Jaw carcinomas

Jaw carcinomas

• Jaw carcinomas are very rare malignant epithelial tumors that affect elderly people.
• They are odontogenic when they develop from odontogenic epithelial residues, or from benign tumors of the jaws.
• Or non-odontogenic when they develop from neighboring epithelial tissues such as sinus mucosa.

1. Definition :

Primary intraosseous carcinoma (PIOC) of the jaw is a rare tumor of epithelial origin, initially developing within the bone. This type of tumor is not found in other

bone structures because it develops from remnants of the odontogenic epithelium. When CIOP destroys the bone cortex and extends to the mucosa, it can be difficult to distinguish it from squamous cell carcinoma of oral mucosa origin.

2. Etiopathogenesis:

Two pathogenic origins have been described:

• Either by malignant transformation of the epithelium of odontogenic cysts.
• Either by degeneration of the remains of intraosseous odontogenic tissues.

Two-thirds of CIOPs derive from the malignant transformation of odontogenic cysts.

• The most incriminated factor in these etiologies is the inflammatory reaction as a stimulus, with or without genetic predisposition.

3. Warning signs and diagnostic approach:
4. Anamnesis:

• The reason for consultation is not specific according to the authors, it is most often pain, swelling (51%), sensory disorders (16%), or even trismus, ADP, signs

neurological, ophthalmological or rhinological…

• The beginning of the signs and the mode of evolution.
• The concept of taking drug treatment.
• The patient’s medical and surgical history.

2. Exo-oral clinical examination: allows

• To specify the location of the swelling and the condition of the covering skin;
• To clarify its clinical limits, by palpating the tumor induration
• To check the presence or absence of satellite adenopathies;
• To specify; by palpation; the consistency of the tumor;

3. Examination of the oral cavity:

Inspection: allows the lesion to be located.

Endo-oral palpation reveals:

• the characteristic induration of cancerous lesions,
• the limits most often exceed the overlying mucosal lesion;
• abnormal tooth mobility.

4. Additional examinations:

Standard clichés

The analysis of an orthopantomogram completes the clinical assessment; it allows the patient’s dental condition to be assessed and any possible bone lysis of neoplastic origin to be visualized, which generally indicates massive bone invasion.

Head and neck computed tomography (CT) scan

This examination allows an excellent assessment of bone structures . Thus, it reveals the tumor mass and its topography, and specifies its degree of extension to neighboring regions.

At the cervical level, the visualization of suspicious adenopathies radiologically contributes to the classification of the lesion.

Magnetic resonance imaging (MRI)

It provides valuable information regarding tumor extension and lymph node areas. The performance of MRI is inferior to that of CT for fine bone exploration, and MRI is often a second-line radiological examination when CT is insufficient.

Extension report

As part of an extension and operability assessment:

• Endoscopic assessment (optical nasal fiberscopy);
• Thoraco-abdominal CT scan;
• Bone scan requested to look for a second location or bone metastases;
• Tomography;
• Biological assessment;
• Cardiovascular examination.

4. Clinical forms
   1. The different locations: In the mandible:

Anterior and lateral carcinomas:	Posteriorly located carcinomas:
the radiological image is osteolytic. Lateral carcinomas In this lesion the mylohyoid muscle is affected.	This is the most common form. Affects the mandibular angle, manifests itself by a slightly painful swelling, sensitivity disorder in the V3 area, trismus due to invasion of the intermaxillary commissure, in the more advanced stage there will be dental mobility and pathological fractures.

In the maxilla:

Anterior and lateral location	Posterior and tuberosity location	Palatal Location
It is rare, it affects the vestibule, the lip, the anterior part of the palate. -Bone destruction can reach the anterior nasal spine, the foot of the septum, the floor of one or both nasal fossae. Lateral location: very frequent, reaches the lower sinus floor more quickly.	very frequent, local extension can reach the vestibule and the cheek, especially the intermaxillary commissure, the velum, the palate and the pterygomaxillary region .	It is less frequent and can be located at the medial, lateral, anterior or posterior level with or without involvement of the maxillary sinuses and nasal cavities.

5. Histological classification of maxillary carcinomas

We will retain those of the WHO 2017.

1. Odontogenic carcinomas of the jaws
   1. Ameloblastic carcinoma

Described in 1974 by Shafer to individualize ameloblastomas presenting a malignant histological transformation. It can occur de novo , most often, or complicate a pre-existing ameloblastoma (often multi-recurring).

Frequency: exceptional.

Location: Predominance in the posterior mandibular region.

Age of discovery and sex ratio

• Average age: 50 years (from 5 to 84 years).
• Slight male predominance. Clinic
• Local curvature, facial deformity, and pain are the most common symptoms. Dental displacement and even spontaneous dental expulsion are possible.
• Trismus can indicate damage to the masticatory muscles. X-ray
  • Most often results in an aggressive-looking mass, often multilocular, with irregular and poorly defined boundaries, the cortices are lysed and the mass extends into the adjacent soft tissues

Anatomopathology

• It is characterized by islets and epithelial trabeculae similar to plexiform and

/or follicular of classic ameloblastoma, with an unremarkable peripheral palisade cellular appearance. On the other hand, the cells themselves present cellular atypia and mitotic activity.

• Evolution: the prognosis, which is poor, is conditioned by local recurrences (often early but sometimes late, more than 10 years, justifying prolonged monitoring) and especially by metastases which predominate at the lymph node or pulmonary level.

2. Primary intraosseous carcinoma: (primary intraalveolar carcinoma):

4.1.2.1. Primary intra-alveolar intraosseous carcinoma:

It is a carcinoma primarily affecting the jaws, without any original connection to the oral mucosa or underlying odontogenic cyst. It probably arises from residues of the odontogenic epithelium.

Frequency: extremely rare.

Location: posterior mandibular predominance (90% of cases). The maxilla is exceptionally affected (location often more anterior).

Age of discovery and ^sex ratio:  5th – 6th ^decades (but all ages can be reached from 4 – 76 years). Very clear male predominance.

Clinical: Pain is most often the symptom. More rarely, it is a local bulge or metastatic lymphadenopathy. These signs are unfortunately late. Asymptomatic findings are not uncommon.

Radio: Very variable

– Result in more irregular, poorly defined osteolysis, immediately suggesting the aggressive nature of the lesion.

Anatomopathology

Does not differ from other squamous cell carcinomas. These are often well-differentiated lesions, often keratinizing, sometimes poorly differentiated. It is therefore essential to exclude an oral origin, as well as a possible metastatic lesion, particularly of pulmonary origin, a frequent source of mandibular metastasis.

Evolution

The prognosis is poor. Metastases to regional or distant lymph nodes are common. Death occurs in 50% of cases within two years of the initial diagnosis.

5.1.2.2. Primary intraosseous CE derived from a keratocystic calcified odontogenic tumor (KCT)

Some can graft onto keratocystic odontogenic tumors: 30 cases (in 2005); in a 40-year-old man; +++ mandible.

• Initially: Clinical and radiological appearances are identical to those of TOCK. Sometimes the radiolucency limits are irregular and jagged.
• At a late stage, destruction +++. Multilocular images, cortical destruction and extensions to soft tissues.

Histhopathology: Well-differentiated keratinized CE associated with TOCK

5.1.2.3. Primitive intraosseous CE derived from a non-TOCK odontogenic cyst

– 2005: 50 cases

• Average age: 56 years
• Mandible +++ with pain, paresthesia or anesthesia of the lower lip.
• Histopathology: that of a cyst with CE; there are varying degrees of epithelial dysplasia. Sometimes verrucous hyperplasia or verrucous carcinoma.

3. Clear cell odontogenic carcinoma

It is considered a low-grade malignant lesion.

• Frequency: exceptional.
• Location: clear mandibular predominance (80% of cases); often in front of the first molar but other areas of the jaws can be affected.
• Age of discovery and sex ratio

Predominance beyond the 4th ^decade (17-89 years, average age: 56 years). Female predominance.

• Clinic: A local bulge is most often revealing.
• Radio: The lesions are lytic. Unigeodic and well-defined in the early stage, they then often become poorly defined. Perimandibular or perimaxillary extension is common, best assessed by CT and/or MRI.
• Anatomopathology

🡪 Macroscopically: it appears as a non-encapsulated and invasive lesion.

🡪Microscopically

• Composed of cells with clear cytoplasm, organized into islands or cell cords, associated with small islands of polygonal cells with eosinophilic cytoplasm and separated by thin trabeculae of connective stroma.
• Lesions differ depending on the presence and extent of cytonuclear atypia and mitotic activity.
• Evolution: Recurrences are in fact frequent (more than 50% of cases) as well as lymph node and/or pulmonary metastases (30% of cases).

5.1.5. Ghost cell odontogenic carcinoma

• It is a tumor that combines aspects of a benign calcified odontogenic epithelial cyst with a malignant epithelial component.
• It is distinguished from both the benign calcified epithelial odontogenic cyst and its solid form, the calcified epithelial odontogenic ghost cell tumor.
• Its etiopathogenesis remains debated: it could occur de novo , after recurrence of a benign calcified odontogenic epithelial cyst or even from another odontogenic tumor.
• Frequency: exceptional.
• Location: maxillary predominance despite the extreme rarity of reported cases.
• Age of discovery and sex ratio : 33 to 72 years. Slight male predominance.
• Clinic: a localized bulge seems to be most often revealing.
• Radio: Relatively non-specific in the form of a tissue mass accompanied by lysis of the surrounding walls or cortex with invasion of adjacent structures.
• Anatomopathology: It combines, on the one hand, the aspects of the benign lesion (base of cubic or columnar basal cells surmounted by several layers of epithelial cells resembling the stellate reticulum associated with clusters of ghost, mummified, necrotic cells, which can calcify), with, on the other hand, foci of atypical epithelial cells presenting cytonuclear atypia, frequent mitoses, as well as areas of necrosis. The benign elements are always recognizable within the lesion, either separate or mixed with the malignant epithelial components.
• Evolution: Very difficult to assess, some lesions show slow growth while others immediately present a very aggressive potential. In nearly half of the cases, multiple recurrences and distant metastases leading to a fatal outcome illustrate the malignant potential of this lesion.

2. Non-odontogenic carcinomas of the jaws
   1. Squamous cell carcinoma (SCC)
      • It is the most common malignant tumor of the facial mass.
      • Frequency: the most frequent malignant tumor of the facial mass (50-60% of TM of the sinuses and nasal cavities).
      • Location: maxillary sinus (60-70% of cases) – nasal cavities (25% of cases) – ethmoid (10% of cases) then sphenoid.
      • Age of discovery and sex ratio : average age: 60 years. Clear male predominance.
      • Clinical

• The revealing symptoms are often non-specific and late, such as facial pain, nasal obstruction with purulent discharge, epistaxis, and more rarely local bulging.
• Neurological symptoms (damage to the cranial nerves) are much rarer.
• Adenopathy and/or metastases are present on initial examination in 18% of cases.
• Radio

• At the sinonasal level, due to the development of the lesion in an air cavity, diagnosis is often delayed in the presence of a large tissue mass. Poorly defined, often heterogeneous, it enhances moderately and heterogeneously after injection.
• CT scan assesses often aggressive bone lysis, adjacent sinus walls, lysis of the orbital floor, pterygoid processes or ethmoid.
• MRI specifies the lesion limits and surrounding muscle invasions.
• Associated CT and MRI: Evaluate an extension towards the base of the skull which may be directly linked to a transosseous extension or via the fissures and canal structures of the base of the skull.
• Evolution: The prognosis remains very poor, with an overall 5-year survival rate of 33% of cases. Pterygopalatine fossa involvement has a very poor prognosis (19% at 3 years), worse than that where orbital involvement exists (46% at 3 years).

2. Adenocarcinoma
3. Adenoid cystic carcinoma

6. Evolution and prognosis:

Depend on many factors, such as:

• TNM stage, age of the subject and general condition, histological variety of the tumor.
• Therapeutic possibilities
• The treatment, its choice and its strategy.

Conclusion

Oral cavity cancers constitute a major public health problem.

These are particularly lethal pathologies since the 5-year relative survival rate is 34%.

The dentist remains fully involved in the early detection of pre-neoplastic lesions and those already transformed.

This early diagnosis allows therapeutic agents to be implemented without delay, thus improving the prognosis of these destructive pathologies.

Bibliographic reference:

1. Fahradyan A, Odono L, Hammoudeh JA, Howell LK. Ameloblastic carcinoma in situ: review of literature and a case presentation in a pediatric patient. Cleft Palate Craniofac J. 2018; 56(1): 94-100.
2. Benlyazid A, Lacroix-Triki M, Aziza R, Gomez-Brouchet A, Guichard M, Sarini J. Ameloblastic carcinoma of the maxilla: case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 104(6): 17-24.
3. Dhariwal R, Ray J, Swain N. Clear cell odontogenic carcinoma of maxilla: a case report and mini review. J Oral Maxillofac Pathol. 2013; 17(1): 89-94.
4. El-Naggar AK, Chan JKC, Takata T, Grandis JR, Slootweg PJ. WHO classification of head and neck tumors. 4th edition. Lyon: International Agency for Research on Cancer; 2017. Chapter 8, odontogenic and maxillofacial bone tumors; p. 203-260.
5. Hussain O, Rendon AT, Orr RL, Speight PM. Sclerosing odontogenic carcinoma in the maxilla: a rare primary intraosseous carcinoma. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013; 116(4): 283-286.
6. Li K, Yang L, Qiao YJ, Liang YJ, Wang X, Liao GQ. Risk factors and prognosis for the primary intraosseous carcinoma of the jaw. Int J Oral Maxillofac Surg. 2019; 48(2): 157-162.
7. Sun ZJ, Zhao YF, Zhang L, Li ZB, Chen XM, Zhang WF. Odontogenic ghost cell carcinoma in the maxilla: a case report and literature review. J Oral Maxillofac Surg. 2007; 65(9): 1820-1824.

Jaw carcinomas

  Wisdom teeth can cause pain if they erupt crooked.
Ceramic crowns offer a natural appearance and great strength.
Bleeding gums when brushing may indicate gingivitis.
Short orthodontic treatments quickly correct minor misalignments.
Composite dental fillings are discreet and long-lasting.
Interdental brushes are essential for cleaning narrow spaces.
A vitamin-rich diet strengthens teeth and gums.
 

Jaw carcinomas