CR0238 Metastatic papillary thyroid carcinoma to the maxilla: a rare case report
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tobacco use, alcohol use, or recreational (including intravenous) drug usage. The review of systems found myopia, depression, and amenorrhea. Detailed physical examination found short stature, with evidence of delayed puberty. Oculocutaneous albinism, facial asymmetry, and lymphadenopathy were negative. Oral examination found poor oral hygiene in her permanent dentition, with gingivitis and multiple restorations. A full-mouth radio- graphic examination found extensive caries, relatively short roots of posterior teeth, and normal bone levels. Consultation with a pediatrician, hematologist, and oncologist confirmed a medical history of an accelerated phase of CHS, allogeneic BMT following conditioning with thiotepa, cyclophosphamide, and 1200 cGy of TBI at age 11 (2008); osteopenia; and endocrine deficiency after TBI and chemotherapy. Conclusions: This case is an atypical phenotype presenta- tion of CHS in that the patient lacked OCA, had no serious in- fections in childhood, and had reached age 11 without previous complications. Remarkably, the CHS-associated oral findings reported in the literature, such as ulcerations and early-onset periodontitis, were absent. CR0360 INTRAOSSEOUS SCHWANNOMA OF THE JAWS: UPDATED REVIEW OF THE LITERATURE Gisele N. Mainville, Adel Kauzman, Nathalie Rei, Volong Dao, Department of Stomatology, Université de Montréal, Mon- treal, Canada Objectives: Schwannomas are benign neural sheath tumors derived from Schwann cells. Although rare, they are the most common of intraosseous neural tumors. We present a case involving the mandible and provide an updated review of the literature on schwannomas arising within the maxilla or the mandible. Summary: A 39-year-old man presented with occasional pain involving the right mandible. There was no paresthesia or bony expansion. A panoramic radiograph found an elongated, scalloped, and well-defined radiolucency centered on the inferior alveolar nerve in the right posterior mandibular body. An inci- sional biopsy found Antoni B tissue, nodules of whorled spindle cells, but no Verocay bodies. Immunohistochemistry found S-100 + (diffuse), vimentin-positive, EMA , SMA , and CD68 cells, leading to a diagnosis of schwannoma. Surgical enucleation was accomplished through a sagittal split osteotomy to preserve the inferior alveolar nerve. The English-language literature in- cludes 74 cases of intraosseous schwannomas of the jaws. Including a Chinese case series and our case, this number in- creases to 83. Intraosseous schwannomas of the jaw show a marked predilection for the mandible (84.3%) compared with the maxilla (15.6%). Posterior segments are more often affected. There is a slight female predilection and a mean patient age of 30.8 years at the time of diagnosis. Over half of cases produce bony expansion and present as a well-defined unilocular radio- lucency. Mandibular cases are largely located within the inferior alveolar nerve canal. Paresthesia is a presenting symptom in only 12% of cases. Treatment includes enucleation, with possible ac- cess by sagittal split osteotomy. Periodic follow-up is recom- mended, although recurrences are uncommon. Conclusions: This is the largest review of the literature to date. Sagittal split osteotomy is a versatile orthognathic surgical technique mainly used to correct dentoskeletal deformities. Leaving no extraoral scars, the technique can be used to access benign tumors of the mandibular body while preserving the inferior alveolar nerve. CR0406 RARE TYPHOID FEVER CASE IN ORAL MEDI- CINE Temitope Omolehinwa, Arthur Kuperstein, Agnes Radwan-Woch, Thomas P. Sollecito, Department of Oral Medicine, University of Pennsylvania, Philadelphia, PA, USA Background: A rare case of typhoid fever, with diagnosis and treatment unsubstantiated, complicated with a space infec- tion, presents to a dental school for emergency care. Summary: A 14-year-old African girl presented to the Emergency Care Clinic, Department of Oral Medicine, Penn Dental Medicine, with a right facial swelling, pain, and fever of 7 days’ duration. The etiology was determined to be related to abscessed maxillary right first premolar. During the medical work-up, her mother said that the patient recently arrived in the United States but had a vague history of a diagnosis of typhoid fever 1 month earlier while in Africa. Because of the uncertainty of her treatment and current infectious level and the elevated contagion risk while in the school environment, and subsequent to discussions with the emergency department physician at Children’s Hospital of Philadelphia on our campus, we chose to send the patient to that hospital to be evaluated and treated in isolation. Laboratory tests were performed, malaria smear was performed, and blood culture was sent. Results for complete blood cell count and liver function tests were within the reference ranges. The rapid malaria result was negative. Blood results were preliminary no growth. Incision and drainage was performed. Pending medical status and risk of contagion being determined, in consultation with an infectious disease specialist, the patient would be able to return to Penn Dental Medicine for further treatment. Salmonella enterica subspecies enterica serovar Typhi does not have nonhuman vectors. Significant modes of trans- mission include oral via food or beverages (handled by an indi- vidual who chronically sheds the bacteria through stool or, less commonly, urine) and hand-to-mouth after using a contaminated toilet and neglecting hand hygiene. Conclusions: The challenge of treating an emergency pa- tient, presenting with potentially infectious disease in a highly populated dental school environment, is discussed. Collaboration with infectious disease specialists is emphasized, to meet the demands of treating an expanding head and neck space infection and protecting the dental school population. CR0238 METASTATIC PAPILLARY THYROID CARCI- NOMA TO THE MAXILLA: A RARE CASE REPORT Mahnaz Fatahzadeh, Gyathri Subramanian, Steve S. Singer, Rabie Shanti, Department of Diagnostic Sciences, Rutgers School of Dental Medicine, Newark, NJ, USA Background: Nearly 1% of all oral malignancies are met- astatic. Although metastatic disease may involve oral osseous and soft tissues, neoplastic spread to the maxilla, particularly from a thyroid source, is uncommon. We describe a rare case of papillary thyroid carcinoma metastatic to the maxillary alveolar process and sinus. Summary: A 43-year-old woman presented with a hemor- rhagic mass in the upper right jaw noted 3 weeks earlier. Her medical history indicated hypertension and papillary thyroid carcinoma with multifocal spread. Her medications included hy- drochlorothiazide, levothyroxine, oxycodone, and recently dis- continued chemotherapy with sorafenib for management of metastatic disease. Social history was noncontributory, and she reported no allergies. There was no lymphadenopathy. The pa- tient was dentate, and the right posterolateral palate appeared swollen with a spongy consistency. An exophytic mass displacing OOOO ABSTRACTS Volume 117, Number 5 Abstracts e369
Transcript of CR0238 Metastatic papillary thyroid carcinoma to the maxilla: a rare case report
OOOO ABSTRACTS
Volume 117, Number 5 Abstracts e369
tobacco use, alcohol use, or recreational (including intravenous)drug usage. The review of systems found myopia, depression, andamenorrhea. Detailed physical examination found short stature,with evidence of delayed puberty. Oculocutaneous albinism,facial asymmetry, and lymphadenopathy were negative. Oralexamination found poor oral hygiene in her permanent dentition,with gingivitis and multiple restorations. A full-mouth radio-graphic examination found extensive caries, relatively short rootsof posterior teeth, and normal bone levels. Consultation with apediatrician, hematologist, and oncologist confirmed a medicalhistory of an accelerated phase of CHS, allogeneic BMTfollowing conditioning with thiotepa, cyclophosphamide, and1200 cGy of TBI at age 11 (2008); osteopenia; and endocrinedeficiency after TBI and chemotherapy.
Conclusions: This case is an atypical phenotype presenta-tion of CHS in that the patient lacked OCA, had no serious in-fections in childhood, and had reached age 11 without previouscomplications. Remarkably, the CHS-associated oral findingsreported in the literature, such as ulcerations and early-onsetperiodontitis, were absent.
CR0360 INTRAOSSEOUS SCHWANNOMA OF THEJAWS: UPDATED REVIEW OF THE LITERATURE GiseleN. Mainville, Adel Kauzman, Nathalie Rei, Volong Dao,Department of Stomatology, Université de Montréal, Mon-treal, Canada
Objectives: Schwannomas are benign neural sheath tumorsderived from Schwann cells. Although rare, they are the mostcommon of intraosseous neural tumors. We present a caseinvolving the mandible and provide an updated review of theliterature on schwannomas arising within the maxilla or themandible.
Summary: A 39-year-old man presented with occasionalpain involving the right mandible. There was no paresthesia orbony expansion. A panoramic radiograph found an elongated,scalloped, and well-defined radiolucency centered on the inferioralveolar nerve in the right posterior mandibular body. An inci-sional biopsy found Antoni B tissue, nodules of whorled spindlecells, but no Verocay bodies. Immunohistochemistry foundS-100+ (diffuse), vimentin-positive, EMA�, SMA�, and CD68�
cells, leading to a diagnosis of schwannoma. Surgical enucleationwas accomplished through a sagittal split osteotomy to preservethe inferior alveolar nerve. The English-language literature in-cludes 74 cases of intraosseous schwannomas of the jaws.Including a Chinese case series and our case, this number in-creases to 83. Intraosseous schwannomas of the jaw show amarked predilection for the mandible (84.3%) compared with themaxilla (15.6%). Posterior segments are more often affected.There is a slight female predilection and a mean patient age of30.8 years at the time of diagnosis. Over half of cases producebony expansion and present as a well-defined unilocular radio-lucency. Mandibular cases are largely located within the inferioralveolar nerve canal. Paresthesia is a presenting symptom in only12% of cases. Treatment includes enucleation, with possible ac-cess by sagittal split osteotomy. Periodic follow-up is recom-mended, although recurrences are uncommon.
Conclusions: This is the largest review of the literature todate. Sagittal split osteotomy is a versatile orthognathic surgicaltechnique mainly used to correct dentoskeletal deformities.Leaving no extraoral scars, the technique can be used to accessbenign tumors of the mandibular body while preserving theinferior alveolar nerve.
CR0406 RARE TYPHOID FEVER CASE IN ORAL MEDI-CINE Temitope Omolehinwa, Arthur Kuperstein, AgnesRadwan-Woch, Thomas P. Sollecito, Department of OralMedicine, University of Pennsylvania, Philadelphia, PA, USA
Background: A rare case of typhoid fever, with diagnosisand treatment unsubstantiated, complicated with a space infec-tion, presents to a dental school for emergency care.
Summary: A 14-year-old African girl presented to theEmergency Care Clinic, Department of Oral Medicine, PennDental Medicine, with a right facial swelling, pain, and fever of 7days’ duration. The etiology was determined to be related toabscessed maxillary right first premolar. During the medicalwork-up, her mother said that the patient recently arrived in theUnited States but had a vague history of a diagnosis of typhoidfever 1 month earlier while in Africa. Because of the uncertaintyof her treatment and current infectious level and the elevatedcontagion risk while in the school environment, and subsequentto discussions with the emergency department physician atChildren’s Hospital of Philadelphia on our campus, we chose tosend the patient to that hospital to be evaluated and treated inisolation. Laboratory tests were performed, malaria smear wasperformed, and blood culture was sent. Results for completeblood cell count and liver function tests were within the referenceranges. The rapid malaria result was negative. Blood results werepreliminary no growth. Incision and drainage was performed.Pending medical status and risk of contagion being determined, inconsultation with an infectious disease specialist, the patientwould be able to return to Penn Dental Medicine for furthertreatment. Salmonella enterica subspecies enterica serovar Typhidoes not have nonhuman vectors. Significant modes of trans-mission include oral via food or beverages (handled by an indi-vidual who chronically sheds the bacteria through stool or, lesscommonly, urine) and hand-to-mouth after using a contaminatedtoilet and neglecting hand hygiene.
Conclusions: The challenge of treating an emergency pa-tient, presenting with potentially infectious disease in a highlypopulated dental school environment, is discussed. Collaborationwith infectious disease specialists is emphasized, to meet thedemands of treating an expanding head and neck space infectionand protecting the dental school population.
CR0238 METASTATIC PAPILLARY THYROID CARCI-NOMA TO THE MAXILLA: A RARE CASE REPORTMahnaz Fatahzadeh, Gyathri Subramanian, Steve S. Singer,Rabie Shanti, Department of Diagnostic Sciences, RutgersSchool of Dental Medicine, Newark, NJ, USA
Background: Nearly 1% of all oral malignancies are met-astatic. Although metastatic disease may involve oral osseous andsoft tissues, neoplastic spread to the maxilla, particularly from athyroid source, is uncommon. We describe a rare case of papillarythyroid carcinoma metastatic to the maxillary alveolar processand sinus.
Summary: A 43-year-old woman presented with a hemor-rhagic mass in the upper right jaw noted 3 weeks earlier. Hermedical history indicated hypertension and papillary thyroidcarcinoma with multifocal spread. Her medications included hy-drochlorothiazide, levothyroxine, oxycodone, and recently dis-continued chemotherapy with sorafenib for management ofmetastatic disease. Social history was noncontributory, and shereported no allergies. There was no lymphadenopathy. The pa-tient was dentate, and the right posterolateral palate appearedswollen with a spongy consistency. An exophytic mass displacing
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the maxillary right second molar and emerging from palatal sul-cus of the right maxillary first molar was present medially. Conebeam computed tomography found a soft tissue mass in the rightmaxillary sinus, loss of lamina dura for the maxillary right secondand third molars, destruction of the alveolus posterior to themaxillary right first molar and effacement of the sinus floor.Clinical and radiographic findings indicated an aggressive pro-cess. The patient’s medical history supported thyroid cancermetastatic to the oral cavity. Primary malignancies includinglymphoma, minor salivary gland tumor, and a tumor of mesen-chymal origin were also considered. Biopsy found papillary andfollicular structures lined by cuboidal cells with round basophilicnuclei within the connective tissue. Microscopic findings indi-cated a metastatic adenocarcinoma, and histologic features sug-gested a thyroid origin. Immunohistochemical staining waspositive for thyroglobulin. The patient received radiation therapyfor metastatic oral disease.
Conclusions: Definitive diagnosis of metastatic malignancyto the oral cavity frequently requires extensive work-up, startingwith a thorough medical history. Dental practitioners should befamiliar with the spectrum of metastatic oral disease and, despiteits rarity, consider this possibility in the differential diagnosis,particularly in patients with prior or current history of malig-nancy.
CR0244 PROLIFERATIVE VERRUCOUS LEUKOPLAKIA:A PROGRESSIVE EVOLVING DISEASE OF ORALMUCOSA Lujain Homeida, Mahnaz Fatahzadeh, Depart-ment of Diagnostic Sciences, Rutgers School of DentalMedicine, Newark, NJ, USA
Background: Proliferative verrucous leukoplakia (PVL) isan uncommon form of leukoplakia with a high propensity formultifocality, malignant transformation, and recurrence afterremoval. We describe an older woman with multiple, long-standing oral lesions that in retrospect followed a clinical courseexpected from PVL, ultimately developing a multitude of ma-lignant and premalignant oral lesions.
Summary: A 62-year-old woman presented for evaluationof multiple asymptomatic oral lesions noted by her prosthodon-tist. She was aware of lesions for years and received 2 prior bi-opsies with benign findings. Her medical history was significantfor osteoporosis treated by oral bisphosphonates. She was achronic smoker but denied alcohol abuse. There was no lymph-adenopathy. She was partially dentate, with implant-supportedfixed restorations in both arches. A broad, mixed verrucopapillarygrowth was visible on the right buccal mucosa. Also notable wereirregular, adherent white patches of variable thickness with orwithout erythema affecting the left buccal mucosa, bilateralventral tongue, anterior attached gingivae in both arches, and hardpalate. Differential diagnosis included verrucous hyperplasia,verrucous carcinoma, and squamous cell carcinoma for the rightcheek lesion and hyperkeratosis, lichen planus, lichenoid muco-sitis, hyperplastic candidiasis, leukoplakia, and dysplasia for otherlesions. Histopathologically, right buccal mucosa growth hadhyperkeratinized epithelium with basal and parabasal cell layersshowing nuclear hyperchromatism. Large, broad epithelial pro-liferations extended deep into the submucosa and displayedkeratinization. Histologic features indicated a malignant kerati-nizing epithelial neoplasm and candidiasis. Two other lesionsexamined histologically had varying degrees of dysplasia. Thepatient was referred to a head and neck surgeon for furtherevaluation and management.
Conclusions: Unfortunately, definitive diagnosis of PVLoften relies on retrospective correlation of clinical and histologicfindings from multiple biopsies over a protracted course. Dentalproviders should be aware of the aggressive behavior of this variantof leukoplakia, identify those affected early on, institute frequentpreventive examinations, and appropriately manage the lesions.
CR0300 NON-BISPHOSPHONATE-RELATED OSTEO-NECROSIS OF THE JAW Lauren Levi, Jamie Cohn, JosephHuryn, Cherry Estilo, Dental Department, Memorial SloanKettering Cancer Center, New York, NY, USA
Background: Osteonecrosis of the jaw (ONJ) is a well-documented adverse effect associated with bisphosphonatetherapy. Nonetheless, recently, other antiresorptive and anti-angiogenic medications have also been implicated in ONJ. Previ-ous case studies have reported ONJ in patients with exposure todenosumab (an inhibitor of receptor activator of nuclear factor k Bligand), bevacizumab (a vascular endothelial growth factor inhib-itor), and sunitinib (a tyrosine kinase inhibitor that targets vascularendothelial growth factor receptors among others). We report 5patients with no known history of bisphosphonate administrationwho displayed clinical findings consistent with ONJ.
Summary: Three patients presented with ONJ related todenosumab administration. In 1 patient, ONJ was linked todenosumab and sunitinib. One patient developed ONJ afterexposure to bevacizumab and denosumab. All but one of thepatients exhibited ONJ with no known history of recent dentalsurgical procedures. Manifestations of ONJ included nondrainingfistulas, mobile teeth, purulent exuberant lesions, and exposedbone. Our treatment approaches included oral antibiotics andchlorhexidine gluconate 0.12% mouthrinses.
Conclusions: The pathogenesis of ONJ is still not well un-derstood, and it appears that denosumab, bevacizumab, and suni-tinib administration may be a risk factor for ONJ development.Further studies are needed to evaluate the risks and prevalence ofnon-bisphosphonate-related ONJ. Given these recent findings,health care providers should be aware that ONJ may also manifestin patients undergoing antiresorptive or antiangiogenic therapy.
CR0404 MUCOSAL LESIONS AFTER HEMATOPOIETICSTEM CELL TRANSPLANT Jamie Cohn, Lauren Levi,Ronald Ghossein, Joseph Huryn, Cherry Estilo, Departmentof Dental Service, Memorial Sloan Kettering Cancer Center,New York, NY, USA
Background: Patients previously treated with hematopoi-etic stem cell transplant (HSCT) often develop oral mucosal le-sions. The nature of these lesions includes oral infections (viral,fungal, or bacterial), oral graft-vs-host disease, and premalignantor malignant conditions. Therefore, vigilant coordination of carebetween the oncologist and oral health specialist are crucial forearly identification and management of oral lesions. We report 7patients who developed isolated, deep, corrugated, painful lesionsafter HSCT.
Summary: Seven patients presented with deep painfulmucosal lesions, some involving skeletal muscle, after HSCT. Allof the patients had hematologic malignancies and underwenteither an autologous or allogeneic HSCT. Each patient was placedon an antiviral therapy before their visit to the Dental Service atMemorial Sloan Kettering Cancer Center, with no resolution ofsymptoms or clinical presentation. The patients’ median presen-tation date was 184 days post-HSCT. Incisional biopsy wasperformed in 2 patients. The pathology report was consistent with
