Osteogenic Sarcoma of Ascending Ramus of Mandible : An Unusual Presentation A Case Report

Dr. C. B. Sharma Professor & Head Department of Oral & Maxillofacial Surgery D.A.V. (C) Dental College And Hospital, Yamuna Nagar 135 001 Haryana, India. Dr. (Ms) Parveen Sharma Professor Department of Oral & Maxillofacial Surgery D.A.V. (C) Dental College & Hospital, Yamuna Nagar 135 001 Haryana, India. Dr. Varun Goel Post Graduate Student Department of Oral & Maxillofacial Surgery D.A.V. (C) Dental College & Hospital, Yamuna Nagar 135 001 Haryana, India. Corresponding Address Dr. Varun Goel C/O Goel Sadan, 1210/7, Urban Estate, Karnal 132001 (Haryana) E- Mail : varungoel2003@rediff.com Phone : 09416261077

Dr. C. B. Sharma, Dr. (Ms) Parveen Sharma, Dr. Varun Goel Key Words: Osteogenic Sarcoma, Ascending Ramus

Case Report A 28 year old man, reported to the department of Oral and Maxillofacial surgery, with a 2 month history of painless swelling of left cheek, gradual limitation of mouth opening and associated pain in one of the lower posterior teeth on left side, for which he had multiple courses of antibiotics. There was no history of any previous extraction or trauma or any discharge intra orally or extra orally (fig.1) No remarkable medical history was present and vitals were in their normal limits. Also there was no history of any tobacco or alcohol use. The general physical examination was non-contributory. Extra Oral Examination A 55 cm. non tender swelling was located at the left angle of mandible which was firm in consistency, & non mobile. There was mild ipsilateral lymphadenopathy of the submandibular

region. Intra Oral Examination Impacted mandibular left third molar associated with pericoronitis was noted which was tender on percussion. There was mild ulceration of retromolar trigone with buccal and lingual bony expansion, although no associated sinus was noted. OPG and lateral oblique view of left mandible showed no significant changes in the bony architecture, except slight radiolucency around the impacted left third molar (fig.2). Since, the history and clinical examination was highly suggestive of a chronic infectious / inflammatory process, a provisional diagnosis of chronic messetric space infection / chronic focal osteomyelitis was made. Surgical removal of third molar was carried out under antibiotic coverage without any further delay. Inspite of this, the chronic pathology never completely resolved, and hence the patient was

advised a C.T. Scan, which depicted the process to be more extensive causing considerable expansion in mediolateral direction in relation to mandibular ramus (fig.3). The duration between the reporting of the patient to the department and C.T Scan was one month. The C.T. Scan findings showed a mixed radiodense mass of size 8x7 cm. involving the left ramus and angle of mandible (fig 4). The lesion was extending medially to involve pterygomandibular space & superiorly to involve candylar process of left mandible. In the light of C.T. findings the neoplastic nature of the lesion was suspected, and hence pathologies like osteochondroma, ossifying fibroma, osteogenic sarcoma, were considered. An incisional biopsy was then carried out from the same area intra orally under local anesthesia (fig.5).

Fig. 2 : Pre-op orthopantomogramp

Fig. 3 : Coronal C.T scan showing full involvement of left ramus of mandible.

A second intervention has been planned for secondary reconstruction, using complex microvascular free flap. Comments Osteogenic sarcoma of the jaws is an unusual lesion representing less than 4% of all recorded osteosarcoma 1.
Fig. 1 : Extra oral photograph (frontal view)

The histopathological report revealed plenty of fibroconnective and fibrocollagen tissue, areas of cartilage and many foci of calcification. The chondrocytes were variable in size; there was crowding of chondrocytes in some places. At places there was fibroblastic proliferation. The tumor cells showed mild variation in size of nuclei. In some places the neoplastic cells were seen forming eosinophilic osteoid matrix. And the report was suggestive of osteogenic sarcoma of the jaws (fig.6). Diagnosis of osteogenic sarcoma of the left ramus of mandible was made. The treatment included surgery along with chemotherapy followed by radiotherapy. Surgical resection (Hemimandibulectomy) of left side was carried out and the defect was repaired with reconstruction plate. Chemotherapy with methotrexate, bleomycine and cyclophosphamide was given which was followed by radiotherapy of dosage of 6500 cGY in 35 fractions for next 7 weeks. (fig.7,8).

The relative paucity of these lesions in the jaws make their analysis difficult in several aspect. When the lesion occurs in mandible, the body of the mandible is usually the primary site, followed by the symphysis and ascending ramus 2,3 The alveolar ridge and antrum are the most common sites in the maxilla 2,3. The usual presentation is of a rapidly growing swelling with loosening and displacement of teeth, which may cause dysaesthesia4. Although in our case, the patient did not show any of these features except a rapidly growing swelling and a tender tooth, Radiographically osteosarcoma may present as an appearance of radiopacity and radiolucency resulting from both the destruction and formation of bone that is characteristic of this tumour. The lesion has ill defined borders with periosteal bone formation and bony spicules aligned at right angles to the host bone. Irregular sunburst appearance of trabeculation with in the destructive and productive lesion is typical feature of osteogenic sarcoma5. This finding may be the same as those of osteosarcoma. But if these finding are not present ,and

swelling is still suspicious, C.T. scan and MRI are helpful in showing intramedullary and extramedullary involvement, tumor calcification and invasion into adjacent tissue5. The similar problem arose while diagnosing this case because of no / mild OPG and plain film radiographic changes. The help of C.T. Scan was then taken because of the complexity of the clinical features and radiographic features. The final diagnosis could be made only after histopathological investigations. The treatment of osteosarcoma of the jaws should be approached in two ways. Primary treatment should be directed towards eradication of the local disease which requires operation3 and chemotherapy to tackle micro metastatic disease 6. Radical surgery is the treatment of choice and is the only treatment that can presently afford a reasonable expectation of cure3,7,8. Surgical margins clear of tumor have a favourable influence on survival. In mandible, hemimandibulectomy is the treatment for tumours of the ascending ramus. Wide resection guided by intra operative frozen section of the surgical margin seams to be the best procedure for parsymphysis osteosarcoma or those of the body of the mandible. If cervical lymphnodes are involved, neck dissection should improve the survival 8. Radiotherapy has been used for residual and recurrent disease and for unresectable tumours. Alone or in

Fig. 4 : Axial C.T scan showing tumor invasion posteriorly including the condyle of in left mandible.

Fig. 5 : Intra operative incisional biopsy site.

Fig. 6 : Histopathological illustration showing lacy osteoid formed by tumor cells.

Fig. 7 : Post op frontal view after Hemi-mandibulectomy.

Fig. 8 : Post op. profile view after radiotherapy.

combination with surgery, it has resulted in long term survival 3,8. The most important factor for survival is adequacy of primary operation. Tumour free margins are easier to obtain in lesions of the mandible than those in the maxilla, giving the former a survival advantage. The five years survival rates in osteosarcoma of the jaw varies from 10% 9 to 85% 3. Death in patients with osteosarcoma of the jaw is usually as a result of local recurrence or extension into the base of skull and brain3. Local recurrence rates have varied from 33% to 69% 2,3. Most patients who die of local recurrence do so within 2 or 3 years. The incidence of distant metastases varies from 6% to as high as 50% 9. Lung, brain, and other bones are the common sites 9 and distant metastases reduce the survival to zero in most cases.

References 1. M. AUGUST , P. MAGENNIS ET AL : Osteogenic sarcoma of the jaws : factors influencing prognosis. Int. J. oral Maxillofac. Sung. 1997:26:198204 BERTONI F, DALLERA P. ET AL : Experience with osteosarcoma of the jaws .Cancer 1991:68:15551563 7. 3. FORTEZ A G COLMENERO B ET AL ; osteogenic sarcoma of the maxilla and mandible. Oral surgery oral med.oral pathol.1986:62:179-184 8. 4. FINKELSTEIN JB ET AL : osteosarcoma of the jaw bones. Radiol.clin.north Am,1970:3:425443 D.C.DOVAL, R.V. KUMAR ET AL ; osteosarcoma of the jaw bones. Br. 6.

Joumal oral and maxillofac. surgery 1997:35,357-362 ROSEN G, CAPARROS B, ET AL : preoperative chemotherapy for osteogenic sarcoma: selection of postoperative adjuvant chemotherapy based on response of the primary tumor to preop chemotherapy. Cancer : 1982: 49:1221-1230 PEASE G.L., MAISEL RH: et al : Surgical management of osteosareoma of mandible. Arch otolaryngol : 1975:101:761-762 Management of osteosareoma of maxilla and mandible. American J.Surg 1980:190:572-576 D ELGADO R, M AAFSE E T AL ostcosareoma of the jaws. Head and neck : 1994:16:246-252.

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