Clinicopathological confere nce

(1)

口腔病理診斷科

Clinicopathological confere nce

Intern Case Report

指導老師 : 林立民醫師陳玉昆醫師

王文岑醫師陳靜怡醫師

D 組：楊駿恒‧鄭婉伶‧曾偉哲‧蔡馥慧‧李佩昕 95,02,07

(2)

Clinicopathological conference Clinicopathological conference

clinical

clinical radiologyradiology pathologypathology A case report

A case report

General features General features

conventionalfilm

conventionalfilm CTCT MRIMRI

treatment treatment

prognosis prognosis

(3)

• Name : 金 XX

• Gender : female

• Age : 13

• Native : 高雄市

• Occupation : 學生

• First visit : 94/09/24

• Attending V.S. : 黃逸岳醫師

General data

(4)

Chief Complaint

Unerupted lower left s econd molar

(5)

Present Illness

• The 13 y/o female p’t suffered from 37 un erupted tooth. She went to see Dr. 謝尚廷 10 months ago. The dentist found there was a dentigerous cyst and referred her t o Dr. 柯政全 for help.

• Dr. 柯 referred her to our OPD for exami nation and treatment.

(6)

Past History

• Past medical history

– Denied any systemic disease

– Denied any drug or food allergy

• Hospitalization :

– Nil

• Past dental history

– Attitude ： afraid – Extraction

– O.D

(7)

Personal History

Alcohol : (-) Betel nut : (-) Cigarette : (-)

(8)

Intraoral Examination

• 37 unerupted tooth

• Mild swelling on 37 area

• Mild expansion

• No purulent drainage w as presented

• Overlying mucosa: norm al color

• No loosening teeth

(9)

Panorex(940924)

18, 28, 38, 48, 37 uneruption

A well-defined ovoid-shaped radiolucent lesion with regular corticated margin over 37 c oronal part to the root trunk, measuring 3x2.5 cm.

The superior border of mandible body over 37 area seems absent.

The left mandibular canal is narrowed and indented over 37 apical area.

37 is well-developed and submerged down to the level 1 cm below the superior alveola r ridge.

(10)

Lateral view

(11)

PA view

(12)

Water’s view

(13)

• Inflammation or Neoplasm?

• Intrabony cystic lesion?

Benign or Malignant?

(14)

Inflammation or Neoplasm?

• No purulent drainage was presented

• No fever

• No complaint of pain or other uncomfortable symptom

• Overlying mucosa: normal color

Neoplasm

(15)

Benign or Malignant?

• A well-defined R-L bony lesion with regu lar, corticated border.

Benign Benign

可能為一個可能為一個

Intrabony benign tumor

(16)

Intrabony cystic lesion?

• Overlying mucosa: normal color

• A well-defined R-L lesion with cortica ted border

可能為一個可能為一個

Intrabony cystic lesion

(17)

Working Diagnoses

Intrabony benign tumor

• Unicystic ameloblastoma

• Ameloblastoma

• Ameloblastic fibroma

• Odontogenic fibroma

• Odontogenic myxoma

• Adenomatoid odontogenic tumor (AOT)

Intrabony cystic lesion

• Dentigerous cyst

• Odontogenic keratocyst

(18)

Unicystic ameloblastoma

High compatible Low compatible

Female predilection Usually with an impacted third molar

Age ： 10-20

Well-defined Radiolucency posterior region of mandible Expansion of cortical plate to the point of destruction

(19)

Ameloblastoma

High compatible Low compatible Mandible, molar-ascending r

amus area

Usually older than 20

Asymptomatic, painless

swelling Multilocular radiolucent lesio n, soap bubble, honeycombe d

An unerupted tooth Irregular scalloping margin

(20)

Ameloblastic fibroma

High compatible Low compatible

Age

：

5~15yrs slightly more common in males

A missing tooth or an uner upted tooth(75%) is assoc iated

Premolar-molar area of mandible

～ unilocular or multilocula r

～ Well defined and often

corticated in a manner sim

ilar to that of a cyst

(21)

Odontogenic fibroma

High compatible Low compatible

Female predilection Mean age 40 y/o Mandible ： posterior to

1st molar

Accompanied with impacted tooth

Well defined R-L lesion

(22)

Odontogenic myxoma

High compatible Low compatible

Usually is well defined corticated margin

honeycomb 、 tennis racket

、 soap bubble

Age ：１ 5 ~ 30 Usually multilocular With an impacted tooth cy

stlike ， unilocular ，

may have a mixed R-L, R-O i mage

Mand.>Max.

(23)

Adenomatoid odontogenic tumor (AOT)

High compatible Low compatible

Female > Male Ant. portion of jaws

follicular, sometimes accompany with

impacted Tooth.

Max.>Mand.

Slow growing, benign, and does not infiltrate bone

(24)

Dentigerous cyst

High compatible Low compatible

With impacted tooth Cyst attaches at the CEJ R-L, Well defined Lower third molar

or upper canine Corticated margin

Unilocular

curved or circular outline

(25)

Clinical Impression

• Dentigerous cyst, 37 area

• Unicystic ameloblastoma, left mandibular

body over 37 area

(26)

Treatment Course

• Incisional Biopsy on 940924

(27)

(28)

(29)

(30)

(31)

(32)

(33)

(34)

(35)

(36)

HP report ：

Odontogenic myxoma with featu

res of cystic odontoma over 37

area

(37)

Treatment Course ^cont~

• OP on 94/10/21

– (Hospitalization:10/20~10/25)

• Extraction of 36 37 38 48

• Excision + bone trimming

• Bone graft (Bio-oss x 3 BT )

• Primary closure

(38)

Treatment Course cont~ 94/10/22

(39)

Treatment Course ^cont~

(40)

Treatment Course ^cont~

(41)

Treatment Course ^cont~

(42)

Treatment Course ^cont~

(43)

Treatment Course ^cont~

(44)

Treatment Course ^cont~

HP report—

• Odontogenic myxoma 37 area

• Root resorption 36 37

(45)

Treatment Course ^cont~

OPD follow up—

• 941029 No numbness and parest hesia

Wound dehiscence

• 941105 Re-suture

(46)

Treatment Course cont~ 94/11/19

(47)

Discussion

(48)

odontogenic myxoma

Definition

• World Health Organization’s classificatio n for histological typing of odontogenic tu mors:

“ A benign tumor,

which is of ectomesenchymal origin and is

a locally invasive neoplasm consisting of r

ounded and angular cells lying in an abu

ndant mucoid stroma ”

(49)

odontogenic myxoma

Relative Prevalence

• The relative prevalence of odontogenic my

xoma is 0.2–17.7% of all odontogenic tu

mors.

(50)

DISCUSSION

(51)

Odontogenic myxoma Odontogenic myxoma

clinical

A case report

(52)

Clinical Features

• About 6% of all odontogenic tumors of t he jaw

• Predominantly in young adults

– Occur over a wide age group

• Average age ： 25 ~ 30

• No sex predilection

• Almost any area of the jaws

• Mandible > Maxilla

(53)

Clinical Features

• Slow growing

• May be associated with an impacted to oth

• Small lesions ： asymptomatic

• Larger lesions ： painless expansion of bone

• Loosening and migration of teeth

• In some instances may grow rapidly

– Accumulation of myxoid ground substance

(54)

(55)

Odontogenic myxomas

in the Hong Kong Chinese ^:

clinico-radiological presentation and

systematic review

DS MacDonald-Jankowski, R Yeung2, KM Lee and TKL Li Dentomaxillofacial Radiology (2002) 31, 71 ~83

(56)

Aim

• to determine the clinical and radiological p resentation on plain films of central odon togenic myxomas (OM) in the Hong Ko ng Chinese

• compare them to other reported series by

a systematic review (SR).

(57)

Methods:

• The files of the

Department of Oral and Maxillofacial Surgery

of the

University of Hong Kong

between

1989 and 2000

we re reviewed for OM cases.

• The relevant literature was identified by

electro

nic databases

(58)

(59)

Results:

• The 10 Hong Kong cases were broadly

consistent with the predilections for

females

and the

mandible

of other reports.

• The mean age at first presentation in the present report is

36.9

,

older

than the other reports.

• Most lesions appear to be

larger

than those in many other reports.

• Although all OMs in the present study are still being followed up after surgery,

none have

recurred

.

(60)

Discussion

‧presentation of larger lesions in the older Chinese could in part be explained

– by attitudes rooted in

traditional medicine

• in spite of the widespread availability of modern medical care in Hong Kong

(61)

• In comparison to other industrialised natio ns

– Hong Kong has a moderately high mortality ra te for cervical cancer

• Hong Kong Chinese women fail to make use of th e almost ubiquitous cervical screening services.

(62)

• Nevertheless, it would appear that long term if n ot

life-long follow-up of OM

is merited

.

– One case, followed for 35 years, recurred

• after prolonged remissions of 20 and then 10 year s

(63)

clinical

A case report

(64)

Conventional image

• Radiolucency

• The lesion is usually well-defined and it often ha s a corticated margin.

-- However , the outline of some lesion , especially in maxilla , is poorl y defined.

• When it occurs pericoronally with an impacted to oth , it is most likely to have a cystlike , unilocul

ar outline , although it may have a mixed radiolu cent-radiopaque image.

• It may be unilocular or multilocular (honeycomb

, tennis racket , soap-bubble)

(65)

Conventional image ^cont~

• When the tumor expands in a tooth-bearin g area , it displaces and loosens teeth , bu t root resorption is rare.

• The lesion also frequently scallops betwee

n the roots of adjacent teeth.

(66)

Conventional image ^cont~

(67)

Benefits of CT & MRI

• CT and MRI should be performed for the dete rmination of tumor extent and margins be fore resection.

→Reduce the recurrence rate, especially for a tu mor spreading widely into the soft tissues.

• Analyses based on CT features may enable a consensus on interpretation and expression of findings of odontogenic myxoma on conventio nal radiographs.

(68)

Computed Tomography

Features:

1. Locularity:

• The multilocular appearance was three-dimensi onally defined as a finding with compartments truly separated by bony septa.

(On conventional radiographs, intralesional trabeculation s might be projected two-dimensionally onto films, formi ng the multiple compartments.)

• CT analyses could contribute to resolving this discrepancy.

T Koseki et al / Dentomaxillofacial Radiology, 2003

(69)

Computed Tomography

^(cont.)

2. Border:

• As many bony structures are superimposed on the maxilla, conventional radiography may not clearly depict the border.

• Most of maxillary tumors with diffuse borders wer e relatively large and spread into the maxillary sin us.

• Both maxillary and mandibular lesions on CT are well defined.

• Even in large tumors without cortical continuity an d with direct contact with the surrounding soft tiss ue, the tumor margin was observed to be smooth and clear on CT images.

(70)

Computed Tomography

^(cont.)

3. Density - “tennis racket” appearance”:

• The fine straight trabeculations form square or triangular compartments appearance on convention al radiographs.

• “soap bubble” or “honeycomb” appearances sugges ting other lesions, including ameloblastoma or odo ntogenic keratocyst.

• This feature was observed definitely on the inner si de of the cortical margins in several cases.

• This typical appearance cannot be observed in all patients, but this CT feature would have significantl y contributed to allowing a diagnosis of odontogeni c myxoma.

(71)

Magnetic Resonance Imaging

• MRI showed soft tissue image.

• Myxoma typically:

Intermediate signal intensity on T1-weighted image High signal intensity on T2-weighted image.

• In contrast T1-weighted image:

– Peripheral with large collagen bundles enhanced→ – Central with cellular mucoid component not enhan→

ced

→MRI and enhanced MRI corresponded to the gross features and the microscopic features of the resec ted tumor.

J. Asaumi et al. / European Journal of Radiology, 2002

Kawai et al. / ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY, 1997

(72)

MRI

^(cont.)

•

MRI showed well the erosive extension into the adjacent structures and the invasion into the int erroots of the teeth

.

→This feature indicated that the lesion was not a c onsistent mass lesion such as ameloblastoma be cause the lesion did not absorb or move the root s of the teeth.

• Recurrent tumors can be detected by their high signal in T2-weighted MRI scans.

(73)

dynamic

Magnetic Resonance Imaging

• Difficult to radiographically

distinguish odontogenic myxomas from ameloblastomas.

→ Noting that although both the gross and microscopi c features are visible by MRI, the signal intensities are not characteristic of odontogenic myxomas alon e.

→

dynamic MRI

- Contrast medium: Gd–DTPA

J. Asaumi et al. / European Journal of Radiology, 2002

(74)

Dynamic MRI

^(cont.)

• The contrast index (CI):

(signal intensity (postcontrast)−signal intensity (precontrast))/signal intensity (precontrast). The time course of the CI (CI curves) was obtained b y plotting the CI on a time course.

(75)

dynamic MRI

^(cont.)

• The CI curves represent the blood behavior, theref ore the enhancement pattern of dynamic MRI may r eflect the intratumoral angiogenesis.

• CI curves of benign tumors increase gradually, while malignant tumors increase rapidly.

• The CI curve:

Pleomorphic adenomas  gradual increased

Warthin's tumors  rapid enhancement, reaching a maximum CI, decreasing rapidly, and then underg oing a gradual wash-out.

• dynamic MRI enhancement have characteristic featur es, and may be useful in making a differential diagno sis.

(76)

clinical

A case report

(77)

• A loose,myxomatous t umor can be seen

• filling the bone marro w spaces between the bony trabeculae

• The inset shows stella te-shaped cells and fi ne collagen fibrils.

(78)

(i)gelatinus ,loose structur e of the myxoma,is obse rved.

(ii)composed of haphazard ly arranged stellate,spind le-shaped,and round cell s in an abundant ,loose myxoid stroma that cont ains only a few collagen fibrils.

histopathologic features

(79)

(iii)small islands of inactive- appearing odontogenic epithelial rests may be s cattered throughout the myxoid ground substanc e.(not required for diag nosis and not in most ca ses)

but….

(80)

• Odontogenic Myxo

ma Showing Active Epithelial Islands

With Microcystic Features

J Oral Maxillofac Surg 59:1226-1228, 2001

(81)

(iv)(in some patients)

the tumor may have a greater tendency to fo rm collagen fibers;suc h lesions are sometim es designated as fibr

omyxomas or myxo

fibromas.

(82)

histochemical study

the ground substance is composed of

glycosaminoglycans,chiefly hyaluronic acid

and chondroitin sulfate.

(83)

Immunohistochemical study

the myxoma cell show diffuse immunoreac

tivity with antibodies directed against vime

ntin,with focal reactivity for muscle-specifi

c actin

(84)

• Less than 1% of tumor and control cells were posi tive for Ki-67.

• Odontogenic myxoma tumor cells did not show an increase in cell division.

The Expression of Apoptotic Proteins and Matrix

Metalloproteinases in Odontogenic Myxomas

^J Oral Maxillofac Surg 61:1463-1466, 2003 Bcl-

2 Bcl-X Ki-67 MMP

-2 MMP-

3 MMP

-9 Bak&Bax

(proapototic pr otein)

Specimen (+), 6.5

%

(+), 10.4

%

<1

% 90

%

- -

Not detected

Control

tissue (+), 1.1

%

(+),

1.2%

<1

% 90

% - -

Not detected

• Odontogenic myxoma tumor cells showed

increased expression of antiapoptotic prot

eins (Bcl-2 and Bcl-X) and the mat rix

metalloproteinase MMP-2.

(85)

• This study suggests that 2 mechanisms of disease progression used by the odontoge nic myxoma are the production of antiapo ptotic proteins and the secretion of matrix metalloproteinases.

The Expression of Apoptotic Proteins and Matrix

Metalloproteinases in Odontogenic Myxomas

(86)

• Irregularly shaped epithelial c ells showing a positive reactio n with CK 19

• The microcystic spaces were li ned with CK 19-positive flatte ned cells

--supports the odontogenic or igin

Odontogenic Myxoma Showing Active Epithelial Islands With Microcystic Features

(87)

• An increased number of

Ki-67-labeled active

cells

Odontogenic Myxoma Showing Active Epithelial Islands With Microcystic

Features J Oral Maxillofac Surg 59:1226-1228, 2001

• some of the

epithelial islands were not only active

morphologically, but also

functionally.

(88)

couclusion~

• From histopathologic study:

1.not encapsulated,tumor cells fill the

bone marrow spaces

• From Immunohistochemical study:

1.odontogenic origin

2.antiapoptotic proteins production, matrix metalloproteinases secretion.

=>recurrence rates approximately 25%

(89)

clinical

A case report

(90)

Treatment

• Small myxomas are generally treated by curett age , but careful periodic reevaluation is nece ssary for at least 5 years.

• For larger lesions, more extensive resection may be required because myxomas are not enca psulated and tend to infiltrate surrounding bone.

• Complete removal of a larger tumor by curettage

is often difficult to accomplish, and lesion of the

maxilla, in particular, should be treated more

aggressively in most instances.

(91)

Slootweg and Wittkampf

(Myxoma of the jaws. An analysis of 15 cases. J Maxillofac Surg 1986;14:46-52.)

• site of the myxoma

– management plans

• Mandible:

– easier to extirpate all visible tumor tissue by enucle ation with thorough curettage.

• Maxilla:

because of the more complex anatomy

vicinity of vital structures

greater risk of infiltrative spread being undetected mac roscopically

because of the greater risk of recurrence.

precludes the more conservative approach

(92)

• Complete surgical removal can be difficult, especially in the maxilla

– myxomatous tissue infiltrates cancellous bone at an early stage,

– impossible to clinically determine the extent of this infiltration if no visible bony destruction h as occurred.

(93)

Management techniques for myxom as of the jaws

(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:348-53)

• enucleation and curettage or wide excision and r esection.

• most recently the trend is toward

more radical surgery, aiming to prevent recurrence.

• Advocates of radical surgery,promote the use of wide excision or resection of the lesion togethe

r with adjacent tissue.

Barros et al

reviewed a series with a recurrence rate of 75% in t hose cases managed conservatively.

Harder

reported that 6 out of 10 lesions treated conservativ ely had recurred in their series

(94)

However, advocates of the more conservative re gime argue that, despite a notable recurrence rate, a significant number of myxomas are treated cons ervatively (by excision or curettage) with no recu rrence.

Kangur TT, Dahlin DC, Turlington EG. Myxomatous tumors of the jaws. J Oral Surg 1975

;33:523-8.

• Therefore, a permanent cure does not always require extensive surgery, removing adjacent uninvolved bone.

(95)

Management techniques for myxom as of the jaws

• enucleation and curettage or wide excision and resection.

• the trend is toward more radical surgery,ai

ming to prevent recurrence.

(96)

To this end, Alphin et al believe an init ial conservative approach sparing uninv olved structures could be used to allow maximal preservation of function reserv ing the more radical approach only for r ecurrences.

• However, it is important to balance the use of the radical approach with

maintaining the presence of vital or

uninvolved structures to preserve

function as fully as possible .

(97)

Prognosis of myxomas of the jaw

Prognosis of myxomas of the jaw is generally good , although recurrence has been described over 30 ye ars after original surgery.

It is suggested that patients be followed close ly for at least 2 years because this is the most likely time for recurrence.

Bucci E. Odontogenic myxoma: report of a case with peculiar features. J Oral Maxillofac Surg 1991;49:91-4.

(98)

Recurrence & Prognosis

• Because of its infiltrative character, this lesion is difficult to be curettaged, and this explains its hi gh recurrence rate.

• Recurrence rates from various studies average approximately 25%.

• In spite of local recurrences, the overall progno

sis is good, and metastases do not occur.

Cryotherapy as an adjunct procedure to curetta ge can be used as such technique minimizes th e risk of recurrence.

Raphael N. Aquilino *, Fabrı ´cio M. Tuji, Nayene L.M. Eid,Omar F. Molina, Hea Y. Joo, Francisc o Haiter Neto

Gurupi Regional University—UNIRG, Gurupi, Tocantins, Brazil

Piracicaba Dental School—UNICAMP, Piracicaba, Sa˜o Paulo, Brazil Received 3 October 2005; accepted 5 October 2005

(99)

Clinicopathological conference Clinicopathological conference

clinical

A case report

(100)

Clinicopathological confere nce

口腔病理診斷科