COM November 2006

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Irregular radiolucency apical to tooth # 31

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

Contributed by
Drs. Pardeep Brar & Jessica Lee
University of Washington, Seattle, Washington

Case Summary and Diagnostic Information

This is a 39-year-old white female who present in September 2006 to the Oral surgery clinic at the University of Washington complaining of pain in her lower right jaw. The patient reported feeling pain in this area in early June 2006. That was followed by tooth #31 gradually becoming loose. The tooth was extracted and the area was biopsied.

Diagnostic Information Available

History of present Illness

This is a 39-year-old white female who present in September 2006 to the Oral surgery clinic at the University of Washington complaining of pain in her lower right jaw. She was referred by her general dentist who on a routine panoramic radiograph found a radiolucent lesion at the apex of tooth #31 involving the body of the mandible and extending posteriorly into the ramus (Fig 1). Tooth # 31 was vital and was loose. The patient reported feeling pain in this area in early June 2006. That was followed by tooth #31 gradually becoming loose. The tooth was extracted and the area was biopsied.

Figure 1. Panoramic radiograph at presentation demonstrating a large unilocular radiolucency with irregular borders at the apex of tooth # 31. The latter has a small filling and was 3+ mobile at presentation. It was also vital. 

Medical History

Her past medical history is significant for cervical cancer treated with chemotherapy and radiation in March and April of 2006. She is currently on Oxycodone and Prozac. She is allergic to Codeine. She has no history for tobacco or alcohol use. 

Clinical and Radiographic Findings

The patient presented with 3+ mobility and pain in association with tooth #31. This tooth was associated with a large and irregular unilocular radiolucency at the apex extending towards the ramus (Fig 1) as demonstrated by the panoramic radiograph. An oral examination demonstrated multiple missing teeth. The CT-scan studies revealed a destructive lesion of the right mandible with soft tissue extension. No other lesions were noted on the CT-scan.

Figure 1. Panoramic radiograph at presentation demonstrating a large unilocular radiolucency with irregular borders at the apex of tooth # 31. The latter has a small filling and was 3+ mobile at presentation. It was also vital. 

Excisional Biopsy

Histologically, the specimen was made up of multiple pieces of soft tissue composed of fibrous and granulation tissue with neoplastic epithelial cells (Fig 2) as demonstrated by antibodies to keratin. The neoplastic epithelial cells were haphazardly arranged and were of variable shapes and sizes including small nests (Fig 3). The neoplastic epithelial cells showed evidence of cellular and nuclear pleomorphism and prominent nucleoli. The morphology of the epithelial cells is consistent with squamous cell carcinoma. Given the history of cervical cancer, her previous biopsy was retrieved and the histology of the primary lesion was similar to the metastatic lesion (Fig 4). Therefore a diagnosis of metastatic cervical cancer to the posterior mandible was rendered. 

Figure 2. Low power (x100) immunohistochemistry stain with AE1/AE3 keratin antibodies demonstrating small islands and clusters of neoplastic epithelial cells occupying the bulk of the specimen. 

Figure 3. Low power (x100) H & E histology demonstrating sheets of malignant epithelial cells arranged in small islands and clusters occupying the bulk of the connective tissue. Compare the histology of this specimen to that of Fig 4. The histology is that of moderately differentiated squamous cell carcinoma.

Figure 4. Low power (x100) H & E histology of the original biopsy (primary lesion) from the cervix. Please note the morphology of the primary squamous cell carcinoma similar to that of the metastatic (Fig 3). The histology is of the cervical primary lesion is also moderately differentiated squamous cell carcinoma.

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