Malignant

diseasesDone by: FatimaFaisal Marhoon

20102050030

Disease mechanism

Uncontrolled growth of tissue Locally invasive High degree of cellular anaplasia Ability to metastasize regionally to

lymph node and distantly to other sites

Etiology of malignant diseases

Viruses Radiation exposure Exposure to carcinogenic chemicals Genetic defects

Classifications of malignant tumors

Based of histopathology Carcinoma (lesion of epithelial origin) Metastatic lesion from distant sites Sarcoma (lesions of mesenchymal origin) Malignancies of hematopoietic system

Clinical features Displaced teeth Loosened teeth over a short time Foul smell Ulcerations Presence of indurated or rolled border Exposure of underlying bone Hemorrhage Sensorineural or sensorimotor deficits Lymphoadenopathy Weight loss Dysgeusia Dysphonia Dysphagia Lack of normal healing after oral surgery Pain or rapid swelling with no obvious dental causes Most oral cancers occur in men 50 years old and

older

Applied diagnostic imaging

Aid in establishment of an initial diagnosis of a tumor

Aid in the appropriate staging of the disease Determine the anatomic spread of the tumor Presence of osseous involvement from soft

tissue tumor Assess the involvement of lymph nodes Determine good biopsy sites Assess treatment outcome Management of patient who has survived

cancer

Imaging modalities available

Intra oral images: provide the best image resolution

Panoramic: provide an overall assessment of the maxillofacial osseous structure

Cone beam computed tomograhy (CBCT) or multidetector CT (MDCT): superior three dimensional analysis of osseous structure

Positron emission tomographic (PET) imaging: detecting abnormal cellular metabolic activity

Magnetic resonance imaging (MRI): provide 3D soft tissue images of tumor

Imaging features

Location Primary carcinoma: more common in tongue,

floor of the moth, tonsillar area, lip, soft palate, or gingiva and may invade the jaws form any of these sites

Sarcomas: mandible and posterior regions of both jaws

Metastatic tumors: posterior mandible and maxilla, apices of teeth or in the follicle of developing teeth

Imaging features

Periphery and shape Ill-defined borders with lack of cortication

and absent of encapsulation Extend from an area of bone destruction to

region of normal bone (infiltrating pattern) Finger like extensions

Imaging features

Internal structures Radiolucent Residual islands of bone might be present,

patchy destruction with residual internal osseous structure

Some metastatic tumors (prostate and breast lesions) → abnormal appearing internal sclerotic osseous architecture

Osteogenic sarcoma produce abnormal bone → radiopaque appearance

Imaging features

Effects on surrounding structure Teeth appear floating in space Root resorption (sarcomas, multiple myloma) Destruction of internal trabecular bone Destruction of cortical boundaries Widening of PDL with destruction of lamina dura Widening of ID canal “Hair one end” or “Sunburst” appearance ,thin

straight spicules of bone (osteosarcoma; metastatic prostate lesions)

Onion skin like appearance (secondary inflammatory lesion)

Ill-defined borders Infiltrating pattern

Destruction of cortical boundary

with soft tissue mass

Invasion and thickening of PD membrane space Multifocal lesion destroying crypt

cortex and displacing tooth occlusaly

Cortical bone destruction without periosteal reaction

Laminated periosteal reaction with cortical bone destruction

and new periosteal bone

Cortical bone destruction with periosteal reaction at the

periphery forming Codman’s triangle

Sunray periosteal reaction

Floating teeth

Carcinomas

1. SQUAMOUS CELL CARCINOMA

ARISING IN SOFT TISSUE

SQUAMOUS CELL CARCINOMA ARISING IN SOFT TISSUE

Synonym Epidermoid carcinoma

Disease mechanism

Most common oral malignancy Malignant tumor originating from surface

epithelium Etiology: Multifactorial; chronic smoking,

alcohol, mucosal human papillomavirues (tonsiliar and tongue lesions)

Histopathology: invasion of malignant epithelial cells into underlying connective tissue, deeper soft tissue, adjacent bone, regional lymph nodes and ultimately distant sites.

Clinical features

Most common in males older than 50 years White, red or mixed patchy lesion Central ulceration; a rolled or indurated

border Palpable infiltration into adjacent muscle or

bone Pain (variable) Regional lymphadenopaty with hard lymph

nodes Soft tissue mass, paresthesia, anesthesia,

dysesthesia, foul smell, trismus, loosened teeth or hemorrhage

Obstruct air ways, the opening of Eustachian tube or the nasopharynx.

Weight loss, feel unwell

Imaging features

Location SCC commonly involves lateral border of the

tongue Bone invasion posterior lingual aspect of the

mandible Lesions of lip and floor of the mouth invade

the anterior mandible Lesions of attached gingiva and alveolar

bone mimic inflammatory diseases Tonsils, soft palate and buccal vestibule

Imaging features

Periphery and shape Polymorphus irregular outline radiolucency Invasion characterized by an ill defined non

corticated borders Well defined border with a narrow transition band

without any residual bone behind the borders Ill defined border with a wide transition zone with

a finger like extensions into surrounding bone Borders show sharpened thinned bone end with

displacement of segments and adjacent soft tissue mass (pathologic bone fracture)

Well defined border with a narrow transition band

without any residual bone behind the borders

Ill defined border with a wide transition zone

with a finger like extensions into

surrounding bone

Internal structure

Radiolucent Small islands of residual normal trabecular

bone might be visible in the center of radiolucency

Effects on surrounding structure

Widening of PDL space, loss of lamina dura Floating teeth in a mass of radiolucent soft

tissue Growth of soft tissue mass with teeth within it

as a passenger Increase of width and loss of cortical boundary

of ID canal and mental foramen Destruction of normal cortical boundaries (floor

of the nose, maxillary sinus, buccal or lingual mandibular plates)

Inferior border of the mandible thinned or destroyed

Pathologic fracture

Floating teeth Destruction of anterior

floor of nasal fossa

Floating teeth

Destruction of floor of maxillary sinus and soft tissue

mass

Destruction of bone in mandibular retromolar

area

Bone resorption around the roots leave teeth without bony

support

Irregular width of ID canal and destructio

n of its cortical borders

SCC destroying the mandible in mental foramen region and

growing down to ID canal

Differential diagnosis

1 ) Inflammatory lesions such as Osteomyelitis Both destructive leaving island of osseous

structure SCC: profound bone destruction or invasive

characteristics Osteomyelitis: produces periosteal reaction

2) Periodontal disease If bone loss from SCC originate in the soft

tissue of the alveolar process SCC enlargement of extraction socket instead

of healing and new bone formation

-Bone destruction similar to periodontal

disease

-Lack of sclerotic bone reaction at the

periphery

Extraction socket has enlarged instead of

healing

Management

Surgery and radiation therapy Depends on the location and severity

of the tumor

2. SQUAMOUS CELL

CARCINOMA ORIGINATING FROM BONE

Synonyms

Primary intra osseous carcinoma Intraavleolar carcinoma Primary intra Intraavleolar epidermoid

carcinoma Primary epithelial tumor of the jaw Central seqaumous cell carcinoma Primary odontogenic carcinoma Intramandibular carcinoma Central mandibular carcinoma

Disease mechanism

Squamous cell carcimona arising in jaw

Arise from intraosseous remnants of odontogenic epithelium

Clinical features

More common in men Fourth and eight decade of life Pain Pathologic fracture Sensory nerve abnormalities

Imaging features

Location More common in mandible More common in molar region than anterior

aspect of the jaws Tooth bearing parts of the jaw

Imaging features

Periphery and shape Ill-defined periphery Rounded or irregular in shape Borders demonstrate osseous destruction varying degrees of extension at periphery Pathological fractures, step defects Thinned cortical borders Soft tissue mass

Imaging features

Internal structures Radiolucent Little residual bone within the lesion

center

•Poor defined periphery•No internal structures•Thinning of overlying mandibular bone

Imaging features

Effect on surrounding structure Destruction of antral or nasal floor Loss of cortical outline of mandibular

neurovascular bundle Loss of lamina dura Floating teeth

Differential diagnosis Periapical cyst or Granulomas Odontogenic cyst Metastatic lesion, Multiple myeloma,

Fibrosarcoma, carcinoma arising in a dental cyst

Surface squamous cell carcinoma

Management Tumors are excised with their

surrounding osseous structure Radiation and chemotherapy as

adjunctive therapies