COM August 2010

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August 2010: Diffuse Radioplaque Expansile Lesion, Right Posterior Maxilla

Dolphine Oda, BDS, MSc
doda@u.washington.edu

Contributed by
Drs. Sean Wittmer & Andrew Vorono
Lakewood Endodontics & Tacoma Oral Surgery, WA

Case Summary and Diagnostic Information

This is a 48-year-old black male who first presented four months ago to his dentist for a routine dental cleaning where swelling of the right posterior maxillary gingiva was noticed.

Diagnostic Information Available

History of present Illness

This is a 48-year-old black male who first presented four months ago to his dentist for a routine dental cleaning where swelling of the right posterior maxillary gingiva was noticed. The patient was placed on antibiotics which were not helpful and the swelling continued to get larger. The patient was referred to an endodontist and later to an oral surgeon who biopsied the area. The lesion was expansile and was described to be three quarter inch wide. Patient complained of minor discomfort. Teeth #s 1-4 were non-responsive to vitality test but were intact and firmly seated with no evidence of caries or periodontal disease. Periapical radiographs revealed a predominantly radiopaque lesion with cotton wool appearance (Figure 1); it was diffuse with no clear margins.

Figure 1 This is a periapical radiograph composite, all demonstrating diffuse radiopaque lesion of the alveolar bone in area of teeth #s 1-4.

Medical History

The patient’s past medical history is significant for fibromyalgia, GERD, depression, sleep apnea, chronic low back pain, TMJ pain and bruxism.

Clinical and Radiographic Findings

The patient presented with progressively growing gingival swelling of the right posterior maxilla. It was first thought to be an infection where antibiotics were prescribed to no avail. The lesion continued to grow and the radiographic findings were those of a diffuse radiopaque lesion (Figure 1). Head/Neck CT scan demonstrated an expansile soft tissue mass centered in the right maxillary sinus that extended posteriorly through the wall of the sinus as well as anteriorly to the maxillary sinus and to the deep soft tissue of the buccal mucosa. The lesion extended superiorly to the level of the orbital floor but did not appear to be penetrating it.

Figure 1 This is a periapical radiograph composite, all demonstrating diffuse radiopaque lesion of the alveolar bone in area of teeth #s 1-4.

Excisional Biopsy

Treatment

Under local anesthesia, an incisional biopsy was performed and the results lead to the patient being referred to Otolaryngology for further evaluation. Under general anesthesia, the patient under went right total maxillectomy and right orbital floor and infraorbital reconstruction. He also underwent a right dacryocystorhinostomy, a split-thickness skin graft from the right thigh to the right cheek, and placement of a palatal prosthesis. The tumor measured 5.8 cm in extent and involved the maxilla and extended into the surrounding soft tissues, maxillary sinus, pterygoid plate and orbital floor.

Incisional Biopsy

The incisional biopsy and surgical specimens were diagnosed by Drs. Muehlenbachs, Morton, Schmidt and Hoch. The incisional and surgical specimen were made up of lobules of neoplastic cartilage that blend in with tumor bone (Figures 2 & 3) and all surrounded by high grade neoplastic spindles cells with hyperchromatic and angular nuclei (Figure 4).

Figure 2 Low power (x40) H & E histology illustrates fragments of hard and soft tissue with neoplastic bone and cartilage lobules partially surrounded by neoplastic spindle cells arranged in layers.

Figure 3 Higher power (x100) H & E histology with a closer look at the lobules of tumor bone and cartilage layered by neoplastic spindle cells.

Figure 4 Higher power (x200) H & E histology with a closer look at one of the lobules made up of tumor bone and cartilage surrounded by layers of neoplastic spindle cells.

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