COM March 2012

Case of the Month Archives

Expansile, Radiopaque/Radiolucent Lesion, Right Posterior Mandible

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

Contributed by: Dr. Thomas Curran
Silverdale Oral & Maxillofacial Surgery, WA

Case Summary and Diagnostic Information

The patient is a 68-year-old male who was referred to the oral surgeon with persistent swelling at the extraction site of tooth #30.

Diagnostic Information Available

History of present Illness

The patient is a 68-year-old male who was referred to the oral surgeon with persistent swelling at the extraction site of tooth #30 (Figure 1). The extraction site had failed to heal fully for almost four months. The panoramic radiograph showed an ill-defined radiopaque/radiolucent lesion involving the area of teeth #s 28-31 (Figure 2). Tooth #31 was vital with 3+ mobility, and teeth #28-29 were vital with no evidence of mobility.

Figure 1. This is a clinical photograph at first visit to the Oral & Maxillofacial Surgeon demonstrating buccal swelling involving the vestibule in the right posterior mandible.

Figure 2 This is the panoramic radiograph taken at first visit to the oral & Maxillofacial Surgeon demonstrating diffuse radiopaque lesion interspersed with some radiolucency.

Medical History

The patient’s past medical history is said to be non-signficant prior to the initial extraction of tooth #30. A few weeks later, the patient had x-rays of the lower spine which revealed a lytic lesion; this lesion was biopsied.

Clinical and Radiographic Findings

This patient had initially presented to his dentist with pain involving tooth #30 which was subsequently extracted. The extraction site remained swollen for almost four months post-extraction (Figure 1). During this time, in the lower spine there was detected a lytic lesion which initially did not seem to be related to the swollen right posterior mandible, the site of an earlier extraction site. The swollen right posterior mandible appeared mostly radiopaque on the panoramic radiograph (Figure 2). Tooth #31 was mobile and therefore was extracted along with incisional biopsy of the surrounding tissue, which was submitted for microscopic evaluation.

Figure 1. This is a clinical photograph at first visit to the Oral & Maxillofacial Surgeon demonstrating buccal swelling involving the vestibule in the right posterior mandible.

Figure 2 This is the panoramic radiograph taken at first visit to the oral & Maxillofacial Surgeon demonstrating diffuse radiopaque lesion interspersed with some radiolucency.

Excisional Biopsy

Treatment

As noted above, incisional biopsy was performed under local anesthesia and the tissue was submitted for microscopic examination. The histopathological and immunohistochemical results led to transfer of the patient to another physician for further workup.

Excisional Biopsy

Histologic examination reveals multiple small pieces of soft tissue composed of fibrous and granulation tissue with small islands of epithelial cells (Figure 3). The fibrous tissue comprises the bulk of the specimen and surrounds small islands of epithelial cells. Some of these epithelial cells display very dark nuclei and alteration in the nuclear/cytoplasmic ratio while others show empty looking cytoplasm. The epithelial islands are present throughout the connective tissue. Also present are fragments of calcified bone with viable osteocytes. The Immunohistochemistry staining is positive with antibodies to PSA (Figure 4) and PAP (Figure 5).

Figure 3. Low power (x40) H & E histology illustrates fragments of hard and soft tissue with normal lamellar and reparative calcified bone and loose connective tissue containing small islands of epithelial cells, some cells with very dark nuclei demonstrating analteration in the nuclear/cytoplasmic ratio while others show empty looking cytoplasm.

Figure 4. Higher power (x200) Immunohistochemistry stain histology with a closer look at the small neoplastic epithelial islands staining positive with antibodies to PSA.

Figure 5. Higher power (x200) Immunohistochemistry stain with a closer look at the small neoplastic epithelial islands staining positive with antibodies PAP.

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