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Intra alveolar carcinama /prosthodontic courses


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Intra alveolar carcinama /prosthodontic courses

  1. 1.
  2. 2. Primary intraosseous carcinoma is a very rare but well recognized entity. First described by Loos in 1913 and named as intra- alveolar epidermoid carcinoma by Wills in 1948. Term primary intraosseous carcinoma (PIOC) was suggested by Pindborg et al in 1972. The term primary intraosseous odontogenic carcinoma (PIOC) has been primarily used to describe a squamous cell carcinoma within the jaws as de novo.
  3. 3. According to WHO classification, PIOC is an odontogenic carcinoma defined as “ a squamous cell carcinoma arising within the jaw, having no initial connection with the oral mucosa, and presumably developing from residues of the odontogenic epithelium.”
  4. 4. Waldron & Mustoe (1989), classification of odontogenic carcinomas - Type 1. Arising ex odontogenic cyst Type 2. Arising ex ameloblastoma A. well differentiated (malignant ameloblastoma) B. poorly differeentiated (ameloblastic carcinoma) Type 3. Primary Intraosseous carcinoma arising de nova (PIOC) A. non-keratinizing B. Keratinizing Type 4. Intraosseous mucoepidermoid carcinoma
  5. 5. CLINICAL FEATURES – Occurs in adult patients in sixth to seventh decade of life. Occurs only in the jaw bones & predominantly in the posterior mandible. Up to 2/3rd of odontogenic carcinoma arise due to its malignant transformation within Odontogenic cyst or tumour while PIOC arising de novo is relatively rare. Affects men more than women with ratio about 2.2 : 1
  6. 6. The most common symptoms is pain and swelling. Facial asymmetry. Overlying mucosa or skin intact. Sensory disturbance like paresthesia and numbness. Cotical plate expansion. Regional lymphadenopathy.
  7. 7. Criteria for diagnosing a lesion as PIOC (de nova) –
  8. 8.
  9. 9. 60 yr. old female visited the department of Oral Medicine & Radiology, Guru Nanak Dev Dental College and Research Institute, Sunam with the chief complaint of pain & swelling over the right side of face since 8-9 months.
  10. 10. History of presenting illness revealed that there was small swelling over the right side of face 8-9 months back which gradually increased in size from last 1 month to attain the present size. H/o pain in the same region since 1 month which was dull, aching, continuous and non- radiating in nature. Aggravated while chewing and opening the mouth and relieved temporarily by taking medication. Difficulty in eating food. Paresthesia of lower lip since 3-4 months.
  11. 11. Excessive salivation No history of trauma, sinus formation or pus discharge. Patient denied the history of any recent development of ulcer or other soft tissue lesion in the oral cavity. No history of fever or decrease in weight in recent past
  12. 12. Medical history revealed that - Patient is known hypertensive since 10 years and not taking medications regularly. Never hospitalized in the past. Not allergy to any drug was reported.
  13. 13. Patient underwent extraction of 47 from local dentist 1 month back because of mobility of tooth . After that pain and progressive swelling of the extraction wound persisted.
  14. 14. Family history was not contributary Personal history – Married Vegetarian diet No history of tobacco or betal nut chewing . Oral hygiene bad , brushes once in 15 – 20 days. Mild to moderate bleeding from gums .
  15. 15. General examination – Gait – no abnormality detected Height – 5’3’’ Weight – 64 kg Average built and moderately nourished. Mild pallor, no cyanosis and clubbing of fingers Except blood pressure (146/ 90mm of Hg) all vitals signs were in normal limits.
  16. 16. Extra oral examination revealed a single oval swelling over the right, lower 1/3rd of face leading to gross facial asymmetry. .ANT – POT. EXTENSION – starts from angle of mouth and goes upto posterior border of ramus of mandible. SUPERIO- INFERIOR EXTENSION – 1.5cm below the ala-tragus line and inferiorly it goes beyond the lower border of the mandible. Skin over the swelling was stretched with no change of color.
  17. 17. On palpation , swelling was tender , hard in consistency without localized increased in temperature Step deformity was appreciated on the right lower border of body of mandible. Two right submandibular lymph nodes both measuring not more than 1.5 cms in size, hard in consistency, tender on palpation, one lymph node was fixed to underlying tissues and other was freely mobile in all directions.
  18. 18. Intraoral examination – Single oval swelling present over the right alveolar ridge in the region of 45 46 47 Examination revealed an intact Overlying normal -appearing mucosa except for 47 region were Extraction socket was present. Medially swelling starts from floor of mouth, Laterally it obliterates the right vestibule w.r.t 45 46 47. On palpation swelling was tender , hard in consistency with expansion of buccal & lingual cortical
  19. 19. Teeth missing – 17 24 32 41 42 43 44 45 46 47 48 Dental caries – 18 (tender on percussion) 26 36 Mobile – grade I (16 23 26 ) Grade II ( 37) Generalized attrition of all the teeth. Severe gingival recession. Bleeding on probing present Both hard and soft deposits present. Vestibule obliterated w.r.t 46
  20. 20. Based on history and clinical examination provisional diagnosis of tumour of mandible was made and differential diagnosis of- Residual cyst Ameloblastoma Osteosarcoma Metastatic carcinoma Chronic osteomylitis Primary Intra-osseous carcinoma Carcinoma arising in odontogenic cyst were
  21. 21.
  22. 22. Hematological examination – Hb : 10gm% ESR : 60mm(1st hour) BT : 01 min 20 sec CT : 04 min 35 sec TLC : 6200/cmm DLC – Polymorphs – 59% Lymphocytes – 37% Monocytes – 02% Eosinophils – 02% Basophils – nil
  23. 23.
  24. 24. Ill-defined non homogenous radiolucency with bay like projections.
  25. 25.  Right lateral oblique view of mandible showing large ill-defined radiolucency with infiltrative borders involving body of mandible.  Discontinue inferior cortex of body of mandible suggestive of pathological fracture.
  26. 26. Large non- homogenous radiolucency involving the right side of body of mandible and ascending ramus with specks of radio-opacities.  Ill defined margins with infiltrative borders. Discontinuity of inferior cortical margin of right side of jaw at angle region suggestive of pathological fracture. Erosion of cortical margins of dental canal. Generalized horizontal bone loss.
  27. 27. Chest radiograph showed no abnormal lesion
  28. 28. Abdomen ultrasound showed no abnormality.
  29. 29. Incisional biopsy of the lesion was performed and the specimen was send for histopathology examination.
  30. 30. The histopathological report of multiple grayish white soft tissue mass was suggestive of WELL DIFFERENTIATED – SQUAMOUS CELL CARCINOMA Eosinophilic cytoplasm Keratin pearls N/C increased
  31. 31.
  32. 32. As confirmed of malignancy, patient was referred to oral and Maxillofacial Surgery department for further management. Commando surgery was performed with right side functional neck dissection and hemimandibulectomy. The resected specimen was send for histopathological examination
  33. 33. Intact mucosa lining Foreign body giant cellsKeratin pearls H/P report was suggestive of Well- differentiated Primary intra-osseous carcinoma of mandible.
  34. 34. Based upon the history, clinical features, radiographic features and histopathological examination final diagnosis of Well -differentiated keratinizing Primary Intra-osseous carcinoma (de nova) of mandible was made.
  35. 35. DISCUSSION
  36. 36. Till now 97 case of Primary intra osseous carcinoma (de nova) have been reported. Tumour is believed to arise from Odontogenic epithelial cell rests. (Lucas et al ) The common factor may be reactive inflammatory stimulus with or without a predisposing genetic cofactor, inducing neoplastic formation. The clinical features were non specific while pain (54.8%) and sometimes sensory disturbances (16.1%) presented in most of cases. Diagnosis of PIOC is difficult, partly the initial symptoms are often thought to be of dental origin. (Mc Gowan RH 1980).
  37. 37. Radiographically there is great variation in the appearance of borders ranging from well defined smoothly contoured to ill- defined infiltrative that makes them indistinguishable from other benign or malignant tumours. (Nolan R 1976) Kaffe et al have proposed that an important feature of PIOC is the presence of indistinct margins without sclerotic outline. PIOC type 3 shows equal tendency toward keratinizing and non- keratinizing types . Prognosis of PIOC is quite poor, and emphasis should be given to early diagnosis so that suitable treatment can be given at the earliest opportunity. (2-year survival rate in 40% patients) (To E H W et al 1991)
  38. 38. CONCLUSION Diagnosing this very rare and well recognized entity is challenging task for oral physician because of its close resemblance to many other benign & malignant lesions both clinically and radiographically. Proper diagnosis at an early stage is important for better prognosis.
  39. 39.