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Author: Barbara Ann Burtness, MD
Chief Complaint
H.R. is a 70-year-old woman who presented to her dentist with a 2-year history of ill-fitting dentures and oral discomfort, and right-sided otalgia (Slide 1).
Relevant History
• H.R. experienced a 20lb weight loss, attributed to pain with eating.
• Past medical history was notable for sarcoidosis and hypertension.
• She gave a 30-pack year cigarette smoking history and used alcohol on a regular basis.
Past Referrals, Evaluations & Assessments
H.R.’s dentist referred her for evaluation by a head and neck surgeon. Examination of the oral cavity was significant for an ulcerated mass of the right hard palate extending past the midline anteriorly and involving the ipsilateral maxillary alveolar ridge.
The area was tender to palpation. The mass was considered suspicious for malignancy. There were no other oral cavity or oropharynx lesions and the neck was without lymphadenopathy.
Scans
A contrast-enhanced CT scan of the neck revealed a 3-cm enhancing mass involving the right anterior maxilla/hard palate (Slide 2). This was associated with bony destruction of the anterior mandible.
The mass crossed the midline anteriorly and involved the soft tissues that form the right nasolabial fold. Coronal reformatted images demonstrated bony destruction extending to the antero-inferior bony nasal septum. There was no lymphadenopathy within the neck.
Diagnostic Procedures
Laryngoscopy (Slide 3) revealed an exophytic well-demarcated friable tumor of the anterior mandibular alveolus crossing the midline, with extension to the labial and buccal mucosa but no significant involvement of the buccal or labial mucosa itself. Lingually, there was extension to involve the hard palate, but the soft palate was not involved.
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Explanation and Treatment
The pathology report described the gross appearance of the biopsy specimen as consisting of a 2.0 × 1.5 × 0.3 cm aggregate of hemorrhagic and friable soft tissue of the right maxilla. The final histopathologic diagnosis was severe keratinizing squamous dysplasia (Slide 4). The surgeon requested additional cuts from the block, given the clinical suspicion of invasive cancer. These also demonstrated dysplasia with no areas of invasion.
H.R. was taken to the operating room for an infrastructure maxillectomy with right modified neck dissection and split-thickness skin graft. Frozen section of the resection margins showed dysplasia. Additional scant margins obtained were negative.
The pathology revealed a 4.1-cm invasive keratinizing squamous cell carcinoma of right maxillary alveolus. Carcinoma invaded through bony maxilla into right lateral nasal wall.
There was no perineural or lymphovascular invasion and all lymph nodes were negative.
The patient was fitted for an obturator. She has been referred for adjuvant radiation. Following radiation she will be referred for consideration of natural bone grafting.
The most important problem presented in this case was the apparent disconnect between the biopsy result, consistent with dysplasia only, and a clinical picture of invasive cancer. Dysplastic lesions of the oral cavity are not associated with bone erosion, whereas the patient’s CT scan showed evidence of extensive bony destruction.
The biopsy specimen had been generous, and repeat biopsy without resection of involved bone may also have failed to demonstrate invasive cancer; however, the strong clinical evidence for cancer mandated resection.
Advanced maxillary and sinonasal cancer is associated with a high rate of recurrence, including in areas difficult to manage with resection or reirradiation, such as the orbit, the infratemporal and pterygopalatine fossae, and the dura of the middle cranial fossa.1
A further important aspect of this case was the decision to undertake ipsilateral lymph node dissection. The risk of nodal involvement from squamous cell carcinoma of the maxillary alveolus and hard palate is known to be substantial.
Simental et al2 reviewed 26 such cases from the University of Pittsburgh, and found that while clinical nodal involvement was uncommon (7.6%), nodal involvement was manifest as regional failure in an additional 27% for an overall rate of nodal involvement of 34.6%.
The patient presents significant challenges in reconstruction because of the location and size of the defect left by the maxillectomy. The hard palate functions as a barrier to the nasal cavity, aids in vocal articulation, and assists in eating.
The use of an obturator is important to contain food in the oropharynx and assist in phonation. Following radiation, the patient may be a candidate for autologous non-vascularized bone grafting.3,4
References
- McMahon JD, Wong LS, Crowther J, et al. Patterns of local recurrence after primary resection of cancers that arise in the sinonasal region and the maxillary alveolus. Br J Oral Maxillofac Surg. 2012 Oct 19. [Epub ahead of print]
- Simental AA, Johnson J, Myers EN. Cervical metastasis from squamous cell carcinoma of the maxillary alveolus and hard palate. Laryngoscope. 2006; 116:1682-1684.
- Kademani D, Mardini S, Moran SL. Reconstruction of head and neck defects: a systematic approach to treatment.Semin Plast Surg. 2008 August; 22(3): 141-155.
- Hamahata A, Saitou T, Beppu T, et al. A new nasal cavity and maxilla reconstruction method using jejunum flap with non-vascularised bone. J Plast Reconstr Aesthet Surg. 2013 Jan;66(1):e12-5.
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