Squamous cell carcinoma arising in a lateral periodontal cyst

oral surgery oral medicine oral pathology with.TfJcrions on endodontics unddental radiology Volume 47, Number 6. Jtrne. 1979 oral surgery Editor-: ROBERT B. SHIRA, D.D.S. School of Dental Medicim, Tufts Universir? I Kneeland Street Boston Massachusetts 02 I I I Squamous-cell carcinoma arising in a lateral periodontal cyst Ronald D. Baker, D.D.S.,” Chapel Hill, N. C., Edmund D. D’Onofrio, D.M.D.,** Washington, D. C., Stamford, Conn., Russell L. Corio, D.D.S., M.S.D., M.A.,*** Benton E. Crawford, D.D.S., M.S.D., M.A.,**** San Diego, Calif., and Bill C. Terry, D.D.S.,***** Chapel Hill, N. C. A rare case of well-differentiated squamous-cell carcinoma arising in the epithelial lining of a lateral periodontal cyst is reported. Submission of surgically removed tissues for histopathologic evaluation is emphasized. The surgical site has been reconstructed and functions well. Because of early diagnosis and treatment, the patient has no evidence of clinical disease 2% years postoperatively. T he lateral periodontal cyst is a relatively uncommon but well-recognized odontogenic cyst found in apposition to the lateral root surface of a vital tooth. It is located within bone and has no communication with the oral cavity. Standish and Shafer’ reviewed the literature on lateral periodontal cysts in 19% and discussed the various theories of origin. The precise origin of these The assertions and opinions contained in this articale are the prtvate ones of the writer\ and are not to be construed as official or as reflecting the view of the Department of the Navy. *Professor of Oral Surgery, University of North Carolma. **Suite I-A, 29 Hoyt St., Stamford. Conn. ***Vice-Chairman, Department of Oral Pathology. Armed Forces Institute of Pathology, Washington. D. C. ****Head. Oral Histopathology Section, Department of Laboratory Medicine, Naval Regional Medical Center, San Diego. Calif. *****Professor of Oral Surgery and Director of Oral Surger, cysts is currently still uncertain. However, two theories of origin are popular: (1) that the cyst may develop from rests of Malassez or (2) that it may be a primordial cyst arising from a supernumerary tooth germ. Soskolne and Shear’ suggested the possibility that these cysts may also arise in supernumerary offshoots of the dental lamina before enamel organ differentiation takes place. The purpose of this article is to report a case in which a lateral periodontal cyst underwent carcinomatous transformation, CASE REPORT A 22-year-old white man was admitted on Aug. 23, 1973, with the complaint of a “bump and slight tenderness of my right lower jab.” He had first noticed a painful swelling of the gingival tissue between the lower right first and second Fig. 2. Photomicrograph magnitication. ~560.) +hwm, ~1 i\landa ot neoplastlc resolve, he prescnred to dental MCL call al the Naval Suhmarine Base in Groton. Connecticu[ Radiographs shov+ed a radiolucent I~XIOII t> pc~al 01 :t lateral periodontal cyst. On examination the area was painful to palpation. The sensory function of the mental ncl\c u a5 not altered. First operation (biopsy) The area v,as exposed surgically mucopetiosteal Hap and was curetted. b) rctlection c)r :I The hiop5,!: qwci~~~~~ epithelium. (Hcmatoxclin ;ind c’0~1n \taln. Original Carcinornatous Volume 47 Number 6 Physical trun$ormation of lateral periodontal cyst 497 examination Several slightly tender. nonfixed lymph nodes were de- tected in the louer qraclavicular area. The nasopharynx was within normal limits, as were also the larynx and the cords on indirect examination. The following teeth missing: 65 67 8 All remaining teeth were vital, as determined by +8 thermal testing. Except for tender. well-healing mucosa in the area of the lower right premolar teeth, the oral examination findings were unremarkable. There was tenderness of the left second intercostal space. The physical examination, when completed. 5howcd no evidence of other disease processes. Laboratory examinations and radiograph report The results of extensive laboratory studies were within normal limits except for an altered differential count. which showed neutrophils 15 percent and lymphocytes 48 percent. These variations acre thought to be related to the recent biopsy procedure. A long-bone survey and a skull series were both interpreted as normal. Posteroantcrior and lateral chest radiographs were within normal limits except for the suggestion of an oxteolytic leGon of’ the left clavicle. An apical lordotic \ic\l of the cheat and coned-down views of both clavicles shomcd a prominent rhomboid fossa on the left, without evidcncc of bony destruction. A radioisotope bone scan ahoacd a focal area of increased activity in the anterior portion of the right mandible corresponding to the recent biopsy site. A panoramic radiograph sho&ed incomplete bony healing of the maxillary second premolar extraction sites (Fig. 3). There was. in addition. a 3 mm. radiolucency in the Icft mandible between the tirst and second premolars. On the sixth hospital day, washings taken at the time of a bronchoscopic examination were submitted for cytologic. funfal. and bacterial testing. The results were unremarkablc. Second operation (biopsy) On the ti,urtcenth da!. a biopsy of the radiolucent area of the left mandible uas performed. Microscopically, the specirregular portions of mature imen consisted of multiple. lamellar bone and mall fragments of librous and fibrofatty marrou. There ua\ no evidence of malipnancy. By the sixteenth hospital day. a complete work-up had unco\ercd no cvidsnce of disease other than at the original biopsy \ite. Third operation Fig. 3. Panoramic radiograph showing lateral periodontal cyst in the right mandible, incomplete bone healins in maxillary second premolar extraction sites. and a 3 mm. radioluccncv in the left mandible between the first and second premolars. (right en bloc resection) On Scp~. 7. 197.1, a local en bloc resection of the right mandibular biopsy site. including the two involved teeth, has performed as recommended by the Head and Neck Tumor Board. Soft-tissue Incisions were placed labially and lingually to lea\ c Ihc FingiL al tissues of the biopsy site attached to the specimen. Labial and lingual mucoperiosteal flaps were subsequently elr\ated adjacent to the resection site. Followiing removal of the mandibular right canine and tirst molar teeth. vertical bon> incisions were made in these alveoli. At the depth of these bong incisions. a horizontal connecting osteotomy proccdurc has carried out. maintaining the lower cortical border ot the mandible in continuity. The en bloc Fig. 4. Panoramic radiograph showing surgical site after rcmoval of lower right central incisor and en bloc rcscction of lo\\er right lateral incisor \cith subjacent boric. resection was completed carefully with chi\cl\, and the \pccimcn wa5 removed intact, The contents of the mandibular canal wcrc removed as fat posteriorly as possible and submitted for pathologic diagnosis as a separate labeled specimen. The canccllous bloc rcmaininf at the base of the resection site ~3s ;II\o rcmo\cd and submitted for diagnosis. After irrigation L\ith copious saline solution rinses, the mucoperiosteal Haps \\erc closed primaril). Histopathology report The histopatholocpic examination describing decalcitied sections taken through the right body of the mandible in the 498 HtiXt I. :/ ii! c 01111116‘ Number6 Fig. 7. Climcal photogqh shwing repair ot mouth. and split-thickness vestibuloplastg. skin graft. plastic Follow-up Complete laboratory and radiographic e\aluationa have been negative for malignancy At the time of this M riting. 2’1~ years have elapxxl since the resection for squan~n~s-cell carcinonla that arow in a lateral periodontal cyst of the right mandible. Right mental nerve paresthesia. secondary to the surgical resection. remains the patient’s sole dcticit related 11) the malignancy. The operative site has been completely rcconstructed. and rhe patient’s prosthetic replacetnent functions usll. DISCUSSION Although the lateral periodontal cyst does not occur frequentI!*. it is a well-recognized entity. The cyst ordinarily does not attain a large size, and for this reason it may be treated without due concern by the dental practitioner. The findings in this case once again emphasize that tissue remo\,ed from surgically treated lesions should be \ubmittod for microscopic evaluation. This is especially true since, statistically, squamous-cell carcinoma in a 22.year-old patient is not expected to occur. Eversole and associates’ have reported that 80.5 percent of all central epidermoid carcinomas occur in the fifth to the eighth decades, while 16.7 percent occur in the third to the fifth decades. In this case, if the original tissue had not been submitted for histopathologic examination, the spread of the tumor locally beyond the cystic area would have indicated a much poorer prognosis. Spread of such centrally occurring tumors will often take the path of Fig. 8. Removable partial denture restoring the resection procedures. teeth removed in least resistance. In this manner, extension can occur along the neurovascular bundle toward the mandibular foramen. with subsequent pterygoid involvement. Although the area of radiograph involvement wa\ limited to the pattern typical of these cysts. and although there was no altered nerve function. it was for this reason that the neurovascular bundle and subjacent cancellous bone were removed as far as possible toward the molar area. The reconstructive bone graft had to be placed on the remaining mandibular basal bone. This necessitated placement of the graft in a position lateral to the original alveolar process. The patient may well be a candidate for future alveolar grafting secondary to both anticipated graft resorption and the less-than-ideal prosthetic positioning. The subsequent graft could be placed in a more medial position to enhance prosthetic replacement. REFERENCES I. Standish. S. M.. and Shafer. VV’. G.: The Lateral C>st, J. Periodontal. 29: 27, 1958. Periodontal 2. Soskoline. W. A.. and Shear, M.: Obwrvations on the Pathogeneais of Primordial Cysts, Br. Dent. .I. 123: 321. 1967. 3. Davis. W. H.. Delo. R. Y.. Weiner. J. R.. and Terry, B. C.: Transoral Bone Graft for Atrophy of the Mandible. J. Oral Sure. 28: 760. 1970. 4. Eversole. L. R.. Sabes. W. R.. and Rovin. S. Aggressi\-e Growth and Neoplastic Potential of Odontogenic Cysts. Cancer 35: 270. 1975.