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Osteogenic sarcoma of the mandible
Osteogenic sarcoma of the mandible William William
M. Cocke, Jr., M.D., Nashville, Tenn., and M. Wade, Jr., D.M.D., Biloxi, Miss.
0
steogenic sarcoma of the mandible is not common. Often the initial signs are loose teeth, the presence of a jaw mass, numbness of the lower lip, and pain in the jaw. The lesion occurs more frequently in males than in females. It may occur at any age, but the average age is 33 years. Differential diagnosis should include chondrosarcoma, fibrosarcoma, fibrous dysplasia, ossifying fibroma, and giant-cell granuloma .e Jaw sarcomas have been treated with diathermy, radiotherapy, chemotherapy, conservative resection, radical resection, or a combination of these.2-5* 7 Radical resection is believed to give the best chance of cure and is the treatment of ch0ice.l Following ablation, the question of primary reconstruction should be considered on an individual basis. The decision will depend on the condition of the patient, the size and behavior of the tumor, and the tissue available for the safe replacement of tissue. The iliac crest is favored as the bone donor site.l Metastases, if present, usually spread by the bloodstream, but in 7 per cent of the reported cases there was metastatic disease in the suprahyoid lymph nodes. Recurrent or metastatic disease usually occurs in the first posttreatment year, and the survival rates range from 5 to 50 per cent.5f 7*g In the first case to be presented here the lesion is classified as osteogenic sarcoma because of the presence of osteoid. Even though the predominant cell is the chondroblast, it is classified as a chondroblastic osteogenic sarcoma. In the second case the predominant cell is the osteoblast, and this tumor is classified as an osteoblastic osteogenic sarcoma. Had the fibroblast been the predominant cell, with the presence of osteoid, the diagnosis would have been fibroblastic osteogenic sarcoma. CASE
1
J. M. V., a 36-year-old Caucasian man, was in excellent health prior to the present illness (Fig. 1). In August, 1966, he noted continuing pain in the region of the left mandibular third molar. In November, 1966, he was treated by a dentist for periodontal disease. In December, 1966, the third molar was extracted, and a biopsy revealed the presence of a sarcoma. The patient was referred for treatment. Shortly after admission to the hospital, he noted the onset of numbness in the left lower chin. The paat history, review of systems,and family history were normal. Physical examination showed a 3.5 cm. ulcerative lesion, which 601
602
Co&e and Wade
Oral November,
Burg. 1970
was tender and friable, in the left lower retromolar area (Fig. 2). The swelling extended to the buccal mucosa and to the anterior tonsillar pillar. The neck was negative for masses. The rest of the examination was normal. A laboratory workup disclosed nothing abnormal. Roentgenograms showed the tumor of the left mandible (Fig. 3). On Dec. 22, 1966, an operation entailing a left mandibulectomy, partial palatectomy, tonsillectomy, pharyngectomy, glossectomy, suprahyoid dissection, and tracheostomy was performed. The masseter, lower facial musculature, and a wide margin of the intraoral mucous membrane were resected with the tumor. A feeding tube was placed. The tumor had broken through the outer plate of the mandible (Fig. 4) and had invaded the mandibular canal (Figs. 4 and 5). The patient had an excellent postoperative course and was discharged on the twelfth postoperative day. Intermaxillary fixation was maintained for 6 weeks. When there was no evidence of recurrence at the end of one year, an iliac crest bone graft wae performed to replace the resected jaw. Three mont.hs later a dermal fat graft was inserted into the infrazygomatic area to replace the resected soft tissue. The patient has experienced no
Table
I. Reported
cases of osteogenic sarcoma of the mandible
Author
Year
Kragh Comez et al.3 al.5 Weinfeld and Dudleyl Rowe and Hungerfords Nahum6 Beasley et al.7 McKenna et al.8 Cornyn ( AFIP) 2
1960 1958 1962 1963 1964 1965 1966 1967
Present Hughes4
1969 1967
report
Cases classified as osteogenic sarcoma 19 49 4 2: 1 7 38 B 142
Fig.
1. Preoperative
photograph.
Cases subolassified as chonaroblastic osteogenic sarcoma i i 0 0 i : 15
Osteogenic sarcoma of mandible
Volume 30 Number 5
Fig. 2. Intraoral
Pig. S. Panographic
photograph
roentgenogram
showing appearance of jaw sarcoma.
showing mass in left retromolar
Big. 4. Gross specimen with soft tissue removed from tumor.
area.
603
Oral November,
Co&e and Wade
604
Fig.
5. Sagittal
section
of mandible
showing
invasion
(mandibular
Surg. 1976
canal).
Fig.
Pig. 6. Postoperative view 2 years after dermal fat graft reconstruction of face. Fig. 7. Preoperative photograph. difficulty with mastication or occlusion. operatively and has returned to full-time The final diagnosis was chondroblastic CASE
resection
and following
He remains free of duty (Fig. 6). osteogenic sarcoma.
iliac
disease
crest
nearly
bone
graft
3 years
and
post-
2
J. E. N., a 36-year-old and inflammation around
the
Caucasian man, was referred lower left molar area (Fig.
with a 4-month history 7). Three months prior
of irritation to admission
Vohlme Number
Osteogenic sarcoma of mandible
30 5
Fig.
8. Intraoral
Fig.
photograph
9. Operative
showing
photograph
after
appearance
removal
of jaw
605
sarcoma.
of specimen.
the tooth was extracted, but the area did not heal and the patient continued to experience inflammation and irritation. Six weeks prior to admission curettage and biopsy of the area demonstrated what was believed to be an ossifying fibroma. Four weeks following this diagnosis, a partial paresthesia over the distribution of the left inferior alveolar nerve developed. Repeat roentgenograms of the area revealed that the defect of the lingual plate of the mandible had increased in size. Re-examination of the biopsy material by the Armed Forces Institute of Pathology resulted in a diagnosis of osteogenic sarcoma. The past history, family history, and review of systems were normal. Physical examination demonstrated expansion of the cortical plate on the lingual side of the left molar area (Fig. 8). This was approximately 2.5 cm. in diameter. Two teeth were missing in the posterior molar area, and numbness was noted over the distribution of the left mental nerve. Oral hygiene was excellent. A chest x-ray and laboratory findings were normal.
606
Cocke and Wade
Fig.
10.
One year following
Oral
Burg.
November, 1970
resection and iliac crest bone graft.
On Jan. 23, 1968, a subtotal left mandibulectomy and a suprahyoid dissection were performed. A small portion of the condyle was left intact and the mandibular symphysis was left, with the mandibular section being made well anterior to the mental foramen. The resection of this tumor was wide and adequate, and the soft tissues in the area were readily amenable to primary reconstruction (Fig. 9). An iliac crest bone graft was wired into plaEe. The patient developed a fistula which resulted in resorption of 75 per cent of the bone graft. The occlusion remained good, however, and the final deformity was minimal. The patient returned to full-time duty and remains free of disease 1% years postoperatively (Fig. 10). The final diagnosis in this case was osteogenic osteosarcoma of the left mandible. REFERENCES
1. Weinfeld, Marvin, and Dudley, H. Robert: Osteogenic Sarcoma With a Follow-up Study of the 94 Cases Observed at MGH From 1920-1960, J. Bone Joint Burg. (Amer.) 44A: 269, 1962. 2. Cornyn, John: Personal communication. 3. Gomez, Alphonse C., Youmans, Robert D., and Chambers, Robert G.: Osteogenic Sarcoma of the Mandible, Amer. J. Surg. 190: 613, 1960. 4. Hughes, Charles L.: Osteogenic Sarcoma of the Mandible, J. Oral Burg. 26: 164, 1967. 5. Kragh, Lyle V., Dahlin, David C., and Erich, John B.: Osteogenic Sarcoma of the Jaws and Facial Bones, Amer. J. Surg. 96: 496, 1958. 6. Nahum, Alan M.: Osteo enic Sarcoma of the Mandible, Arch. Otolaryng. 80: 566, 1964. 7. Beasley, William R., ZI% ren, Sidney E., and Hale, Merle L.: Osteogenic Sarcoma fnvalving the Mandible: Report of a Case, J. Oral Surg. 23: 254, 1965. 8. McKenna, Robert J., Schwinu, Charles P., Sooog, K. Y., and Higinbotham, Norman L.: Sarcomata of the Osteogenm Series (Osteosarcoma, Fibrosarcoma, Chondrosarcoma, Paroeteal Osteogenic Sarcoma and Sarcomata Arising m Abnormal Bone), J. Bone Joint Surg. (Amer.) 48A: 1, 1966. 9. Rowe, Nathaniel H., and Hungerford, Richard W.: Osteosarcoma of the Mandible, J. Oral Burg. 21: 42, 1963. 191s
Hayes
St.
Nadwillc, Term.
( W.M.C.)
M. Cocke, Jr., M.D., Nashville, Tenn., and M. Wade, Jr., D.M.D., Biloxi, Miss.
0
steogenic sarcoma of the mandible is not common. Often the initial signs are loose teeth, the presence of a jaw mass, numbness of the lower lip, and pain in the jaw. The lesion occurs more frequently in males than in females. It may occur at any age, but the average age is 33 years. Differential diagnosis should include chondrosarcoma, fibrosarcoma, fibrous dysplasia, ossifying fibroma, and giant-cell granuloma .e Jaw sarcomas have been treated with diathermy, radiotherapy, chemotherapy, conservative resection, radical resection, or a combination of these.2-5* 7 Radical resection is believed to give the best chance of cure and is the treatment of ch0ice.l Following ablation, the question of primary reconstruction should be considered on an individual basis. The decision will depend on the condition of the patient, the size and behavior of the tumor, and the tissue available for the safe replacement of tissue. The iliac crest is favored as the bone donor site.l Metastases, if present, usually spread by the bloodstream, but in 7 per cent of the reported cases there was metastatic disease in the suprahyoid lymph nodes. Recurrent or metastatic disease usually occurs in the first posttreatment year, and the survival rates range from 5 to 50 per cent.5f 7*g In the first case to be presented here the lesion is classified as osteogenic sarcoma because of the presence of osteoid. Even though the predominant cell is the chondroblast, it is classified as a chondroblastic osteogenic sarcoma. In the second case the predominant cell is the osteoblast, and this tumor is classified as an osteoblastic osteogenic sarcoma. Had the fibroblast been the predominant cell, with the presence of osteoid, the diagnosis would have been fibroblastic osteogenic sarcoma. CASE
1
J. M. V., a 36-year-old Caucasian man, was in excellent health prior to the present illness (Fig. 1). In August, 1966, he noted continuing pain in the region of the left mandibular third molar. In November, 1966, he was treated by a dentist for periodontal disease. In December, 1966, the third molar was extracted, and a biopsy revealed the presence of a sarcoma. The patient was referred for treatment. Shortly after admission to the hospital, he noted the onset of numbness in the left lower chin. The paat history, review of systems,and family history were normal. Physical examination showed a 3.5 cm. ulcerative lesion, which 601
602
Co&e and Wade
Oral November,
Burg. 1970
was tender and friable, in the left lower retromolar area (Fig. 2). The swelling extended to the buccal mucosa and to the anterior tonsillar pillar. The neck was negative for masses. The rest of the examination was normal. A laboratory workup disclosed nothing abnormal. Roentgenograms showed the tumor of the left mandible (Fig. 3). On Dec. 22, 1966, an operation entailing a left mandibulectomy, partial palatectomy, tonsillectomy, pharyngectomy, glossectomy, suprahyoid dissection, and tracheostomy was performed. The masseter, lower facial musculature, and a wide margin of the intraoral mucous membrane were resected with the tumor. A feeding tube was placed. The tumor had broken through the outer plate of the mandible (Fig. 4) and had invaded the mandibular canal (Figs. 4 and 5). The patient had an excellent postoperative course and was discharged on the twelfth postoperative day. Intermaxillary fixation was maintained for 6 weeks. When there was no evidence of recurrence at the end of one year, an iliac crest bone graft wae performed to replace the resected jaw. Three mont.hs later a dermal fat graft was inserted into the infrazygomatic area to replace the resected soft tissue. The patient has experienced no
Table
I. Reported
cases of osteogenic sarcoma of the mandible
Author
Year
Kragh Comez et al.3 al.5 Weinfeld and Dudleyl Rowe and Hungerfords Nahum6 Beasley et al.7 McKenna et al.8 Cornyn ( AFIP) 2
1960 1958 1962 1963 1964 1965 1966 1967
Present Hughes4
1969 1967
report
Cases classified as osteogenic sarcoma 19 49 4 2: 1 7 38 B 142
Fig.
1. Preoperative
photograph.
Cases subolassified as chonaroblastic osteogenic sarcoma i i 0 0 i : 15
Osteogenic sarcoma of mandible
Volume 30 Number 5
Fig. 2. Intraoral
Pig. S. Panographic
photograph
roentgenogram
showing appearance of jaw sarcoma.
showing mass in left retromolar
Big. 4. Gross specimen with soft tissue removed from tumor.
area.
603
Oral November,
Co&e and Wade
604
Fig.
5. Sagittal
section
of mandible
showing
invasion
(mandibular
Surg. 1976
canal).
Fig.
Pig. 6. Postoperative view 2 years after dermal fat graft reconstruction of face. Fig. 7. Preoperative photograph. difficulty with mastication or occlusion. operatively and has returned to full-time The final diagnosis was chondroblastic CASE
resection
and following
He remains free of duty (Fig. 6). osteogenic sarcoma.
iliac
disease
crest
nearly
bone
graft
3 years
and
post-
2
J. E. N., a 36-year-old and inflammation around
the
Caucasian man, was referred lower left molar area (Fig.
with a 4-month history 7). Three months prior
of irritation to admission
Vohlme Number
Osteogenic sarcoma of mandible
30 5
Fig.
8. Intraoral
Fig.
photograph
9. Operative
showing
photograph
after
appearance
removal
of jaw
605
sarcoma.
of specimen.
the tooth was extracted, but the area did not heal and the patient continued to experience inflammation and irritation. Six weeks prior to admission curettage and biopsy of the area demonstrated what was believed to be an ossifying fibroma. Four weeks following this diagnosis, a partial paresthesia over the distribution of the left inferior alveolar nerve developed. Repeat roentgenograms of the area revealed that the defect of the lingual plate of the mandible had increased in size. Re-examination of the biopsy material by the Armed Forces Institute of Pathology resulted in a diagnosis of osteogenic sarcoma. The past history, family history, and review of systems were normal. Physical examination demonstrated expansion of the cortical plate on the lingual side of the left molar area (Fig. 8). This was approximately 2.5 cm. in diameter. Two teeth were missing in the posterior molar area, and numbness was noted over the distribution of the left mental nerve. Oral hygiene was excellent. A chest x-ray and laboratory findings were normal.
606
Cocke and Wade
Fig.
10.
One year following
Oral
Burg.
November, 1970
resection and iliac crest bone graft.
On Jan. 23, 1968, a subtotal left mandibulectomy and a suprahyoid dissection were performed. A small portion of the condyle was left intact and the mandibular symphysis was left, with the mandibular section being made well anterior to the mental foramen. The resection of this tumor was wide and adequate, and the soft tissues in the area were readily amenable to primary reconstruction (Fig. 9). An iliac crest bone graft was wired into plaEe. The patient developed a fistula which resulted in resorption of 75 per cent of the bone graft. The occlusion remained good, however, and the final deformity was minimal. The patient returned to full-time duty and remains free of disease 1% years postoperatively (Fig. 10). The final diagnosis in this case was osteogenic osteosarcoma of the left mandible. REFERENCES
1. Weinfeld, Marvin, and Dudley, H. Robert: Osteogenic Sarcoma With a Follow-up Study of the 94 Cases Observed at MGH From 1920-1960, J. Bone Joint Burg. (Amer.) 44A: 269, 1962. 2. Cornyn, John: Personal communication. 3. Gomez, Alphonse C., Youmans, Robert D., and Chambers, Robert G.: Osteogenic Sarcoma of the Mandible, Amer. J. Surg. 190: 613, 1960. 4. Hughes, Charles L.: Osteogenic Sarcoma of the Mandible, J. Oral Burg. 26: 164, 1967. 5. Kragh, Lyle V., Dahlin, David C., and Erich, John B.: Osteogenic Sarcoma of the Jaws and Facial Bones, Amer. J. Surg. 96: 496, 1958. 6. Nahum, Alan M.: Osteo enic Sarcoma of the Mandible, Arch. Otolaryng. 80: 566, 1964. 7. Beasley, William R., ZI% ren, Sidney E., and Hale, Merle L.: Osteogenic Sarcoma fnvalving the Mandible: Report of a Case, J. Oral Surg. 23: 254, 1965. 8. McKenna, Robert J., Schwinu, Charles P., Sooog, K. Y., and Higinbotham, Norman L.: Sarcomata of the Osteogenm Series (Osteosarcoma, Fibrosarcoma, Chondrosarcoma, Paroeteal Osteogenic Sarcoma and Sarcomata Arising m Abnormal Bone), J. Bone Joint Surg. (Amer.) 48A: 1, 1966. 9. Rowe, Nathaniel H., and Hungerford, Richard W.: Osteosarcoma of the Mandible, J. Oral Burg. 21: 42, 1963. 191s
Hayes
St.
Nadwillc, Term.
( W.M.C.)