Cancer of the mandible

In cancer of the mucous membrane of the alveolar process, the lower jaw is predominantly affected secondarily. Primary cancer of the lower jaw, which, according to some authors, arises from the tooth germ, is extremely rare. Often, when establishing such a diagnosis, examination reveals metastases of epithelial tumors of other localizations to the lower jaw. Treatment of secondary tumors is the same as for other localizations of cancer of the oral mucosa.

[ 1 ], [ 2 ], [ 3 ]

Cancer of the mandible of non-epithelial origin

Among malignant tumors of the jaws, a special place is occupied by non-epithelial cancer of the lower jaw, the source of development of which can be both bone, connective tissues, and bone marrow, tissues of the tooth germ, soft tissues surrounding the jaw bones. This leads to a variety of histological forms of non-epithelial tumors, and the rarity of this pathology determines the unsatisfactory knowledge of the clinical manifestations and the possibilities of various methods of treating non-epithelial tumors of the jaws by doctors.

The International Histological Classification of Tumors classifies cancer of the lower jaw according to its histological type, with all neoplasms divided into three groups: bone, soft tissue, and monogenic.

Bone cancer of the lower jaw.

1. Bone-forming tumors.
   1. Osteogenic sarcoma.
   2. Parosteal sarcoma.
2. Cartilage-forming tumors.
   1. Chondrosarcoma.
3. Bone marrow tumors.
   1. Reticulosarcoma.
   2. Plasmacytoma.
   3. Lymphosarcoma.
4. Vascular cancer of the mandible.
   1. Hemangiopericytoma.
   2. Angiosarcoma.
5. Connective tissue tumors.
   1. Malignant fibrous histiocytoma.
   2. Fibrosarcoma.
   3. Undifferentiated sarcoma.
6. Neurogenic sarcoma.
7. Unclassifiable sarcoma.

Soft tissue cancer of the mandible.

1. Leiomyosarcoma.
2. Rhabdomyosarcoma.
3. Synovial sarcoma.

Odontogenic cancer of the mandible.

1. Malignant ameloblastoma.
2. Myxosarcoma.
3. Ameloblastic sarcoma.
4. Ameloblastic odontosarcoma.

The most common are osteogenic sarcoma, chondrosarcoma, malignant fibrous histiocytoma, recently isolated from the group of polymorphic cell sarcomas and fibrosarcomas, rhabdomyosarcoma and leiomyosarcoma. Other types of neoplasms are extremely rare.

[ 4 ], [ 5 ], [ 6 ], [ 7 ], [ 8 ], [ 9 ], [ 10 ]

Osteogenic sarcoma

Osteogenic sarcoma accounts for 22% of all non-epithelial neoplasms of the jaws. This is one of the most malignant forms of cancer of the lower jaw. When localized on the upper jaw, in 91% it originates from the alveolar process, its anterior outer part.

Symptoms

The first symptom is deformation of the affected bone, moderately painful on palpation. Sometimes, before pain appears, paresthesia appears in the area of the infraorbital or mental nerve exit. Changes in the skin in the form of a vascular pattern are determined in widespread processes. Hyperemia of the skin and mucous membrane in osteogenic sarcoma is not characteristic of this tumor and occurs only in children.

Diagnostics

Radiologically, three types of osteogenic sarcoma are distinguished: osteoblastic, osteolytic and mixed. When the lower jaw is affected, the third type of lesion is predominant. Osteogenic sarcoma is characterized by small and medium focal destruction, sometimes against the background of bone rarefaction, foci of destruction alternate with foci of compaction.

In more than half of the cases, cancer of the lower jaw is accompanied by destruction of the cortical plate, periosteal reaction in the form of needle-like or linear periostosis (presence of spicules), which indicates invasion of the neoplasm into the surrounding soft tissues.

The extraosseous tumor component contains dense inclusions. In the lytic variant, a pathological fracture of the lower jaw is possible. At the same time, it is not always possible to conduct differential diagnostics between osteogenic sarcoma and chondrosarcoma.

Currently, CT has become widely used in radiodiagnostics of facial skeletal tumors, providing a lot of additional information. One of the clinical signs is metastasis to distant organs; metastasis to regional lymph nodes is rare. Before determining the treatment plan, it is necessary to perform a biopsy and histological examination. The percentage of local relapses is very high. The preliminary diagnosis is supplemented by morphological studies based on clinical and radiological data.

Treatment

The main method of treatment is surgery. In osteogenic sarcomas, it can be independent or combined. The scope of the operation and the possibility of radical removal of the neoplasm largely depend on the localization, clinical course, prevalence and direction of tumor growth.

Considering the high sensitivity of osteosarcoma of the extremities to drug treatment, the improvement of survival rates with combined treatment using non-adjuvant or adjuvant chemotherapy, it is advisable to use epirubicin preparations.

Chondrosarcoma

Among malignant non-epithelial neoplasms of the jaws, this cancer of the lower jaw occurs in 2.1-5% of cases.

Symptoms

The course of the tumor is more latent than osteogenic sarcoma, however, along with slowly progressing forms, rapidly growing neoplasms are also encountered.

Clinically, two forms of chondrosarcoma are conventionally distinguished: peripheral and central. The peripheral form develops in the anterior part of the lower jaw, has rapid growth, and often recurs. Clinically, cancer of the lower jaw manifests itself as a node covered with a bright red mucous membrane. When injured by teeth, it usually ulcerates. The central form is initially asymptomatic, sometimes minor pain is noted. With further growth of the tumor, deformation of the jaw occurs. Relapses in chondrosarcomas occur in 48%, distant metastases - in 16%.

Diagnostics

Chondrosarcoma is characterized by the presence of dense inclusions, due to which the radiographs show random accumulations of calcareous inclusions, lumpy calcification both in the intraosseous component of the neoplasm and in the soft tissue. This characteristic feature allows the correct diagnosis to be made based on radiographic data. However, the final diagnosis is established based on morphological examination, therefore, before determining the treatment tactics, a tumor biopsy is necessary.

Histologically, in slowly growing cancer of the lower jaw, well-differentiated cartilaginous cells are determined, separated from each other by a large amount of interstitial substance. The absence or rarity of mitoses does not always indicate a benign tumor, since chondrosarcoma cells reproduce mainly by amitotic means. Fast-growing and less differentiated chondrosarcomas are significantly richer in cells, and chondrosarcomas prone to metastasis are abundantly vascularized.

Treatment

Treatment is surgical. This cancer of the lower jaw is practically insensitive to drug and radiation treatment, which are used only for palliative purposes.

[ 11 ], [ 12 ], [ 13 ], [ 14 ]

Malignant fibrous histiocytoma

This type has only recently been isolated from the group of polymorphic cell sarcomas and fibrosarcomas, so literature data on it is extremely limited. Meanwhile, among malignant non-epithelial tumors, it ranks third in frequency of occurrence (9%).

Symptoms

Clinically, mandibular cancer differs little from fibrosarcomas and is a tuberous neoplasm that occurs in the peripheral parts of the jaw. The mucous membrane above the tumor is purple-red; ulceration occurs with trauma. This form of sarcoma is most prone to recurrence. Recurrences in malignant fibrous histiocytoma occur in 69% of cases. However, regional metastases occur infrequently - in 14% of cases, and distant metastases - in 9%.

Diagnostics

The radiological picture of malignant fibrous histiocytoma is characterized by significant destructive changes and lysis of bone tissue without clear boundaries.

The final diagnosis of this type of neoplasm is established on the basis of histological examination data. However, interpretation of the histological picture in some cases presents certain difficulties.

Treatment

This cancer of the lower jaw is treated surgically. Considering the tumor's tendency to recur, the scope of the operation should be extensive. In recent years, encouraging results have been obtained in drug therapy of this neoplasm.

[ 15 ], [ 16 ], [ 17 ], [ 18 ]

Ewing's sarcoma

Rarely found in jaw bones.

Symptoms

Cancer of the lower jaw can begin with an attack of aching, dull pain in the area of the tumor, a burning sensation and heat, which is soon joined by loosening of the teeth, swelling, and an increase in body temperature.

Diagnostics

The radiographic picture of the neoplasm is nonspecific and is characterized by various forms of bone tissue destruction with elements of sclerosis. When the tumor spreads to the cortical layer and periosteum, the reaction of the latter is manifested in the form of a needle-like or bulbous periosteum. Histologically, Ewing's sarcoma is a cell-rich undifferentiated tissue. The cells are round, slightly oval, of the same size, contain a large hyperchromic nucleus. They are located densely, evenly, sometimes in layers and can simulate poorly differentiated cancer.

Treatment

Ewing's sarcoma, like other bone marrow neoplasms (reticulosarcoma, plasmacytoma, lymphosarcoma), is highly sensitive to radiation and drug treatment. According to M.A. Kropotov, out of 5 cases of this type of sarcoma, chemoradiotherapy achieved complete tumor regression in all of them, whereas with other histological forms of neoplasms such an effect occurred only in isolated observations.

[ 19 ], [ 20 ], [ 21 ], [ 22 ], [ 23 ], [ 24 ]

Reticular sarcoma

Clinically and radiologically, reticular sarcoma differs little from Ewing's sarcoma, belongs to the group of bone marrow tumors, and histologically differs in larger cell sizes and the presence of a delicate network of reticulin fibers. The frequency of damage to regional lymph nodes in bone marrow sarcomas is 29%.

[ 25 ]