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Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
Tumors of the head and neck
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Tumors of the head and neck

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Oral Pathology II …

Oral Pathology II
Forth Year

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  • 1. Tumors of the head & neck Odotogenic Tumor Originate from : Epithelium mesenchyme Both ODONTOGENIC TUMORS Epithelium Origin Tumor 1) Ameloblastoma :        Local growth in the maxillofacial area . Ability to produce marked deformity . Recurrence after conservative Tx . Locally aggressive behavior . Can start as malignant. Slight metastatic potential Originate within the mandible or maxilla from epithelium that is involved in the formation of the teeth ( enamel organ, reduced enamel epithelium, rest of malassez & serres ).  The stimulus for this neoplastic transformation is unknown .  Clinical feature : - any age , 50% are in 20-40 years old - No gender predilection . - Site: 80% mandible, 3/4 in the under ramus area,20% in maxilla. - Slow growth with expansion and dental changes . - X-ray: classic multilocular lytic lesion .  Histopathology : proliferating cord , island & srtands of odontogenic epithelium.  Ameloblastoma differentiation : ??  Tx : a- conventional ameloblastoma ( multilocular or infiltrative lesion ) : aggressive therapies such as en bloc , marginal or segmental resection ( partial ) mandiblectomy or maxillectomy may be required. b- Unicystic ameloblastom ( uniocular ) : conservative therapy such curettage . " follow up needed due to it's recurrence – may cause death – "
  • 2.  Variant of ameloblastoma : a- ameloblastic carcinoma : cytologic malignant epithelium odontogenic tumors with ameloblastic differentiation . Pursue an aggressive clinic course. b- Peripheral ameloblastoma : arising from oral mucosa surface – 1% of ameloblastoma – middle ages adults – occur in gingival & alveolus – some cases reported basal cell carcinoma. c- Malignant ameloblastoma : atypical one that metastasizes commonly in lungs, lymph nodes & bones. Histological similar to itrabony ameloblastoma. 2) Adenomatoid odontogenic tumor :        Age : 5-30 years , mean 18 , 75% in Pts <24 Sex : 2:1 female predilection Site : Appear 80% in the anterior jaw 2/3 in the maxilla & 1/3 in the mandible. 15% in the posterior jaws. X-ray : circumscribed, uniocular lucency radiopaque flecks & 75% associated with impacted tooth. Histopathology : whorled epithelium duct like structure. Tx : nucleation. 3) Squamous odontogenic tumor :        Age : young adult age 20-40, average 37 Sex : no gender predilection . Site : any site of alveolus. X-ray : triangular lytic defect adjacent to tooth root with radiopaque border. Derived from rest of Malassez. Histopathlogy : - similar to ameloblastoma. - lack of columnar peripherally palisaded layer of epithelium cells. Tx : because it's invasive, it reoccur after conservative therapy. It need curettage or excision. 4) Calcifying epithelial odontogenic tumor :      Age : 2nd to 10th decades, average 40. Sex : no gender predilection . Site : mandible is affected twice the maxilla & common at molar-ramus area. Peripheral lesion usually in the anterior gingival. X-ray : associated with impacted tooth, uni or multiocular take honeycomb shape. Tx : enucleation or resection.
  • 3.  Histopathology : - large polygonal epithelial cells, seen in sheets & islands, contain nuclei that show variation in size & shape. - epithelioid strandnestssheets. - amyloid and calcification - mitotic figure and clear cell variant are rare. 5 ) Clear Cell Odontogenic Tumor       Age : older adults mostly more than 50 years. Sex : possible female predilection. Site : posterior jaws maxilla & mandible. x-ray : lytic lesions with ill defined margin. Histopath : islands and nest of clear odontogenic epithelium in dense fibrous stroma. Complete resection, locally aggressive with metabolic potential & need aggressive therapy. Oral pathology "2" ,, 4th lecture by Dr.Louiy ,, 6/3/2011 ODONTOGENIC TUMORS Mesenchymal Origin Tumor 1) Odontogenic Myxoma - It mimic microscopically the dental pulp. - it's benign tumor. – it may be infiltrative & aggressive. – it may be recur. Clinical Features : - Age from 10 to 50 years. – no gender predilection. - anywhere in the jaw can be seen. - It's gelatinous & sticky so may remain some of it after treatment. X-ray : - Radiolucent lesion , well circumscribed or diffused.
  • 4. - Multiocular and has a honeycomb pattern. - cortical expansion or perforation & root displacement can be seen. Histopath : - Myxomatous CT. - benign fibroblasts with collagen fibers in mucopolysaccharide matrix. - odontogenic rest are typically absent. Differential Diagnosis : central hemangioma ( honeycomb pattern ). Tx : surgical excision. 2) Central Odontogenic Fibroma ( within the bone ) - it's considered as the central counterpart to peripheral odontogenic fibroma. - appear in all age groups - appear at any location in the jaw. X-ray : multiocular radiolucent lesion with cortical expansion. Histopath : - simple type : mass of fibrous tissue containing epithelial rests. Tx : enucleation or excision ( compared to myxoma is conservative therapy ) 3) Cementoblastoma - it's rare benign neoplasm of cementoblast origin. - it occur mostly in 2nd & 3rd decades of life preferably in the mandible posterior lesion. - no gender predilection. - associated with the tooth root but the tooth remain vital. - cortical expansion. – low grade intermittent pain. X-ray : - this neoplasm is an opaque lesion that replaces the root of the tooth. - it's usually surrounded by a radiolucent ring representing the periodontal ligament space. Hostopath :
  • 5. - dense mass of mineralized cementum like material. - intervening well vascularized soft tissue containing cementoblast. Differential Diagnosis : - odontoma, osteoblastoma, focal sclerosing osteomyletis & hepercementosis. Tx : removal with associated tooth + bone relief is required. 4) Periapical Cementossous Dysplasia ( PCOD ) - it represents a reactive or dysplastic process. - it appear to be unusual response of periapical bone and cementum to undermined local facrors. Clinical Features : - it occurs in the apex of vital tooth. -middle age black women ( 40 years ) represent the typical group of patients. - anterior mandible region & it's asymptomatic. - discovered during routine examination. X-ray : - appear first as periapical radiolucency ( similar to periapical granuloma ). - as a lesion develop, it develop into mixed or mottled pattern because of bone repair. - the final stage appear as a solid opaque mass. 5) Fluoride Cemento-Osseous Desplasia – FCOD - it appears to be an exuberant form of a PCOD. - there no clear cause. - occur bilaterally + asymptomatic except if there is complication of osteomylitis. X-ray : diffuse, radiopaque mass. Histopath : - mixture of benign fibrous tissue, bone & cementum. Differential diagnosis : - paget diseases, chronic diffuse sclerosing osteomylitis.
  • 6. Tx : no treatment just follow up. ODONTOGENIC TUMOR ( Mixed Origin : Epithelium + mesenchyme ) 1) Odontoma - is composed from both epithelium & mesenchymal dental hard tissue ( enamel & dentin ). - compound odontoma : numerous miniature teeth. - complex compound : amorphous hard tissue. Clinical Feature : - it's lesion of children and young adults ( age : 2nd decades of life ) - maxilla > mandible. - anterior jaw ( mostly compound odontoma ) & posterior jaw ( mostly complex odontoma ). - signs that are suggested of odontoma presence : 1- impacted tooth 2-retained primary tooth 3-alveolar swelling. X-ray : - numerous tiny teeth in a single focus. - location between root of impacted teeth. - amorphous mass ( complex one ) in same previous location. - early stage of tumor development " radiolucent with focal area of pacification ". Histopath : - enamel, dentin, cementum & pulp can be seen. - ghost cell keratinization can be seen. Differential diagnosis : - focal sclerosing osteitis, osteoma, periapical cemental dysplasia, ossifying fibroma & cementoblastoma. Tx : - odontoma have limited growth potential. - enucleation.
  • 7. - a rare variant is odontoblastoma ( little is know but to be considered as ameloblastoma ). Oral pathology "2" ,, 5st lecture by Dr.Louiy ,, 13/3/2011 2) Ameloblastic fibroma and ameoblastic fibro-odontoma:  The difference between these two lesions is the preaence of odontoma.  They are benign lesions.  They are composed of neoplastic epi. and mesenchme.  the biological behavior are the same for both. Xray:   Well circumscribed (usually surround by sclerotic margin) ameloblastic fibroma (lucent) and ameloblastic fibro-odontoma (compound lucent-opaque) Clinical features:  No gender prediction  They are predominatly in children and young adults  Mandibular molar ramus are the preferred location Histopathology:  The lesion is lobulated & surrounded by fibrous capsule.  primaitive appearing myxoid connective tissue.  strands of odontogenic epithelium.  one or more foci of enamel and dentin (ameloblastic fibro-odontoma). Differential diagnosis " ameoblastic fibroma": i. Ameloblastoma ii. Odontogenic myxoma iii. Dentigerous cyst iv. OKC v. Central giant cyst granuloma
  • 8. Differential diagnosis " ameoblastic fibro-odontoma": i. CEOT ii. CEOC iii. Adenomatoid odontogenic tumer Tx: Conservative surgical procedure (encapsulation) A malignant counterpart of ameloblastic fibrosarcoma can arise from pre-existing or recurrent ameloblastic fibroma.      fibrisarcoam : appears at any age. Maxilla <Mandible. Pain and paresthesia. locally aggressive with metastatic potential. resection is the treatment of choice. 3) Ceratocystic odontogenic tumer:       Unique cyst histopathology and aggressive clinical behavior. Anterior-posterior growth pattern without obvious clinical expansion. Typically 2-4th decade, slight male predilection. Most common in mandibular ramus/3rd molar region. Other findings include thooth displacement, mobility, root resorption, root divergence, pain and swelling. Peripheral variants have been reported. Key histology & treatmen/prognosis        Corrugated parakerathinized stratified squamous epithelium. Usually 6-8 cells thik, hyperchromatic, palissaded basal cell layer. Inflammation may focally. Alter architecture. Recurrence rate of approximately 30%. Enucleation [] resection . Long term clinical and radiographic follow-up. 4) Ossifying fibroma
  • 9. It’s a benign neoplasm of bone that has the potential for excessive growth, bone destruction and recurrence. It is composed of fibrous connective tissue stroma in which a new bone is formed. Clinical features:  Age: third and fourth decades.  F < M.  Slow growing & expansile.  Asymptomatic.  It arise in the tooth-bearing regions.  Mandibular molar-premolar area.   X-ray: well circumscribed & well defined border. The lesion presents a variable appearance depending on the density of calcification present . Histopathology:  Fibrous connective tissue & fibroblasts.  Bone is immature surrounding by osteoblasts. Differential diagnosis:  Fibrous dysplasia.  Osteoblastoma.  Focal cementoosseous dysplasia.  Focal osteomyelitis.  Periapical cementoosseous dysplasia. Treatment: Surgical removal: enucleation or curettage. 5) Fibrous Dysplasia  A condition where a normal medullary bone is replaced by an abnormal fibrous connective tissue. Etiology: Genetic alteration may ultimately affect the proliferation and differentiation of fibroblasts/osteoblasts that make up the lesion.
  • 10. Clinical features:  Asymptomatic-painless.  Slow enlargement of the involved bone.  Involvement of single (monostotic).  Involvement of multiple bone (polyostotic).  Maxilla < Mandible.  Unilateral swelling.  Onset during the 1st and 2nd decades of life. X-ray:  It ranges from radiolucent to uniformly radiopaque mass.  Poorly defined radiographic and clinical margins. Histopathology:  Fibrous connective tissue.  Trabeculae of immature bone.  Capillaries are prominent and uniformly distributed. Differential diagnosis:  Ossifying fibroma.  Chronic osteomyelitis (symptomatic). Treatment & prognosis:  It stabilizes after a variable period of prepubertal growth .  Small lesion my require no treatment (biopsy confirmation).  Larg lesion: surgical recontouring. 6) Osteoblastoma/Osteoid Osteoma  It is thought that osteoid osteoma represent a smaller variation of osteoblastoma. Clinical features  Osteoblastoma < 1.5 cm in diameter.  Osteoid osteoma > 1.5 cm in diameter.  Posterior tooth-bearing region are the usual site.  Most cases occur during the 2nd decades of life.
  • 11.   Male < Female 2:1. Pain relived by NSAID (Osteoid osteoma) , no pain relief with Osteoblastoma. X-ray " Osteoblastoma" :  Well circumscribed.  Mixed radiolucent-radiopaque lesion. Histopathology " Osteoblastoma" :  Irregular Trabeculae of immature bone lined by osteoblasts. Differential diagnosis: i. Cementoblastoma. ii. Ossifying fibroma. iii. Fibrous dysplasia. iv. Osteosarcoma. Treatment & prognosis: Conservative surgical approach. 7) Osteoma     It is a benign lesion tumer composed of mature compact or cancellous bone. When arise on the surface of bone: Periosteal osteomas. When arise centrally: Endosteal osteomas Cause is unknown (trauma, infection & developmental abnormalities have been suggested). Clinical features:  Age: 2nd to 5th decades of life.  Male < Female.  Solitary except in Gardner`s syndrome.  Asymptomatic - Headache, recurrent sinusitis & ophthalmologic complaints may occur when skull bone are .  Slow growing hard mass. Gardner`s syndrome: It is characterized by:   Intestinal polyposis (very high rate of malignant transformation) Multiple osteomas
  • 12.      Fibromas of the skin Epidermal cyst Impacted permanent & supernumerary teeth Odontomas Osteomas Histopathology:  One dorm composed of dense compact bone.  Other form composed of trabeculae of cancellous bone. Treatment:  Surgical excision.  In some instances periodic observation of small, asymptomatic osteomas is appropriate. Oral pathology "2" ,, 6th lecture by Dr.Louiy ,, 20/3/2011 8) Desmoplastic Fibroma : Clinical Features : - it's benign locally aggressive bone lesion. - cause is unknown. - age 30 years. - most common area : body ramus region. - asymptomatic, eventually cause swelling of the bone. X-ray : - uni or multi ocular. - either well demarcated or poorly defined. - cortical proliferation & root resorption may be seen. Histopathology : - densely collagenous fibers. - spindle shape fibroblast & collagenous fibers. - bone isn't produced. DD : Odontogenic cyst, odontogenic tumor, non-odontogenic lesion.
  • 13. Local perforation may suggest malignancy. Tx : surgical excision. 9) Chondroma : Clinical Features : - benign eartilanous tumor of unknown cause. - painless slowly progressive lesion. - Common site is the anterior region or coronoid process. - age : mostly before 50 years. x-ray : irregular radioleucent area and foci of calcification may be seen. Histopathology : mature hyline cartilage. Tx : surgical excision. 10 ) Osteochondroma ( benign lesion of the jaw ). 11) Central Giant Cell Granuloma CGCG : - it's a benign proliferation of fibroblast and giant cells. X-ray : occur as solitary radioleucent lesion, multioccular, center of the bone. Etiology : - is classified as a benign neoplasm. - tumor fibroblast are believed to be responsible for recruiting of monocytes & Subsequently for transformation into multineucleated giant cells. Clinical Features : - age : children & young adult. – female more 2 : 1 . - mandible > maxilla. – painless expansion. - margin in x-ray are well demarcated. – aggressive CGCG exhibit rapid growth, root resorption & perforation of cortical bone. Histopathology :
  • 14. - uniform fibroblast in collagenous stroma, capillaries, & multineucleated giant cells. - foci of osteoid may be seen. Deferential Diagnosis : Ameloblastoma, odontogenic myxoma, OKC, adenomatoid odontogenic tumor. Tx : surgical management, more extensive surgery needed if there are aggressive clinical features. 12) Hemangioma of the Bone : - it's mimic odontogenic & nonodontogenic lestion. Clinical Features : - more in the mandible, posterior region. – female > male. - age : 2nd decade. – asymptomatic expansion. – firm slow growing. - spontaneous bleeding of the gingival. - possible vertical mobility of the involved teeth. X-ray : multiocular radioleucencies, angular lobulation or cyst like radioleuncy & resorption root may be seen. of the Histopathology : - it represents a proliferation of blood vessels. - has cavernous type. Differential Diagnosis : Ameloblastoma, myxoma, CGCG, ABC. Tx : - may become a life threating if improperly treated. - needle aspiration is critical. - surgery, radiation therapy sclerosing agent, cryotherapy & presurgical embolization technique. 13) Langerhans Cell Diseases : - it's characterized by a proliferation of cells exhibiting phenotypic characteristics of langerhans cells. - etiology : is remains obscure ( similarities to langerhans cells located in the rpidermis & mucosa ). It's suggested that immunologic defects may affect normal regulatory mechanism with langerhans cell proliferation.
  • 15. Clinical Features : - age : children, young & older adults. - any bone can be involved. - oral manifestation can be initial manifestation (80%) : a- tenderness, pain & swelling. b- loosening of teeth ( floating in space ) --- Very important --- gingival tissue is inflamed, hyperplastic and ulcerated. x-ray : radioleucent lesion ( solitary or multiple ). - cervical lymphodymopathy, mastoditis & otitis are common in multifocal involvement. Histopathology : - proliferation of large cells with abundant cytoplasm. - eosinophils and other inflammatory cells. - macrophages. - multineucleated giant cells & foci of necrosis. Differential Diagnosis : Juvenile or diabetic periodentitis, leukemia, hypophostaphasia, cystic neutropenia , malignant neoplasm, odontogenic tumor and cyst. 14) Tori & Exostosis : - they are nodular protuberances of mature bone. - they are neoplastic lesion. - they are rarely a source of discomfort. - surgical removal for propose of prosthetic rehabilitation. - Etiology & Pathogenesis : unknown. - parafunctional habit. - high occurance in some population. ( Torous Platinous + Torous Mandibularis + Exostosis + their Histopathology )  read it from the book. 15) Coronoid Hyperplasia : ( enlargement of coronoid process ).
  • 16. Etiology & pathogenesis : unknown. Clinical features : bilateral, limit mandible movement, painless, no swelling or asymmetry & common in young male patient. Histopathology : - mature & hyperplastic bone which cartilaginous of fibrous CT. Tx : surgical excision + post operative physiotherapy. Malignancies of the Jaw 1) Osteosarcoma : ( 20% of all sarcoma ) - 5% occurs in the jaws. - it occur in different clinical setting including pre exciting bone abnormalities : 1-chronich osteomylitis 2fibrous dysplasia 3-giant cell granuloma 4-multiple osteosarcoma 5-paget's diseases 6-osteogensis imperfecta. - the majority involve long tubular bone ( adjacent to knee ). - can be classified to : a- conventional type ( medullary cavitiy ). b- juxtacortical tumors ( periosteal surface ). c- extra skeletal ( soft tissue ). - some gene have been cited as contributing to osteosarcoma e.g P53. Clinical Features : - male prevalence 60%. – age: 2nd decade for the skeletal osteosarcoma. - 3rd & 4th decade as general. – swelling. - more in the mandible than maxilla (body-symphesis- angle-ascending ramus-TMJ) - localized pain. – loosening, displacement of teeth and parasthesia.
  • 17. - epistaxis. – nasal obstruction & eye problems. - mucosal ulceration ( not occur until late stage ). X-ray : - at early tumor stage is widening of PDL. - in late stage, mouth eaten irregular radioleucencies. Histopathology : All histological variant reflect the multi potentionality of the neoplastic mesenchymal cells in producing osteoid, cartilage & fibrous tissue. DD : chronic osteomylitis, clacifying epithelium odontogenic tumors. Oral pathology "2" ,, 7th lecture by Dr.Louiy ,, 27/3/2011 2) Parasteal osteosarcoma : - arise at periosteal surface. slow grow swelling or palpable mass. Age :39 , Male predominance for jaw involvement. Dull or aching sensation. X-ray : radio-dense and attached to the external surface of bone. A radiolucent clear space corresponding to the periosteum can be identified. Histopathology : - spindle cell stromae separating irregular trabecular. - periphery is less ossified than base. - invasion of underlying bone can be seen. Differential diagnosis : Osteoma , osteochondroma ,extosis. Treatment : #periosteal osteosarcoma : -enblock resection. -recurrence rate is high if cortical bone is not removed. - 5 year survival rate is 80%. #osteosarcoma : -surgery and chemotherapy. -when cortex is affected , surrounding tissue will be invaded. - 3 cm margin resection.
  • 18. Pre-operative chemotherapy : -elimination of micro-metastasis. -size reduction. -induction of necrosis. -increase chance for tumor free margins. 3) Osteosarcoma : -intramedullary sarcomas showed no response to radiation therapy. -5 years survival rate is 25-40%. -prognosis of mandible is better than maxilla. -recurrence rate 40-70%. -areas of metastasis : lung and brain. - survival rate : 6 months when metastasis occur. - can manifestation in the jaw at early stage as widening of PDL. -2nd decade = skeleton osteosarcoma. -3rd to 4th decade for jaw involvement (8 - 85 years). 4) Chondrosarcoma : -well differentiated chondrogenic neoplasms to be considered potentially malignant. - Maxilla more than mandible. - adulthood disease. -painless swelling loosening of teeth. - signs can occur from surrounding bone invasion. - X-ray : range from mouth eaten radiolucency to diffusely opaque lesion. Histopathology : - Grade I : increase number of chondrocyte in chondroid to myxomatous storma (0% metastasis). - Grade II : myxoid storma with enlarged chondrocyte nuclei (10% metastasis). - Grade III : markedly cellular with spindle cell component and mitotic figure (70% metastasis ). - Grade I > II > III in prognosis. Differential diagnosis : Osteosarcoma , pleomorphic adenoma. Treatment : -Lesion is radio-resistant. -local or radical surgical excision is best.
  • 19. 5) Ewing’s sarcoma: -it is highly lethal round cell sarcoma. -cause is unknown. -the cell of origin is uncertain ( related to primitive neuroectodermal tumor ). - 1% occur in jaws. - ramus of mandible is preferred site. Clinical features : - Age : 5 – 30 years ( average of 11 years in head and neck ). - Male > Female - Pain and swelling ( facial deformation ). - Mucosal ulcers. - Destruction of alveolar bone with loosening of teeth and mucosal ulcers. - Non-specific radiographic features. - Mouth eaten radiolucency of medullary bone , cortical erosion and expansion. Histopathology : - proliferation of uniform , closely packed cells ( round nuclie ) and fibrous bands. Differential diagnosis : Lymphoma , leukemia , chondrosarcoma , osteosarcoma. Treatment : -surgery and radiation for local control. -chemotherapy for systemic micro-metastasis.

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