged in strands and rosettes. The nuclei were oval and showed pleamorphism and occasional hyperchromatism. Few collagen fibers were present, and them was little intercellular substance (Fig. 6). In other areas collagen fibers were seen in the foreground, and the number of cells was reduced. There was some edema. Very loosely arranged fibers, with entrapped plcomorphic cells, plasma cells, and a few polymorphonuclrar neutrophils were observed in still other areas (Fig. 7). The section was lined with respiratory epithelium. Another section of the tumor consisted of a solid sheet of markedly cellular mrsrnchymal elements. Pleomorphism and hyperchromatism were noted (Fig. 6). A small number of collagtmous fibers permeated the entire mass. An incrrasetl number of mitotic figures were

Volume Ii Number j

ORAL

FIBROMYXOSARCOMA

noted. Numerous capillaries were small round nucleus and cells with noted in the area of the round nuclei. Diagnosis : Fibrosarcoma gingivae and antrum.

with

OF

Two types seen. a spindle-shaped myxomatous

of cells nucleus.

change

in

were noted: The increased

the

right

FOLLOW-up.-Follow-up with clinical and x-ray examination tively revealed no evidence of recurrence of the disease. The replaced with a dental prosthesis at a later date.

Fig. 6.-Photomicrograph arranged in strands. The little intercellular substance. Fig. 7.-Photomicrograph

oval

of tumor. Note the predominance nuclei show pleomorphism and showing

very

loosely

arranged

233

MAXILLA

fibers

maxilla

cells with a mitoses were involving

the

six months postoperamaxillary defect will be

of mesenchymsl hyperchromatism. with

entrapped

elements There is cells.

VAZIKANI

AND

BOLDEN

0.

S.. 0.

M.. Mmh.

& 0. I’. 1958

Summary A case has hwn prcseutcd which illust,rat,es the clinical firiclinffs aud uianagc~ment of oral fibrosarcoma. It is pointed out that oral and rhinologic. consultat,ion is essential to establishment of an early diagnosis. Because of surfaw necrosis and secondary infection, repeat biopsies may be necessary to SCCUIY~ representative tissue.

References Pathology, 1. Anderson, TV. A. D.: 2. Bernier, J. L.: The Management Company, p. 776. Oral Pathology, 3. Thonla, K. H.: 840

s.

WOOD

ST.

cd. 3, St. Louis, 1953, The C. V. Mosby Company, p. 1827. of Oral Diseases, ed. 1, St. Louis, 1955, The C. V. ~Moshx ed. 4., St. Louis,

1954,

The

C. V. Mosby

Company,

p. 1212.