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1097-0142 (197402) 33 2 324 Aid-Cncr2820330205 3.0.co 2-U PDF
1097-0142 (197402) 33 2 324 Aid-Cncr2820330205 3.0.co 2-U PDF
TABLE
2. Ameloblastoma of Mandible Treated b y External Radiation (9 Cases)*
Recurrence Subsequent
Age/Sex Year treated (years later) mandibulectom y Result
25 P t 1921 t Segmental N E D * 47 yrs.
48 0 1927 2.5 Hemi N E D 23 yrs.
30 0 1933 6 Segmental Op. death
50 P 1940 3 Hemi Died osteo. 3 mos.
49 3 1944 7 Hemi N E D 24 yrs.
19 Pt 1947 t Segmental N E D 25 yrs.
50 0 1948 8 Segmental N E D 12 yrs.
47 3 1951 2 Segmental N E D 12 yrs.
* 1 Patient had residual disease; no subsequent Rx L F U * 3 yrs.
t Residual disease
* LFU = Lost t o followup; NED = No evidence of disease.
No. 2 AMELOBLASTOMASeizdev et al. - 329
16 Yearsalter Seurn$ry Tnatmnt
0 Mandible (72 Cases)
B Maxilla (20Cases
n -
- NED
NED
NED
NED
Segmental NED
Nt D
-- DIED NED
LFU NED
NED
RLC
LfU NED
NED
Hem1 DIED NED
NED
Hemi + pttial WD
Months Years Recorded Maxillectomy NED
FIG. 4. Duration of signs and symptoms of patients FIG. 6. Managcment of recurrent lesions after curct-
with ameloblastoma. tagc in ameloblastoma of mandible.
treated by further resections. Six patients un- Pain was reported by 8 patients, all of whom
derwent hemi-mandibulectomy. Their lesions had recurrent tumor. Nasal obstruction and
were somewhat larger, the size varying from 3 epistaxis occurred only in previously treated
cm to 9 cm, averaging 6 cm. They are all alive patients. I n 14 patients the duration of symp-
and free of disease. toms was less than 1 year. T h e mass was clini-
cally described as cystic, solid, or ulcerated.
Maxilla Seven of the primary cases had radiologic eval-
Of 20 patients with ameloblastoma of max- uation of their paranasal sinuses. T w o showed
illa treated at Memorial Hospital, 9 had pri- calcifications in cystic tumors; 3 showed opac-
mary treatment elsewhere. T w o patients were ity of maxillary antrum; and 2 showed de-
referred here after biopsy. Eleven patients struction with opacity of the antrum.
(55%) were male and 9 (457&) female, corre- Treatment: Radiation therapy, curettage,
sponding to an over-all ratio of 52 males to 48 and partial or radical maxillectomy, were the
females i n the collected statistical data of modalities of treatment employed (Table 4).
Rockoff.IF T h e size of lesion was recorded T w o patients who were treated (one in 1936
as 3-10 cm with an average diameter of 5 cm. and one i n 1937) with external radiation ther-
Since signs and symptoms of ameloblastoma apy, had recurrence of their tumors; one after
of maxilla are not mentioned in most of the 6 months, the other after 15 years. Both subse-
reports, brief discussion of these is relevant quently underwent successful partial maxillec-
here. tomy and died without evidence of recurrence
Swelling, either of cheek, gingiva, or hard 12 years postoperatively.
palate was the chief complaint in 19 patients. Recurrences occurred in all I I patients
treated by curettage. Management of these pa-
Years after Secondary Treatment tients is summarized in Fig. 7. Of the three
0 2 4 6 8 10 12 14 16 18 20 22 24
I I I I I I I I I I i I I
patients treated by radical maxillectomy, two
were cured, and the third died of massive
External RT DOD
local recurrence with proven pleuro-pulmo-
External RT
+Implant
- LFU with Dixase
NO
nary metastases. Partial maxillectomy was
done in two cases; one patient had recurrence
Marginal
&Section
- REC 7 years later, and the other is free of disease
Died
after 4 years. Five patients were treated by re-
Hemimandib- NED FED peated curettage. One patient received exter-
ulectomy LFU FED nal radiation therapy, and died of disease 1
WD
year later.
Re-Curettage IFU NED
T h e most effective treatment modality ap-
No Treatment 2 Patients
pears to be adequate resection (Table 4).
FIG. 5. Managcment of persistent ameloblastoma of Seven of the 11 primary cases were treated by
mandible after curettage. LFU = Lost to followup;
REC = Recurrence; NED = No evidence of disease; resection at Memorial Hospital. Six of these
DOD = Died of diseasc. had partial and 1 radical maxillectomy. Five
3 30 February 1974
CANCER VOl. 33
TABLE
3 . Over-all Results of Treatment in Ameloblastoma of Mandible
Secondary treatment (resections)
Initial No. of Recurrence Controlled
treatment patients No. % No. treated No. %
External R T 9 9 100 8 7” 87
Curettage 32 29 90 27 21 77
Resection
Marginal 2 - 0
Segmental 23 5 22 100
Henti- 6 -
-_ __
Twr.4~ 72 43
* Operative death.
of the patients treated by partial maxillec- tooth extraction, trauma, or infection at the
tomy are alive and free of disease 9-18 years site of ameloblastoma.15 Georgiade et al. noted
postoperatively. T h e sixth patient died of that ’70% of their patients had had tooth
pneumonia 2 months after surgery. T h e pa- extraction, trauma, or infection at the site of
tient who had radical maxillectomy as the ini- ameloblastoma.4 I n 14 of 18 patients with
tial treatment of a large 6 cm tumor is alive history of tooth extraction, diagnosis of amelo-
and well at 18 years. blastoma was made only after the removal of
an impacted tooth resulted in nonhealing of
DISCUSSION the wound, sinus formation, or further growth
of the tumor. Because there is no other abso-
Ameloblastoma of mandible has been dis- lute way of making diagnosis of ameloblas-
cussed extensively in the literat~re.5.~3,1~,17.20toma, careful histologic examination of the
Since ameloblastoma of maxilla forms only lining of all odontogenic cysts has been re-
about 20y0 of the total reported cases,16 and peatedly empha~ized.l,l~,~Q,*0 Five examples of
each series has only a few patients, the natural ameloblastoma developing in the wd1 of the
history of maxillary ameloblastoma has, so dentigerous cyst were seen in this series. None
far, been unclear. Vitriolic arguments for and was associated with primordial cysts.
against “conservative” and “radical” excisions Once the diagnosis of ameloblastoma has
abound with no clearcut criteria for prefer- been established, it may be difficult to decide
ence of either. I n an effort to arrive at a sem- on the best form of therapy. T h e results of
blance of rational management, analysis of curettage obtained in 32 patients with amelo-
patients treated over 50 years is presented, blastoma of mandible and 11 patients with
and some of the controversial points are ex- ameIoblastoma of maxilla have certainly indi-
amined in light of data obtained. cated the ineffectiveness of this form of ther-
Eighteen of the 92 (20%) patients seen apy in achieving tumor eradication. Only 3 of
with ameloblastoma gave a history of tooth 32 patients have stayed free of recurrence after
extraction without recognition of presence of repeated curettage for mandibular ameloblas-
ameloblastoma at that time. Sixty-five per- toma-a cure rate of only 10%. Subsequent
cent of Rankow’s patients gave a history of treatment by segmental or hemi-mandibulec-
TABLE
4. Over-all Results of Treatment in Ameloblastoma of Maxilla
Secondary treatment (resections)
Initial No. of Recurrence Controlled
treatment patients No. % No. treated No. %
External R T -7 2 100 2 2 100
Curettage 11 11 100 11 4 36
Resection
Partial 6 * 0
Radical 1 _ 0
-_ __ -_ -- __ __
-_ TOTAL 20 13 0 13 6 46
* 1 died of pneumonia N E D 2 months later, 1 LFL. after discharge.
No. 2 AMELOBLASTOM
A Sehdeu et al. - 33 1
Yearsifter Ssmnaly Tnaimnt
0 2 4 6 7 8 1 2 1 4 1 6 1 8 Z l 2 2 2 4 X 2 8 3 l
T h e opening of the maxillary antrum to di-
I I I I I I I I I I I I I I I I rect, and clinically invisible, spread of amelo-
Radi~l
Marilledomy
DOD
NED blastoma by currettage, perhaps contributes to
Dled NED
delay in early recognition and hence adequate
PtRltl -NED
treatment of recurrence. Once the tumor
Marlllactomy
Re-curettage
-
- RC
DDD
RC LFU
NED
~
the Haversian systems of compact bone. Thus, undifferentiated appearance although struc-
although the compact bone of the lower bor- turally these resembled the primary tumor in
der of mandible may be eroded it is unlikely their histologic pattern. Epidermoid carci-
to be invaded. He, therefore, concludes that in noma in association with ameloblastoma was
the treatment of these lesions, if it is thought not noticed in any of these.
desirable on general clinical and surgical Two additional patients had clinical evi-
grounds to save this part of the bone, then as dence of metastases to organs other than
a calculated risk the cIinical and radiologic lungs, i.e. liver and bone (Table 6). They had
margin of the lesion in this area may be re- no evidence of local recurrence at time of
garded as the true margin." It can, therefore, death.
be stated that marginal resections in small pri-
mary cases of ameloblastomas may give satis- SUMMARY
factory results but that its use in curettage
failure was followed by 100% recurrence rate Results of various treatment modalities in
in three patients in whom it was tried. 72 patients with mandibular and 20 patients
Reconstruction after segmental resection of with maxillary ameloblastoma are analyzed.
mandible was performed in 12 of 32 patients Certain conclusions are reaffirmed, others
using autogenous bone or metal prosthesis. I n emerge anew. All of these may be summarized
only one patient infection developed and the as :
steel mesh had to be removed. All other recon- 1. Curettage was followed by local recur-
structions were successful. rence in 90% of mandibular and 100% of
Nine of 92 patients died because of uncon- maxillary ameloblastomas.
trolled ameloblastoma. Four of these showed
2. Whereas mandibular resection may con-
pulmonary metastases clinically before death,
trol the recurrence after curettage in most pa-
but died as a direct consequence of uncon-
tients, maxillary resection for recurrence, even
trolled local tumor.
Seven patients with ameloblastoma of the when radical, is usually ineffective or impossi-
jaw developed distant lesions, consistent with ble.
metastasis. Five patients showed pleuro-pul- 3. Whereas marginal resection may control
monary metastasis, histologically proven in the small primary mandibular ameloblastoma,
four (Table 5). All five of these patients had it was followed by relatively prompt recur-
massive locally recurrent ameloblastoma in rence whenever it was performed for curettage
spite of multiple attempts at eradication. T h e failure.
metastatic deposits had a comparatively more 4. Whereas resection offered a good chance
TABLE
5. Results of Treatment in Five Patients with Pulmonary Metastases
Treatment
Age a t onset Elsewhere Memorial Hospital Survival after onset
19 d' Tooth extraction Hemimandibulectomy 4 months
Excision X 2
21 0 Curettage
Excision X 2 RT 39 years
RT
Radical inaxillectomy
60 0" Curettage X 2 Excision recurrence 10 years
Excision metastases
Mandibulectomy
44 8 Mandibulectorny RT 34 years
Mandibulectomy
Multiple excisions
45 0" Curettage X 2 Orbital exenteration 28 years-Living
Cryosurgery X 16
No. 2 -
AMELOBLASTOMA Sehdev et al. 333
TABLE
6. Results of Treatment in Two Patients with Non-Pulmonary Metastases
Treatment
Age a t onset Elsewhere Memorial Hospital Survival after onset Site of metastases
55 3 Maxillectomy None 2 years Lumbosacral spine
RT
36 3 Curettage Implant 17 years Liver
Right mandibulectomy
of cure after recurrence following curettage, followed by adequate resection did not seem
radiation therapy or repeated curettage only to worsen prognosis.
served as palliation, with no control over 6. Whereas distant metastases are rare and,
spread of the tumor. perhaps, not the direct cause of death, they do
5. Whereas external radiation therapy ap- occur. Early, adequate resection might avoid
pears to be ineffective in controlling the repeated procedures and increased chance of
tumor, early recognition of therapeutic failure distant metastasis.
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