DENTAL SCIENCE

NON ODONTOGENIC TUMORS

• dr. I Gede Budhi Setiawan, SpB(K)Onk

 CANCER DEFINITION
• Cancer is a group of diseases characterized by
uncontrolled growth and spread of abnormal cells.
• Normal cells carry out specific functions of the
body and the cells' growth is controlled by a
complicated biochemical mechanism of the body.
• Cancer cells grow in an uncontrollable manner and
are unable to recognize their own natural
boundaries due to faulty gene mutations in the
cancer cells.
 DERIVATION OF CELLS
• Embryo  Cells Differentiation.
• The cells arrange into distinct layers called
germ layers:

▪ Ectoderm (outer).
▪ Endoderm / Entoderm (inner).
▪ Mesoderm, develops between the ectoderm and
the endoderm.
 DERIVATION OF TISSUES
• The body tissues and organs develop from three primary germ layers
• The tissues derived from the ectoderm are:
– Epithelial tissue (epidermis)
– Modified epidermal tissue
– Nerve tissue, salivary glands,
– Epithelial tissue and mucous glands of the nose and mouth.
• Epithelial tissue derived from ectoderm is generally squamous epithelium

• The tissue derived from the endoderm are :

– Epithelial lining of the digestive tract, except at the open ends,
• Epithelial tissue derived from endoderm is essentially glandular epithelium.
 DERIVATION OF TISSUES
• The body tissues derived from mesoderm include:
– Muscles
– Fibrous tissue
– Bone and cartilage
– Fat or adipose tissue
– Blood and lymph vessels
 CANCER CLASSIFICATION
Carcinoma
• Malignant neoplasm of epithelial origin or cancer of the internal or
external lining of the body.
• Malignancies of epithelial tissue, account for 80 to 90 % of all cancer
cases.
• Epithelial tissue is found throughout the body.
• Carcinomas are divided into two major subtypes:
– Adenocarcinoma, which develops in an organ or gland,
– Squamous cell carcinoma, which originates in the squamous
epithelium.
 CANCER CLASSIFICATION
Sarcoma
• Sarcoma refers to cancer that originates in supportive and
connective tissues such as bones, tendons, cartilage, muscle, and fat.
• Generally occurring in young adults.

Lymphoma
• Lymphomas develop in the glands or nodes of the lymphatic system
 CANCER DIAGNOSIS
• The diagnosis of cancer entails an attempt to..
▪ Accurately identify the anatomical site of origin of the
malignancy
▪ The type of cells involved

• The body part in which cancer first develops is known as the

primary site.
• The body part where metastasized cancer cells grow and form
secondary tumors are known as secondary site.
 CANCER TREATMENT

• Surgery

• Radiotherapy

• Chemotherapy

• Hormonaltherapy

• Targetted therapy
 Oral Cavity Anatomy Component
• The oral cavity extends from vermilion border of
lips to the plane between junction of the hard
palate and soft palate
• Lips : upper and lower lip
• Oral cavity
• Buccal mucosa
• Tongue
• Ginggiva
• Retromolar area
• Flour of mouth
• Hard palate
 NON ODONTOGENIC TUMORS
Benign :
• Ossifying fibroma - Juvenile ossifying fibroma
• Fibro-osseous tumors
• Osteoma
• Osteoid osteoma and osteoblastoma
• Desmoplastic fibroma
• Chondroma
• Giant cell tumor
• Langerhans cell disease

Malignant :
• Squamous Cell Carcinoma HNSCC
• Osteosarcoma
• Chondrosarcoma
• Malignant fibrous histiocytoma
• Malignant peripheral nerve sheath tumor
• Ewing’s sarcoma
• Burkitt’s lymphoma
• Multiple myeloma
• Metastatic carcinoma
 Ossifiying Fibroma
• Etiology
– Unknown
• Predilection
– Onset between 5 and 15 years of age
– Maxilla and paranasal areas predominate
• Clinical appearance
– Rapid growth over several weeks
– Expansile lesion of bone, Cortices intact
– May produce deformity, malocclusion, dysfunction
– Well-defined radiolucency
 Ossifiying Fibroma
• Differential Diagnosis
– Osteosarcoma
– Central giant cell granuloma
– Odontogenic tumor
• Treatment
– Wide local excision
• Prognosis
– Recurrence rate of 30 to 50%
 Osteoma
• Etiology
– Unknown, May be a component of Gardner’s syndrome
• Predilection
– Mostly mandibula
– Rare Maxilla and sinus frontoethmoid
• Clinical appearance
– Sporadic form, may be Multiple
– Well-defined radioopacity
 Osteoma
• Differential Diagnosis
– Ossifying fibroma
– Osteoblastoma
– Focal sclerosing osteitis
• Treatment
– Wide local excision
• Prognosis
– Excellent, Low recurrence rate
 Osteoid Osteoma
• Predilection
– Young age, under 30
– Rarely in jaw, most common in femur and tibia
• Clinical appearance
– Soft tissue mass in cortex and may produce swelling of
overlying tissue
– intense pain depend to size
– Less than 2 cm, more than 2 cm  Osteoblastoma
 Osteoid Osteoma
• Differential Diagnosis
– chronic suppurative osteomyelitis

• Treatment
– Surgical excision

• Prognosis
– Excellent, Low recurrence rate
 Chondroma
• Central benign cartilaginous tumor
• Predilection
– Anterior portion of the maxilla, condyle and coronoid
process are the most common
– Rarely in jaw
• Clinical appearance
– Slow growing tumorproducing destruction and exfoliation
of teeth
– Painless
– Cyst like radiolucencies
 Chondroma

• Treatment
– Surgical excision

• Prognosis
– Excellent, Low recurrence rate
 Giant Cell Tumor
• Etiology
– Unknown, May be a component of Gardner’s syndrome
• Predilection
– Young, Female
– Ginggiva
• Clinical appearance
– Small, often lobulated
– Smooth-surfaced or pebble-surfaced
– Painless nodule
• Treatment
– Conservative surgical excision
 NON ODONTOGENIC TUMORS
Benign :
• Ossifying fibroma - Juvenile ossifying fibroma
• Fibro-osseous tumors
• Osteoma
• Osteoid osteoma and osteoblastoma
• Desmoplastic fibroma
• Chondroma
• Giant cell tumor
• Langerhans cell disease

Malignant :
• Squamous Cell Carcinoma HNSCC
• Osteosarcoma
• Chondrosarcoma
• Malignant fibrous histiocytoma
• Malignant peripheral nerve sheath tumor
• Ewing’s sarcoma
• Burkitt’s lymphoma
• Multiple myeloma
• Metastatic carcinoma
 RULES of SARCOMA

• Behavior
• Diagnosis
– Grading
• Treatment
– Surgery
 Osteosarcoma
• Etiology
– Associated with pre-existing bone
– Mutation/amplification of p53, c-myc, c-JUN, c-fos, MOM2,
CDK4, SAS
• Predilection
– Onset between 5 and 15 years of age
– Mandibula > Maxilla
• Clinical appearance
– Swelling, Pain, paresthesia, trismus, sinus obstruction
– Tooth mobility (vertical)
– Jaw mass may be ulcerated
 Osteosarcoma
• Treatment
– Radical ablative surgery
• Hemimandibulectomy
• Partial maxillectomy ± orbital exenteration
– Adjuvant chemotherapy/radiotherapy

• Prognosis
– Survival ranges from 12 to 58% at 5 years
– Mandibula better than maxila
 Chondrosarcoma
• Malignant tumor characterized by the formation of
cartilage, but not of bone
• Predilection
– Wide range of age, peak 30-40
– Maxilla (anterior) more freqwent than mandibula
(molar premolar)
• Clinical appearance
– Slow-growing, painless mass or swelling
– Minority cause pain
– Nasal symptoms, visual disturbances, and sensory
alterations
– Osteolytic lesion with poorly defined borders
 Chondrosarcoma
• Treatment
– Radical ablative surgery
– Adjuvant Radiotherapy (not survival, Longterm benefit )

• Prognosis
– Survival ranges from 32 to 81% at 5 years
– Mandibula better than maxila
 Ewing’s Sarcoma
• Etiology
– Unknown
– Chromosomal translocations
• Predilection
– 60% in males; over 95% in those under 20 years
– Second most common bone tumor of children
• Clinical appearance
– Chiefly in bone and soft tissues
– Highly malignant
– Pain, numbness, and swelling often early complaints
– Diffuse, irregular, lytic bone lesion, Cortical expansion
 Ewing’s Sarcoma
• Differential Diagnosis
– Osteosarcoma
– Lymphoma
– Peripheral neuroectodermal tumor
• Treatment
– Radiation and multiagent chemotherapy
• Prognosis
– 54 to 74% 5-year survival rate in localized osseous form
– Late relapse not uncommon
 Malignant Fibrous Histiocytoma
• Malignant neoplasm of soft tissue and bone, which is
composed of fibroblasts
• Clinical appearance
– Rarely in jaw
– Highly malignant, aggresive tumor
– Propensity for recurence and Lung metastasis
• Treatment
– Radical ablative surgery
– Adjuvant chemotherapy/radiotherapy
 Burkitt’s Lymphoma
• High-grade, non-Hodgkin’s B-cell lymphoma
• Activation c-myc oncogene through chromosomal
translocations
• Predilection
– 3 - 8 years of age
– Jaw involvement is common and progress rapidly as facial
swelling and huge exophitic mass
• Treatment
– Intensive chemotherapy resulted a dramatic improvement
– Survival rate 70-85%, but deadly if untreated
 Metastatic Cancer
• Predilection
– Usually from lung, breast, prostate, colon, kidney
– Only 1%, sometime underestimate
• Clinical appearance
– Swelling and pain
– As primary tumor pattern
• Treament
– Combination of chemo and radiotherapy
• Prognosis
– Poor
 Squamous Cell Carcinoma

• 90% SCC:..................HNSCC
Well/Moderate/Poorly/Undiff
Exophytic, Ulcerative, Infiltrative, Verucous
• Adeno Carcinoma
malignant minor salivary gland tumors
 Squamous Cell Carcinoma
Site Predilection
⦿ Tongue (35%)
⦿ Floor of mouth (30%)
⦿ Lower alveolus (15%)
⦿ Buccal mucosa (10%)
⦿ Upper alveolus/hard palate (8%)
⦿ Retromolar (2%)
⦿ Lips
○ lower 93%,
○ upper 5%,
○ commissure 2%
 Squamous Cell Carcinoma
Risk Factor
• Heavy tobacco
• Alcohol.
• Syphilis
• Viruses (EB, HSV, HPV)
• Neglect of oral dental hygiene
• Chronic infection
• Unfit dentures
• Lichen planus
• Immunosuppression
• Malnutrition
• Clinical appearance
– Premalignant lesions:
• Leucoplakia
• Hyperplasia
• Erythroplakia
• Dysplasia
 UICC/AJCC STAGING SYSTEM FOR ORAL CANCER 2002

Primary Tumor (T)

Tx Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor 2 cm or less in greatest dimension
T2 Tumor more than 2 cm but not more than 4 cm in greatest dimension
T3 Tumor more than 4 cm in greatest dimension
T4a(lip) Tumor invades through cortical bone, inferior alveolar nerve, floor
of mouth, or skin (chin or nose)
T4a(oral cavity) Tumor invades through cortical bone, into deep / extrinsic
muscle of tongue (genioglossus, hyoglossus, palatoglossus and
styloglossus), maxillary sinus, or skin of face
T4b (lip and oral cavity) Tumor invades masticator space, pterygoid plates,
or skull base, or encases internal carotid artery
Regional Lymph Nodes (N)
Nx Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
N2 Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than
6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more
than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes,
non more than 6 cm in greatest dimension
N2a Metastasis in single ipsilateral lymph node more than 3 cm but not
more than 6 cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in
greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6
cm in greatest dimension
N3 Metastasis in a lymph node more than 6 cm in greatest dimension

Distant Metastasis (M)

Mx Presence of distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
 Stage Grouping

Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T1, T2 N1 M0
T3 N1 M0
Stage IV A T1, T2, T3 N2 M0
T4a N0, N1, N2 M0
Stage IV B Any T N3 M0
T4b Any N M0
Stage IV C Any T Any N M1
Oral tongue cancer
 Squamous Cell Carcinoma
• Treatment
– Radical ablative surgery
• Radical excision for Primary tumor
• Neck dissection for node metastasis
– Adjuvant chemotherapy/radiotherapy
 Follow Up
• All cancer treatment should be followed in the
right way and right time
• Be the first to know the recurrent tumor
• What should be to followed up?
– treatment of the cancer
– the progress of the entire cancer’s patient
– survival
 Prevention

• Hygiene of oral cavity daily

• Dental security
• Avoid alcohol and smoking or tobacco
• Nutrition – carotene and retinoid
• Excision of pre-malignant lesion
• Medical check up on schedule
◼ Most of oral cancer are visible disease
and recognized easily
◼ Performed clinical diagnosis gently and
on the right way
◼ Precaution of pre-malignant lesion
◼ Most of them are already in late stage
and inoperable disease
◼ 90 % of oral cancer are SCC
◼ Oral cancer is devastating disease from
beginning
◼ Precaution of malnutrition threatening
◼ Surgery still as a main therapy and
reconstruction surgery needed for
aesthetic purpose
Suksma