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Malignant Tumours
Ass.Professor Dr.Ali Munasser
BDS
HSC.OMFS
JB.OMFS
AB.OMFS-1
• Non-Odontogenic tumors of jaws:
1. Osteosarcoma
2. Ewing Sarcoma
3. Multiple myeloma
• Odontogenic malignant tumours of jaws:
1. Ectoderm origin: Intra alveolar carcinoma
2. Mesoderm origin: Odontogenic Sarcoma
3. Ectoderm origin: Ameloblastic fibrosarcoma
 Squamous Cell Carcinoma
• According to the WHO histological publication of oral and
oropharyngeal tumours, oral squamous cell carcinoma is described as
a tumour consisting of irregular nests, columns or strands of
malignant epithelial cells, infiltrating subepithelially.

• The tumour cells may resemble any or all of the layers of stratified
squamous epithelium
Aetiology:
1. • Unknown.
2. • Use of alcohol and tobacco.
3. • Irritation from poorly fitting dentures.
4. • Environmental exposure to paint fumes, plastic by-products,
wood dust, asbestos and gas line fumes.
5. • EBV and HPV infection.
• Differential diagnosis of squamous cell carcinoma of oral cavity
Squamous cell carcinoma is most often characterised as:
1. Exophytic
2. Ulcerative
3. Combination of both.
Exophytic lesions:
1. Less common, slower growing and less infiltrative.
2. They can become deeply infiltrative and invasive in advanced cases.

Ulcerative lesions:
1. More common.
2. They appear as red or greyish ulcers with heaped up edges that bleed easily.
3. Deeply infiltrative.
4. Predilection for area where saliva tends to pool, e.g. floor of mouth and
neighbouring sites (side of the tongue).
Clinical features:-

• Early lesions:-
1. Asymptomatic
2. White or red patches
3. Small exophytic growth
4. Small indolent ulcer
Intermediate lesions:- Advanced lesions:-

1. Persistent ulceration 1. Haemorrhage or necrosis of

2. Induration exophytic mass
3. Fixation to underlying 2. Destructive crater-like ulcer
structures with raised or rolled edges
4. Lymph node enlargement 3. Pain, paraesthesia
4. Bone destruction, invasion,
fracture
5. Mobility of teeth
Histologic features:-
Graded from low to high by degree of keratinisation, nuclear pleomorphism
and frequency of mitoses.
Low-grade tumours
• More extensive keratinisation, infrequent mitoses and little nuclear
pleomorphism.
• Maintain orientation from basal to keratinised layers.

High-grade tumours
• Little keratin, increased mitosis and extreme nuclear pleomorphism.
Well differentiated
• Presence of keratin pearls, masses of prickle cells within connective tissue
surrounded by basal cell with central keratinisation.
• Basement membrane is absent.

Moderately differentiated
• Keratin pearls are sparse or absent
• Prickle cells are more pleomorphic
• A typical mitotic figures
Poorly differentiated (anaplastic)
• No keratin
• Extreme pleomorphism and hyperchromatism
• Cells cannot be recognised as keratinocytes
Modes of spread:-

• Local infiltration
Spreads in centrifugal manner in soft tissue, but altered when bone is
encountered.
Various modes of spread in bone:-
1. Via periosteal or subperiosteal layer, particularly on lingual alveolar
aspect of mandible.
2. Through periodontal membrane when teeth are present.
3. Diffuse spread within marrow cavity.
4. Perineural spread, especially along inferioralveolar nerve, most often
proximally, in direction of pterygoid fossa and skull base and then
towards trigeminal ganglion.
5. It also spreads via lymphatics and blood stream.
• Histologic variants of squamous cell carcinoma:-

1. Basaloid squamous cell carcinoma—aggressive variant

2. Verrucous squamous cell carcinoma

• Basaloid squamous cell carcinoma:-

1. Characterised by basaloid cells that are arranged in nests or cords

with pseudoglandular spaces and a high mitotic rate

2. Worse prognosis

3. Develop distant metastasis more frequently

• Verrucous carcinoma or Ackerman tumour:-
1. Low-grade variant
2. Found in elderly (>60 years) who chew tobacco or consume snuff

3. Characterised by their whitish, warty, bulky, cauliflower-like growth with a

broad base.

4. Grossly, described as ‘pebbly, mammillated’ in appearance or piled up in

rugal folds with deep cleft-like spaces between them.

5. Predilection for buccal mucosa.

Histologic features:-
• Thickened epithelium, prominent surface keratin, down growth of
club-shaped fingers of hyperplastic epithelium that push rather than
infiltrate deeply towards an intact basement membrane.

• Prominent inflammatory reaction in the underlying connective tissue.

Differential diagnosis:-
1. Verrucous hyperplasia,
2. Chronic hyperplastic candidiasis,
3. Pseudoepitheliomatous hyperplasia.
Prognosis:-
• Characterised by an extension of lesion into underlying connective tissue,
deep to adjacent normal epithelium. It has more favourable prognosis.
Management:-
• Surgical resection.
 Basal cell carcinoma (Rodent ulcer)
• It affects facial skin.

• More common in older age group.

• Slow-growing tumour which infiltrates locally; pattern of spread laterally

rather than deep.

• It does not metastasize.

Histologic features:-
1. Clumps of cells lying in a connective tissue stroma.

2. Peripheral palisading: Clumps contain basophilic cells which resemble immature cells of basal
cells of epidermis with a peripheral layer of columnar cells packed together surrounded by a
basement membrane.

3. Morphoeic pattern: Small groups of tumour cells sparsely scattered in more than usually
abundant stroma. At the margins, thin strands of tumour cells infiltrate surrounding tissues.

4. Sclerosing: If fibrosis is marked.

5. In case of infiltrative lesions, the morphemic and sclerosing patterns are seen
Clinical features:-
1. Early stage presents as a nodule giving a pearly appearance, which
is also the diagnostic feature.

2. In larger lesions pearly appearance is not apparent immediately and

the diagnostic feature is the presence of telangiectatic vessels.

3. Pearling is made more obvious by stretching the skin to blanch it.

The translucent pearl then becomes readily recognised.
Gorlin–Goltz syndrome is characterised by:

1. Multiple basal cell carcinomas after puberty, mainly on exposed sites, can also occur
on unexposed sites.

2. Multiple keratocysts in jaws.

3. Growth abnormality of facial skeleton.

4. Anomalies of ribs.

5. Calcification of falx cerebri.

6. Frontal and temporoparietal bossing, hypertelorism and mandibular prognathism.

 Ewing’s sarcoma (endothelial myeloma,
round cell sarcoma)

• Ewing’s sarcoma is an uncommon malignant neoplasm, which occurs

as a primary destructive lesion of bone that most commonly involves
the pelvis and lower extremities.

• Origin of the cells might be derived from marrow endothelium or

from undifferentiated cells of the reticuloendothelial system
Clinical features:-
1. This neoplastic disease occurs predominantly in children and young adults, rarely in older
patients.
2. An episode of trauma often precedes development of the tumour.
3. Pain is of intermittent nature and swelling of the involved bone is often the first clinical
sign and symptom of Ewing’s sarcoma.
4. Bones most commonly affected are long bones of the extremities, although the skull,
clavicle, ribs, shoulder and pelvic girdles may be involved, as well as the maxilla and
mandible.
5. When there is involvement of the jaws, there is facial neuralgia and lip paraesthesia.
6. Appearance of the jaw swelling is often relatively rapid and the intraoral mass may
become ulcerated.
7. Patient might present with low-grade fever and an elevated white blood cell count due
to presence of infection
Radiographic features:-

1. The lesion is destructive in nature and produces an irregular diffuse

radiolucency within the bone.

2. A common characteristic radiographic feature is the formation of layers

of new subperiosteal bone producing the so-called ‘onion skin’
appearance on the film. This thickened cortex is usually infiltrated by the
tumour.

3. Osteophyte formation may also be visible in the radiograph and in such

cases may be similar to the ‘sunray’ appearance of osteosarcoma
Histologic features:-
1. Ewing’s sarcoma is an extremely cellular neoplasm composed of solid
sheets or masses of small round cells with very little stroma, large round
or ovoid nuclei.

2. Mitotic figures are common. Many tiny vascular channels may also be
present.

3. Necrosis is also a common microscopic feature.

4. Tumour cells of Ewing’s sarcoma contain histochemically demonstrable

intracytoplasmic glycogen.
Treatment and prognosis:-

1. It has been common for metastatic foci to appear in other bones

and organs, such as lungs and lymph nodes, within a matter of few
weeks or months.

2. Integrated therapies are surgery, multi-agent chemotherapy and

radiotherapy
 Osteosarcoma (osteogenic sarcoma)
• Osteosarcoma is a malignancy of mesenchymal cells that have the
ability to produce osteoid or immature bone.

• Osteosarcoma is the most common primary neoplasm originating

within bone.

• Osteosarcomas of the jaws are uncommon and account for 6%–8% of

all osteosarcomas.
Clinical features:-
1. These tumours have been seen in patients ranging from young children to the elderly, but
these occur most often in the third and fourth decades of life.
2. Maxilla and mandible are involved in about equal frequency.
3. Mandibular tumours arise more frequently in the posterior body. These are more common in
the horizontal ramus rather than the ascending ramus.
4. Swelling and pain are the most common symptoms.
5. Loosening of teeth, paraesthesia in the area supplied by the mental nerve and nasal
obstruction especially in the cases of maxillary tumours may be seen.
6. Some patients report symptoms for relatively long periods before diagnosis, which indicates
that some osteosarcomas of the jaws growrather slowly.
7. Metastasis to lungs develops early.
Radiographic features:-
1. Radiographic findings vary from dense sclerosis to a mixed sclerotic and
radiolucent lesion to an entirely radiolucent process.
2. The classic ‘sunburst’ or ‘sunray’ appearance caused by osteophytic bone
production on the surface of the lesion is noted frequently.
3. An important early radiographic change in patients with osteosarcoma
consists of a symmetric widening of the periodontal ligament space.
4. Presence of widening of inferior dental canal, widening of periodontal
ligament and sunray effect is pathognomonic of osteosarcoma.
• Histopathologic features:-

• Essential microscopic criterion is direct formation of osteoid by malignant

mesenchymal cells.

• The tumour cells may vary from relatively uniform round or spindle-shaped
cells to highly pleomorphic cells with bizarre nuclear and cytoplasmic
shapes.

• The amount of matrix materials produced in the tumour may vary

considerably.
Treatment and prognosis:-

• Osteosarcoma of the jaws is rapidly invasive. Early radical excision is

the first requirement. This may be combined with pre or
postoperative radiotherapy and adjuvant chemotherapy.

• Recurrence of tumour in excised margin is the major problem.

 Multiple myeloma(plasma cell myeloma,
plasmacytoma)
• Multiple myeloma is a neoplasm of bone. It originates from cells of
the bone marrow.

• These cells resemble plasma cells, which are common constituents of

an inflammatory infiltrate.

• The neoplasm is thought to be of multicentric origin; lesions arising in

numerous areas at approximately the same time, but each
independent of the other lesions.
Clinical features:-

1. Multiple myeloma occurs mostly in adults, although it may occur in much younger persons
with a predilection for men than women.

2. Patients usually present with pain as an early feature of the disease and because of the
destruction of bone, pathological fracture is fairly common.

3. Swelling over the areas of bone involvement may be detected.

4. Destruction of haematopoietic bone marrow can result in anaemia, fatigue,

thrombocytopaenia with purpura, epistaxis, infection and fever due to leucopaenia.

5. Renal disease results from hypocalcaemia and the overwhelming amounts of light-chain
proteins in the blood.
Oral manifestations:-
• Signs and symptoms of jaw involvement include pain, swelling,expansion of
the jaw, numbness

• Abnormal healing after extractions, mandibular fracture and mobility of

teeth.

• In addition, extraosseous lesions occur, which may resemble gingival

enlargements or epulis.

• Extension of the disease to the lymph node, skin and viscera are also
encountered.
• Radiographic features:-

• Radiographic examination usually reveals numerous sharply punched

out areas in numerous bones of active haematopoiesis like vertebrae,
ribs, skull, jaws and ends of long bones.

• These lesions may vary in size from a few millimetres to a centimetre

or more in bone reaction.

• Diffuse destructive lesions of bone may also occur.

Laboratory features:-

• Certain laboratory findings help in establishing the diagnosis of multiple

myeloma.

• Many patients exhibit a hyperglobulinaemia resulting in a reversal of the serum

albumin–globulin ratio, and an increase in total serum protein to a level of 8–
16g%.

• In addition, presence of Bence Jones protein that coagulates when the urine is
heated to 40–60°C, disappears when the urine is boiled and reappears if cooled.

• Anaemia is also a common finding in multiple myeloma.

Histologic features:-

1. Usually the lesion is composed of sheets of closely packed cells resembling

plasma cells. These are round or ovoid cells with eccentrically placed nuclei
exhibiting chromatin clumping in a ‘cartwheel’ or ‘checkerboard’ pattern.

2. Two nuclei within a single cell membrane are seen rarely. A perinuclear halo
may be present.

3. Russell bodies are common.

4. Plasma cell neoplasms demonstrate monoclonal light chains within the

5. cytoplasm of plasma cells.
Treatment and prognosis:-
• Chemotherapy is presently the treatment of choice for multiple myeloma using alkylating agents
such as melphalan or cyclophosphamide, in combination with prednisone.

• Another common regimen is vincristine, doxorubicin and dexamethasone.

• Localised radiotherapy can be given for palliation of painful bone lesions.

• Bone marrow transplant has been used for patients who do not respond to chemotherapy.

• Chemotherapy is associated with a variety of side effects, most notably bone marrow depression.

• Radiation therapy is also used, often in combination with chemotherapy.

 Odontogenic sarcoma
Clinical features:-
1. It is a malignant counterpart of odontogenic fibroma.

2. It is a very rare tumour.

3. It is an aggressive and destructive lesion which produces a fleshy

and bulky growth.

4. At times pain may be present.

Histopathological features:-
• Malignant cells exhibit a considerable mitotic activity and resemble
immature fibroblasts. They appear as elongated cells containing ovoid
nuclei with varying degree of pleomorphism.
Treatment and prognosis:-
• This condition is treated by radical surgery and resection of the
affected jaw.
• The prognosis is poor.
 Ameloblastic fibrosarcoma
Clinical features:-
1. It is a malignant counterpart of ameloblastic fibroma.

2. It is an extremely rare condition. Mandible is affected more commonly than maxilla.

3. Most common in young adults. No sex predilection.

4. Tumour mass grows rapidly and causes destruction of the jaw bone and loosening of
teeth.

5. Generally the condition is not painful.

6. Very rarely, ulceration and bleeding of the overlying mucosa can be seen
Radiographic features:-
• Appear as large multilocular radiolucencies.
• Extensive areas of bone destruction with irregular and indistinct
margins from expansion or thinning of cortical bone are seen.
Histopathological features:-
• •Mostly shows malignant transformation of a benign ameloblastic
fibroma.
• Malignant mesenchymal cells show increased cellularity with the
fibroblasts being bizarre and pleomorphic with hyperchromatic nuclei
Treatment and prognosis:-

• The condition is treated by radical resection. Recurrence is common;

hence, prognosis is poor.
 Intraalveolar carcinoma
Clinical features:-
1. Very uncommon disease.

2. Men are affected more frequently than women.

3. Can occur at any age.

4. Mandible is affected two times more commonly than maxilla.

5. Presence of swelling of the jaws with pain and mobility of the teeth in
the involved area.
Pathogenesis:-
• Intra-alveolar carcinoma develops due to malignant transformation of
the epithelial lining of odontogenic or nonodontogenic
ameloblastomas.
Radiographic features:-
• Not characteristic.
Histopathological features:-
• It has alveolar or plexiform pattern with the peripheral cells of the
tumour masses showing palisading appearance which resembles
odontogenic epithelium.
Treatment:-

• Surgical resection is preferred over radiotherapy.

• Distant metastasis of the tumour occurs frequently and hence
prognosis is poor.
Staging and grading of oral cancer

• TNM classification by AJCC