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Tumors of the head & neck

Odotogenic Tumor Originate from :

Epithelium

mesenchyme

Both

ODONTOGENIC TUMORS
Epithelium Origin Tumor

1) Ameloblastoma :
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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 – "
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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 :
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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 :
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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 :
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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.
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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
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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.
- 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 :
- 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.
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.
- 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:
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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
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.
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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:
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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
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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
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.
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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.
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.
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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
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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:
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Intestinal polyposis (very high rate of malignant transformation)
Multiple osteomas
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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.
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 :
- 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.
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 ).
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.
- 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 :
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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.
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.
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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Tumors of the head and neck

  • 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.