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Tumour.

DEFINITION :
A tumour is an abnormal mass of tissue the growth of which exceeds
and is uncoordinated with that of normal tissue and persists in the same excessive
manner after cessation of stimuli of which evoked the change.

CLASSIFICATION :
(A) Benign :

(a) Soft Tissue Tumours :


01. Papilloma.
02. Fibroma.
03. Lipoma.
04. Myoma.
05. Neuroma.
06. Neuro-ectodermal tumour of infancy.
07. Haemangioma.
08. Lymphangioma.
09. Pyogenic granuloma.
10. Pregnancy tumour.

(b) Giant Cell lesions :


01. Giant cell gralnuloma –
i) Central.
ii) Peripheral.
02. Osteoblastoma.
03. Cherubism.

(c) Odontogenic Tumour :


01. Epithelial Odontogenic Tumour :
>> No inductive change in connective tissue.
i) Ameloblastoma.
ii) Adeno-ameloblastoma.
iii) Calcifying odontoganic epithelial tumour.
>> Inductive change in connective tissue.
i) Ameloblastic fibroma.
ii) Ameloblastic sarcoma.
iii) Dentinoma.
iv) Odontoma.
v) Ameloblastic odontome.
02. Mesodermal Odontogenic Tumour :
i) Odontogenic myxoma or fibromyxoma.
ii) Cementifying fibroma.
iii) Cementoma.

(d) Osteogenic tumour :


1. Osteoma.
2. Osteoblastoma.
3. Osteochondroma.
4. Chondroma
5. Fibrous dysplasia.
6. Myxoma.

(B) Malignant Tumour :


(a) Carsinoma :
01. Squamous cell carcinoma.
02. Adenocarcinoma.
03. Varicous carcinoma.
04. Nasopharyngeal carcinoma.

(b) Sarcoma :
01. Osteosarcoma.
02. Chondroma.
03. Fibroma.

(c) Malignant Odontogenic Tumour :


01. Odontogenic carcinoma.
02. Odontogenic sarcoma.

(d) Others :
01. Malignant melanoma.
02. Multiple myeloma.
03. Hodgkin’s disease.
04. 2-wing’s disease.
Ameloblastoma :
It is a true neoplasm of enamel organ which does not under go
differentiation to the point of enamel formation.

Origin :
1. Cell rest of enamel organ either remnant of dental lamina or remnant of
Heart Wing’s Root Sheath the cell rest of malassez.
2. Epithelium of odontogenic cyst particularly dentigerous cyst or odontoma.
3. Disturbance of developing enamel organ.
4. Basal cells of surface epithelium of the jaw.
5. Hetaroplastic epithelium in other parts of the body specially pituitary
gland.

Clinical Feature :
1. Ameloblastoma may be intra-osseous or extra osseous, but generally they
are intra osseous.
2. They are most neoplasm of jaws.
3. Age—30 to 50 years, rare in children and elder person.
4. Site—80% in the mandible, particularly to the posterior of the mandible
often involve ramous.
5. Generally they are asymptomatic appear multilocular radiolucent larger
ameloblastoma provide symptom.
6. Spread—Locally invasive, metastasis does not occur.
7. Rediographically they are typically formed rounded, cyst like radiolucent
areas with moderately well defined margins and typically appears
multilocular. Lingual expansion some times seen some verity of
honeycomb pattern.

Histological Features :
They are 5 types according to histopathological finding—
1. Follicular.
2. Plexiform.
3. Acanthomatous.
4. Granular cell ameloblastoma.
5. Basal cell ameloblastoma.
1. Follicular Type :
Contains cuboidal/ columnar with polarized nuclei as pre-ameloblastic cell.
2. Plexiform Type :
Arranged as irregular mass(Mesh work like).

3. Acanthomatous Type :
Under goes squamous metaplasia in stellate reticulum with keratin pearls.
4. Granular Cell Type :
Cytoplasm has coarse granular eusinophilic appearance.
5. Basal Cell type :
 Rare.
 Consist of most dirty staining cells.
 Predominantly in a trabicular pattern.
Treatment :
Surgical management of ameloblastoma has been debated topic thought out.
Some group advocates conservative approach like curettage etc. where as
other group is in favors of radical excision of the tumour. Because of the recurrent
nature of tumour.The various treatment modalities are as follows:-
(a) Curettage.
(b) Chemical cauterization.
(c) Electro cauterization.
(d) Enblock excision.
(e) Radical resection with or without reconstruction.
(a) Curettage :
Due to high rate of recurrence the curettage is no more considered to be
desirable from of treatment in the management of ameloblastoma curettage
involves eradication of the macroscopically visible mass of tumour by
scarping procedure.
(b) Chemical Cauterization :
Chemical cauterization of the tumour bed is supplemented with the
curettage. The bed of tumour is cauterized with concentrated Carbolic Acid.
Use of “Carney Solution” is also recommended for fixing the tissue in the
tumour bed contents— Absolute alcohol - 6ml.
-- Chloroform -------3 ml.
-- Glacial accetic acid—1ml.
(c) Electro cauterization :
(d) Enblock excision :
An intro-oral or extra-oral enblock reaction of the tumour at distance of 1-
2cm beyond the radio-graphic margin.
(e) Radical Resection Or Segmental Resection : It is considered to be most effective
method of treatment of ameloblastoma.
Fig- Ameloblastoma. Typical presentation. There is a
rounded, bony swelling of the posterior alveolar,
bony and angel of the mandible. There is no
ulceration, a feature only seen in very large tumours
which have perforated the cortex.

Fig- Ameloblastoma. At high power in this follicular


Ameloblastoma the palisaded, elongated peripheral
cells with reversed polarity are seen to be very
similar in appearance to Ameloblasts.
Fig- Ameloblastoma, This Ameloblastoma forms a
monolocular radiolucency enveloping the crown of
an uncorrupted tooth. The radiological appearance
mimics a dangerous cyst, reinforcing the maxim that
ameloblastoma should be considered in the
differential diagnosis of every radiolucency at the
angel of the mandible.

Fig- Ameloblastoma. Plexiform Ameloblastoma


composed of interconnecting strands of epithelium
Fig- Ameloblastoma, Islands of follicular surrounding islands of connective tissue. Several of
ameloblastoma comprising stellate reticulum and a the stromal islands have degenerated to form small
peripheral layer of elongated ameloblast-like cells. cystic cavities.
Fig- Ameloblastoma, plexiform type. There are thin,
interlacing strand of epithelium but typical
ameloblasts are not seen.
Fig- Ameloblastoma, islands of Ameloblastoma.
Penetrating surrounding bone at the periphery of the
lesion. such bony infiltration demands that
ameloblastoma is excised with a margin rather than
curetted.

Fig- Ameloblastoma, soft tissue spread after


repeated inadequate excision.

Fig- Ameloblastoma, Granular cell change in an


Ameloblastoma. Ameloblast and stellate reticulum-
like cells have undergone degenerative change to
form large pink granular cells. In some tumours this
change is extensive and the term ‘granular cell Fig- Squamous metaplasia in an Ameloblastoma.
Ameloblastoma’ is applied. Stellate reticulum-like cells have undergone
squamous metaplasia to form keratin
Calcifying Epithelial Odontogenic
Tumour / Pindborg Tumour :
Although it is epithelial origin yet less similar to ameloblastoma. This
tumour with bizarre microscopic feature is often termed as Pindborg tumour.

Clinical feature :
1. Adults mainly affected.
2. Average age of about 40 years.
3. There is no significant difference in occurrence between the sex.
4. Mandible and maxilla ratio—2:1.
5. The prevalence in the molar region is 3 times that in the bicuspid region.
6. The lesions are asymptomatic and painless swelling.
7. The typical site is the posterior body of mandible.

Histological Feature :
1. The calcifying epithelial odontogenic tumour is composed of polyhedral
epithelial cell.
2. The tumour cell have a well outline cell border with a finally granular
eosinophilic cytoplasm.
3. The nuclei are pleomorphic with giant nuclei and multinucleation.
4. A well recognized form of this neoplasm is the clear cell variant.
5. The nucleus may remain round or oval in centre of the cells or be flattened
against the cell membrane.
6. According to “Kroll’s and Pindborg” the histomorphology variation most of the
clear cells are muci-carmine negative although a few may show a fainting.
7. This tumour are not encapsulated are locally invasive.

Treatment :
Complete excision of the tumour with a boundary of normal bone should be
curative, but recurrence follows incomplete excision.
Fig- Calcifying epithelial odontogenic tumour (Pindborg tumour). The tumour is composed of strands and sheets
of polyhedral epithelial cells lying in pale pink staining amyloid-like material. Some of the material has
mineralized, stains a darker blue colour and gives rise to radiopacities, within the lesion.

Fig- Calcifying epithelial odontogenic tumour. At higher power the epithelial cells are seen to have sharply defined
cell membranes resembling squamous epithelium and pleomorphic hyper chromatic nuclei. The pale pink
maerialis amyeloid-like

Odontogenic Tumour :
Odontogenic tumours are neoplasm that arise from the dental lamina or any
of its derivatives. Most of them are benign and at least one is malignant.

In United States odontogenic tumours constitute about 09% of all tumours


of oral cavity and 2.4% of all lesions biopsied in dental office. By contrast in some part
of Africa one odontogenic tumour alone constitutes more than 25% of all tumour at the
jaws. Thus are incidence of this group of lesion has a geographic variation.

Classification Of Odontogenic Tumours :


(A) Epithelial tumours.
(B) Mesodermal tumours.
(C) Tumour of unknown origin.

(A) Odontogenic Epithelial Tumour :


(a) Benign tumours.
(b) Malignant tumour.

(a) Benign Tumours :

Tumour producing minimal inductive changes in the connective tissue.


1. Ameloblastoma.
2. Calcifying Odontogenic tumour.
3. Adeno-ameloblastoma.
4. Ameloblastic fibroma.
5. Ameloblastic fibro odontoma.
6. Odonto-ameloblastoma.
7. Compound composite odontome.
8. Complex composite odontome.

(b) Malignant Tumours :


01. Primary intra-alveolar epidermoid carcinoma.
02. Malignant ameloblastoma.
03. Ameloblastic carcinoma.

(B) Odontogenic Mesodermal Tumours :


01. Benign tumour.
02. Malignant tumour.
(a) Benign Tumours :
01. Central odontogenic fibroma.
02. Odontogenic myxoma.
03. Cementoma.
03. Dentinoma.

(b) Malignant Tumours :


01. Odontogenic fibro-sarcoma.

(C) Tumour Of Unknown Origin :


01. Malignant neuroectodermal tumour of infancy.

Relative Incidence Of Odontogenic Tumour Of Jaw :


Types. -- Numbers. -- Percentage.
Ameloblastoma -- 78 -- 18.18 %.
Adeno-Ameloblastoma -- 14 -- 03.26 %.
Melano-Ameloblastoma -- 03 -- 00.70 %.
Cementoma -- 46 -- 10.73 %.
Odontogenic Myxoma -- 25 -- 05.83 %.
Odontogenic Fibroma -- 98 -- 22.84 %.
Ameloblastic Fibroma -- 11 -- 02.50 %.
Ameloblastic Fibro-odontoma -- 14 -- 03.26 %.
Compound Odontoma -- 43 -- 10.03 %.
Complex Odontoma -- 22 -- 05.13 %.
Cystic Odontoma -- 30 -- 06.99 %.
Odontoma (Uncalcified) -- 31 -- 07.23 %.
Odontogenic Tumour (Rare) -- 14 -- 03.26 %.
Total -- 429 -- 100.00 %.

Based on personal analysis of clinical radiographic microscopic


and follow up data on more than 20,000 cases.
Odontogenic Myxoma :
The odontogenic myxoma is a tumour of jaws which apparently arises from
the masenchymal portion of tooth, germ, either the dental papilla, the follicle or
periodontal ligament.

Clinical Feature :
1. It occurs most frequently in the 2nd and 3rd decade of life, average age is 23 to
30 years.
2. There are particular sex predilection in the occurrence of the tumour.
3. It occurs usually in the mandible, usually in the condyle or neck of the condyle.
4. This is a central lesion at the jaw which expand the bone and may causes
destruction of the cortex.

Histological Feature :
1. It made up at loosely arranged spindle shaped and stellate cell.
2. The loose tissue is not highly cellular and cells punts do not show evidence of
significant activity.
3. The inter cellular substance is nuclei.
4. The tumour is usually interspersed which is a variable number of tiny capillaries
and occasionally standards of collagen.

Treatment :
1. Treatment is surgical excision followed by cautery.
2. Extensive lesion may required resection to eradicate the tumour.
Fig- Odontogenic myxoma of the mandible. An occlusal view showing the finely trabeculated. Soup-bubble
appearance and gross expansion of the mandible. Evidence of residual tumour was still present after 35 years in
sprite of vigorous treatment, both surgery and radiotherapy, in its earlier stages.

Fig- Odontogenic myxoma. This cross-section of the mandible through a myxoma shows extensive bony
resorption and gross expansion. The pale staining myxoid lesion gives the tumour an empty appearance.

Fig- Odontogenic myxoma. High power view showing the typical appearance of sparse fibroblasts lying in a
myxoid or ground substance-rich matrix.
Osteogenic Sarcoma :
Osteogenic sarcoma is highly malignant and the most common primary
neoplasm of bone.

Causes :
Osteogenic sarcoma rarely have identifiable cause but a few develop late in
life after irradiation or ‘Paget’s’ disease of bone.

Age and sex :

Osteogenic sarcoma of the jaws is typically seen between the ages of 30 to


40 years. Males are slightly more frequently affected.

Site :
The body of the mandible is most common site.
There is typically a firm swelling which grows noticeably in a few months
and become painful. There may be paraesthesia Or loss of sensation in the mental
nerve area. Metastases to the lungs may develop early.

Radiological Feature :

Radio graphically appearances are variable but irregular bone destruction


usually predominates bone formation.
Bone formation in a soft tissue mass is highly characteristic.
It may appearance or Codman’s triangular at the margins, due to lifting of periosteum
and new bone formation are rarely seen and not specific to osteogenic sarcoma.
Radiograph of the chest should also be taken as secondary deposit may be
present.
Pathology :

The neoplastic, osteoblastic very in size. They may be small and angular or
large and hyper-chromatic.It may be seen particularly in the more highly cellular areas.
Giant cell may be conspicuous, but many cells are non
Bone formation does not necessarily predominate and osteoid formation is
the main diagnostic criteria and is seen in metastases.
Cartilage and fibrous tissue are usually also present and sometimes
predominate but usually only in part of the tumour.
A small biopsy may therefore show only a single tissue, such as cartilage
and be mistaken for a chondro-sarcoma.

Management :

Osteosarcoma is rapidly invasive and metastasis early.


Treatment is by early mandibulectomy or maxillectomy together with wide
excision of any soft tissue extensions of the tumour.
This may be combined with radio therapy or chemotherapy.
The prognosis depends mainly on the extant of the tumour at operation and
determined with spread to the soft tissue to lymphnode or to the base of the skull.
In approximately 50 % there is local recurrence with in a year of treatment
and a sharp deterioration in prognosis.
Fig- Osteosarcoma. The tumour cells show
pleomorphic and polymorphic features with direct
formation of osteoid by sarcoma cells (H & E, x
Fig- Osteosarcoma.Rediograph of the jaw removed 100).
from the patient seen, show the irregular bone
destruction and pattern of new bone formation
which replaces the normal structure.

Fig- Osteosarcoma. Trabeculae of abnormal woven


Fig- Osteosarcoma. A post-mortem specimen of bone surrounded by atypical cells which mitoses
lung from the same patient shown in fig-9.15. are frequent and pleomorphism is conspicuous.
Malignant cells infiltrate the alveoli and are
forming woven bone(left).
Squamous Cell Carcinoma :
Over 90% of malignant neoplasm of the mouth are squamous cell carcinoma
arising from mucosal epithelium.

Distribution Of Oral Carcinoma By anatomical Site, Age, Sex Of Patients :

Anatomical Site. Age Range(Year). Causes In Males Causes In Females


(% Of Total). (% Of Total).
Lower Lip. 14.99 97.50 02.50
Tongue. 14.99 92.50 07.50
Gingiva. 20.99 93.60 06.40
Palate. 14.99 85.90 14.10
Upper Lip. 20.99 92.30 07.70
Buccal Mucosa 20.99 78.70 11.30

Etiological Features :
1. Possible carcinogens—Tobacco, Alcohol, Areca nut (Betel).
2. Sunlight (Lip only).
3. Infections—Syphilis, Candidacies, Viruses.
4. Mucosal Diseases—Oral epithelial dysplasia, Lichen planus, Oral sub-mucous
Fibrosis.
5. Genetic disorder—Dyskeratosis congenital, Fanconi’s anemia.

Clinical Features :
1. In the earliest stages, carcinoma appear as painless red speckled or white
patches and only a monitory are ulcerated.
2. If a carcinoma enlarges, it may develop into a raised module or become
ulcerated.
3. Indurations result from inflammation and fibrosis and infiltration of the tissues.
4. Carcinoma has formed an indurated ulcer with the typical rolled border.
5. Ulceration may be associated with soreness or stinging pain when sharply
flavored food is eaten.
6. Spontaneously bleeding or to mild trauma is also a late feature.
Histological Features :

1. Squamous cell carcinoma consist of sheets and nests of cells with obvious
origin form squamous epithelium.
2. These cells are generally large and show a distinct cell membrane, although
intercellular bridges or tonofibrils often cannot be demonstrated.
3. The nuclei of the neoplastic cells are large.
4. Nuclei which stain heavily with haematoxylin are referred to as hyper
chromatic.
5. Presence of individual cell keratinization and the formation of numerous
epithelial or keratin, pearls of varying size.

Metastasis :

Metastasis from intra oral carcinoma of different sites involved chiefly the sub-
maxillary and superficial and deep cervical lymph nodes.

Treatment :

Each case is judged individually and biopsy mandatory.


Options of treatment as—
-- Surgery.
-- Chemotherapy.
-- Radiotherapy.
are considered in the benefit of each patient.

Mode of Treatment—
-- Radiotherapy.
-- Chemotherapy.
-- Radiotherapy and Chemotherapy.
-- Surgery and Radiotherapy.
-- Chemotherapy and Surgery, Radiotherapy.
-- Cryosurgery and others—if lesion is small.
Fig- A small squamous carcinoma. At low power the Fig- Squamous carcinoma. In this poorly-
epithelium is seen to invade deeply into the differentiated carcinoma there is little or no keratin
connective tissue and underlying muscle. At this formation and the malignant cells show great
early stage there is no ulceration. pleomorphism with variably-sized nuclei, many of
which are hyper chromatic, and frequent mitotic
figures.

Fig- Squamous carcinoma. At high power a group of


tumour cells shows typical cytologic irregularity. Fig- Squamous carcinoma. In this carcinoma
Surrounding and beneath the tumour, muscle fibers malignant epithelium is invading around nerve
are being destroyed. sheaths. Although this is infrequent, occasionally
carcinoma may spread some distance from the main
tumour mass along nerve trunks.

Fig- Squamous carcinoma. In this moderately well-


differentiated tumour many of the neoplastic Fig- Squamous carcinoma. Less frequent than
epithelial cells are forming keratin pearls. perineural invasion is vascular invasion. Here a
cluster of poorly- differentiated malignant epithelial
cells have eroded the wall of the vessel and entered
the circulation
TNM Classification :
T --- Primary tumour.
N --- Regional lymphnode.
M --- Distant metastasis.

01. Primary tumour :


T0 --No evidence.
T15--Carcinoma in situ.
T1 --Tumour less than 02 cm in diameter.
T2 --Tumour greater than 02 cm but less than 04 cm in diameter.
T3 --Tumour greater than 04cm in diameter with deep invasion in
Surrounding structure.
02. Regional lymphnode :
N0– No clinically positive node.
N1– Single clinically positive homolateral node less than 3 cm in diameter.
N2– Single clinically positive homolateral node more than 3cm but less than
06 cm in diameter.
N2a--Single clinically positive homolateral node 3-6 cm in diameter.
N2b--Multiple clinically positive homolateral nodes over 6 cm in diameter.
N3-- Massive homolateral node, bi-lateral nodes or contra-lateral nodes.
N2a--Clinically positive homolateral node.
N3b--Bilateral clinically positive node.
N3c—Contra-lateral clinically positive nodes only.

Stage Grouping :
Stage— І : T1 , No , Mo.
Stage— ІІ : T2 , No , Mo.
Stage—ІІІ : T3 , No , Mo.
T1 Or T2 Or T3 , N1 , Mo
Stage-- ІV : T4 , No Or N1 , Mo
Any T1 , N2 Or N3 , Mo
Any T , Any N , M1

References : (a) Prof. Kruger.


(b) Prof.Vinod Kapoor.
(c) Prof. Nilima.
(d) Prof. R.A. Cawson.
(e) Contemporary.

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