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Osteogenic sarcoma of maxilla
Osteogenicsarcomaof maxilla Report
of Q case
Robey C. McDonald, Chicago, Ill. DENTAL
SERVICE,
D.D.X.,”
VETERANS
and Walter H. Fredricks,
ADMINISTRATION
WEST
SIDE
D.D.S.,“”
HOSPITAL
T
he osteogenic sarcoma exhibits considerable variation, both clinic&ly and histologically, because it is composed of cells and tissues in different stages of bone development. It is for this reason that we find a wide range of types. The Registry of Bone Sarcoma of the American College of Surgeons recognizes a classification based upon the location and the predominant histologic pattern. Shafer and associates1 believe this to be a cumbersome classification. Lichtenstein has outlined the criteria for the diagnosis of osteogenic sarcoma. He emphasizes that those tumors which show production of osteoid tissue by malignant cells fall into the osteogenic sarcoma group, although tumor cartilage may be a prominent feature of some of them. He further shows the need for the removal of chondrosarcoma from the osteogenic group. Coventry and Dahlin,3 in their study of bone tumors encountered at the Mayo Clinic, further classified the osteogenic sarcoma histologically as either osteoblastic, ehondroblastic, or fibroblastic. They also found it to be the most common malignant primary tumor of bone, exclusive of multiple myeloma. The prognosis of osteogenic sarcoma of the jaws may not be as poor as one might expect. Kragh and Dahlin4 state that the prognosis for osteogenic sarcoma of the jaws is, in fact, surprisingly good in spite of the frequent delay in proper therapy. They conclude that a tendency to late systemic spread and a relatively low average degree of malignancy are among the factors that contribute to successful therapy. Nevertheless, it has been sub’stantiated that the treatment of choice requires radical surgical removal of the neoplasm, with the excision getting well into normal tissue. *Clinical Dentist, Veterans Professor of Prosthetics, Loyola **Clinical Dentist, Veterans
736
Administration West Side Hospital; University, Dental School. Administration West Side Hospital.
Clinical
Associate
Osteogenic sarcoma of maxilla
Pig.
1. So-called
%un-ray”
appearance
of typical
sclerosing
osteosarcoma
737
on periapical
film.
Fig. 8. A, Model of surgical defect from right first B, Model also shows dimples prepared in remaining molars.
premolar
to left
second premolar.
CASE REPORT On Sept. 4, 1966, a 32-year-old man sought relief from a sensation of “tightness” of the maxilla and was admitted to the hospital. Three months prior to admission, the patient had first noticed a small swelling posterior to the upper central incisors. It was not painful but became progressively larger, causing “tightness.” The medical history was essentially negative, and physical findings were within normal limits. Radiographic
findings
Radiographs revealed a typical but moderate sun-ray appearance of bone superimposed over the central incisors (Fig. 1). This is radiographic evidence of excessive formation of bone radiating to the periphery. (Kragh and Dahlin* state that a radiating “sunburst” was uncommon but that in many instances negative findings were due to treatment prior to examination.)
730
McDonald
and Predricks
Fig. 3’. Postoperative
laboratory
profile
023, O.M. & O.P. November, 1968
view showing loss of tissue.
findings
A routine diagnostic work-up was essentially negative and did not reveal any evidence of metastatic growth. The tissue submitted for biopsy was diagnosed as osteochondroma. The decision for wide surgical resection was made. Surgical
procedure
Bilateral Weber-Fergusson incisions were made, and partial resection of the maxilla (to include right first premolar and the left second premolar) (Fig. 2$), with bilateral antrostomy, partial resection of the nasal septum, and partial resection of a central portion of the upper lip and columella of the nose, was performed. The postoperative course was uneventful (Fig. 3). Pathology
report
Microscopic examination of sections from the maxilla revealed a bone-forming growth extending into the soft tissue. This was diagnosed as osteogenic sarcoma of the maxilla, osteoblastic type. The pattern of the neoplastic tissues varied from area to area. In some places the stroma was very cellular and anaplastio with multinucleated cells; other areas showed cells differentiating toward poorly calcified cartilage and osteoid, while still other areas showed atypical bone formations represented by thick and coarse but poorly calcified trabeculae in sarcomatous stroma (Fig. 4 and 5). Thus, the two criteria for a diagnosis of osteosarcomaz-(1) malignant proliferating cells and (2) ,osteoid production by at least some of the malignant cells-were met. Prorthotic
appliance
Approximately 3 weeks following the surgical procedure consideration was given to the type of prosthetic replacement that would be most desirable for the patient. A survey of the models disclosed that of the five remaining teeth in the maxilla only the right second premolar could be clasped efficiently. The other teeth were extremely short and conical and had no available undercuts. In ,order to make these teeth more desirable for
Volume Number
Osteogenic sarcoma of maxilla
26 5
739
Fig.
Fig. 5
st1
showing anaplastic and multi .nucle Bated cellular E‘ig. 4. 0 steogenic sarcoma of maxilla morn a. calcified cartilage and bon e. b ‘ig. 5. ost .eogenic sarcoma showing irregularly
Fig. 6. Chrome-cobalt
skeletons fabricated
in acrylic
denture base.
Fig.
Fig.
Fig. 7. Profile showing minimal Fig. 8. Rehabilitated patient.
surgical
deformity
aftvr
inwrt ion of applianc~l~.
clasping, “dimplelike” retention points were gronnd into the enamel surfaces of the first and second molars (Fig. 23). A chrome-cobalt skeleton was cast with bar clasps terminating in the prepared buccal and lingual dimple undercuts. Teeth were then set up to give support to a normal curvature of the upper lip. The appliance was fabricated in an acrylic denture base (Fig. 6). The obturator was inserted, and the patient was discharged with satisfactory functional and esthetic results (Fig. i).
DISCUSSION In designing this obturator, the main objectives were to construct an appliance that would be light in weight and would seal off the nasal cavity from the oral cavity. It had to permit the patient to masticate and take in fluids without nasal regurgitation. In addition, the appliance should restore facial esthetics, improve phonetics, and give upper lip support.5 Several months after insertion of the obturator, it became evident that gradual elongation of the lip had taken place. This elongation improved esthetics greatly, making replacement of the columella unnecessary (Fig. 8). SUMMARY In the foregoing case, wide surgical resection was performed. The pathology report revealed osteogenic sarcoma of the maxilla with a wide periphery of normal tissue. The surgical defect was made less noticeable by the insertion of a chrome-cobalt acrylic-base obturator. Postinsertion elongation of the upper lip made it unnecessary to replace the columella. In such cases, more alertness on the part of dentists and physicians would favor earlier correct diagnosis and treatment of osteogenic sarcoma of the jaw.
8
Volume Number
26 5
Osteogenic sarcoma of maxilla
We gratefully acknowledge the assistance of Dr. Massumeh Tel&hi, Pathology, and Mr. Charles Marshall, Department of Medical Illustration, istration West Side Hospital.
741
Department of Veterans Admin-
REFERENCES
Philadelphia, 1958, 1. Shafer, W. G., Hine, M. K., and Levy, B. M.: Oral Pathology, W. B. Saunders Company. 2. Lichtenstein, L.: Bone Tumors, ed. 3, St. Louis, 1965, The C. V. Mosby Company. 3. Coventry, M. B., and Dahlin, D. C.: Osteogenic Sarcoma, J. Bone & Joint Surg. 39-A: 741-757. 1957. 4. Kragh,‘L. V., and Dahlin, D. C.: Osteogenic Sarcoma of the Jaws and Facial Bones, Am. J. Surg. 96: 496-505, 1958. 5. Ackerman, A. J.: The Prosthetic Management of Oral and Facial Defects Following Cancer Surgery, J. Pros. Dent. 5: 413-432, 1956.
of Q case
Robey C. McDonald, Chicago, Ill. DENTAL
SERVICE,
D.D.X.,”
VETERANS
and Walter H. Fredricks,
ADMINISTRATION
WEST
SIDE
D.D.S.,“”
HOSPITAL
T
he osteogenic sarcoma exhibits considerable variation, both clinic&ly and histologically, because it is composed of cells and tissues in different stages of bone development. It is for this reason that we find a wide range of types. The Registry of Bone Sarcoma of the American College of Surgeons recognizes a classification based upon the location and the predominant histologic pattern. Shafer and associates1 believe this to be a cumbersome classification. Lichtenstein has outlined the criteria for the diagnosis of osteogenic sarcoma. He emphasizes that those tumors which show production of osteoid tissue by malignant cells fall into the osteogenic sarcoma group, although tumor cartilage may be a prominent feature of some of them. He further shows the need for the removal of chondrosarcoma from the osteogenic group. Coventry and Dahlin,3 in their study of bone tumors encountered at the Mayo Clinic, further classified the osteogenic sarcoma histologically as either osteoblastic, ehondroblastic, or fibroblastic. They also found it to be the most common malignant primary tumor of bone, exclusive of multiple myeloma. The prognosis of osteogenic sarcoma of the jaws may not be as poor as one might expect. Kragh and Dahlin4 state that the prognosis for osteogenic sarcoma of the jaws is, in fact, surprisingly good in spite of the frequent delay in proper therapy. They conclude that a tendency to late systemic spread and a relatively low average degree of malignancy are among the factors that contribute to successful therapy. Nevertheless, it has been sub’stantiated that the treatment of choice requires radical surgical removal of the neoplasm, with the excision getting well into normal tissue. *Clinical Dentist, Veterans Professor of Prosthetics, Loyola **Clinical Dentist, Veterans
736
Administration West Side Hospital; University, Dental School. Administration West Side Hospital.
Clinical
Associate
Osteogenic sarcoma of maxilla
Pig.
1. So-called
%un-ray”
appearance
of typical
sclerosing
osteosarcoma
737
on periapical
film.
Fig. 8. A, Model of surgical defect from right first B, Model also shows dimples prepared in remaining molars.
premolar
to left
second premolar.
CASE REPORT On Sept. 4, 1966, a 32-year-old man sought relief from a sensation of “tightness” of the maxilla and was admitted to the hospital. Three months prior to admission, the patient had first noticed a small swelling posterior to the upper central incisors. It was not painful but became progressively larger, causing “tightness.” The medical history was essentially negative, and physical findings were within normal limits. Radiographic
findings
Radiographs revealed a typical but moderate sun-ray appearance of bone superimposed over the central incisors (Fig. 1). This is radiographic evidence of excessive formation of bone radiating to the periphery. (Kragh and Dahlin* state that a radiating “sunburst” was uncommon but that in many instances negative findings were due to treatment prior to examination.)
730
McDonald
and Predricks
Fig. 3’. Postoperative
laboratory
profile
023, O.M. & O.P. November, 1968
view showing loss of tissue.
findings
A routine diagnostic work-up was essentially negative and did not reveal any evidence of metastatic growth. The tissue submitted for biopsy was diagnosed as osteochondroma. The decision for wide surgical resection was made. Surgical
procedure
Bilateral Weber-Fergusson incisions were made, and partial resection of the maxilla (to include right first premolar and the left second premolar) (Fig. 2$), with bilateral antrostomy, partial resection of the nasal septum, and partial resection of a central portion of the upper lip and columella of the nose, was performed. The postoperative course was uneventful (Fig. 3). Pathology
report
Microscopic examination of sections from the maxilla revealed a bone-forming growth extending into the soft tissue. This was diagnosed as osteogenic sarcoma of the maxilla, osteoblastic type. The pattern of the neoplastic tissues varied from area to area. In some places the stroma was very cellular and anaplastio with multinucleated cells; other areas showed cells differentiating toward poorly calcified cartilage and osteoid, while still other areas showed atypical bone formations represented by thick and coarse but poorly calcified trabeculae in sarcomatous stroma (Fig. 4 and 5). Thus, the two criteria for a diagnosis of osteosarcomaz-(1) malignant proliferating cells and (2) ,osteoid production by at least some of the malignant cells-were met. Prorthotic
appliance
Approximately 3 weeks following the surgical procedure consideration was given to the type of prosthetic replacement that would be most desirable for the patient. A survey of the models disclosed that of the five remaining teeth in the maxilla only the right second premolar could be clasped efficiently. The other teeth were extremely short and conical and had no available undercuts. In ,order to make these teeth more desirable for
Volume Number
Osteogenic sarcoma of maxilla
26 5
739
Fig.
Fig. 5
st1
showing anaplastic and multi .nucle Bated cellular E‘ig. 4. 0 steogenic sarcoma of maxilla morn a. calcified cartilage and bon e. b ‘ig. 5. ost .eogenic sarcoma showing irregularly
Fig. 6. Chrome-cobalt
skeletons fabricated
in acrylic
denture base.
Fig.
Fig.
Fig. 7. Profile showing minimal Fig. 8. Rehabilitated patient.
surgical
deformity
aftvr
inwrt ion of applianc~l~.
clasping, “dimplelike” retention points were gronnd into the enamel surfaces of the first and second molars (Fig. 23). A chrome-cobalt skeleton was cast with bar clasps terminating in the prepared buccal and lingual dimple undercuts. Teeth were then set up to give support to a normal curvature of the upper lip. The appliance was fabricated in an acrylic denture base (Fig. 6). The obturator was inserted, and the patient was discharged with satisfactory functional and esthetic results (Fig. i).
DISCUSSION In designing this obturator, the main objectives were to construct an appliance that would be light in weight and would seal off the nasal cavity from the oral cavity. It had to permit the patient to masticate and take in fluids without nasal regurgitation. In addition, the appliance should restore facial esthetics, improve phonetics, and give upper lip support.5 Several months after insertion of the obturator, it became evident that gradual elongation of the lip had taken place. This elongation improved esthetics greatly, making replacement of the columella unnecessary (Fig. 8). SUMMARY In the foregoing case, wide surgical resection was performed. The pathology report revealed osteogenic sarcoma of the maxilla with a wide periphery of normal tissue. The surgical defect was made less noticeable by the insertion of a chrome-cobalt acrylic-base obturator. Postinsertion elongation of the upper lip made it unnecessary to replace the columella. In such cases, more alertness on the part of dentists and physicians would favor earlier correct diagnosis and treatment of osteogenic sarcoma of the jaw.
8
Volume Number
26 5
Osteogenic sarcoma of maxilla
We gratefully acknowledge the assistance of Dr. Massumeh Tel&hi, Pathology, and Mr. Charles Marshall, Department of Medical Illustration, istration West Side Hospital.
741
Department of Veterans Admin-
REFERENCES
Philadelphia, 1958, 1. Shafer, W. G., Hine, M. K., and Levy, B. M.: Oral Pathology, W. B. Saunders Company. 2. Lichtenstein, L.: Bone Tumors, ed. 3, St. Louis, 1965, The C. V. Mosby Company. 3. Coventry, M. B., and Dahlin, D. C.: Osteogenic Sarcoma, J. Bone & Joint Surg. 39-A: 741-757. 1957. 4. Kragh,‘L. V., and Dahlin, D. C.: Osteogenic Sarcoma of the Jaws and Facial Bones, Am. J. Surg. 96: 496-505, 1958. 5. Ackerman, A. J.: The Prosthetic Management of Oral and Facial Defects Following Cancer Surgery, J. Pros. Dent. 5: 413-432, 1956.