AN ENIGMATIC ELUSIVE LESION OF THE MANDIBLE THAT REFUSED TO HEAL: A PATHOLOGIST’S NIGHTMARE!!!

Abstract

<h3>Case report</h3> A 62-year-old woman complained of a nonhealing extraction socket in the lower left back teeth region. She underwent extraction of tooth no. 37 at a private clinic, after which an ulceroinfiltrative lesion developed on the operated side. Multiple biopsies from the lesion were inconclusive. The patient was referred to ONCO OPD at the medical hospital. Fine-needle aspiration cytology and histopathology of an excised lymph node confirmed reactive lymphadenitis. Computed tomography revealed an osteolytic lesion radiologically simulating carcinoma or a chondrosarcoma. Because of persistent debilitating symptoms, the patient underwent white-light examination with left segmental mandibulectomy. Frozen sections were negative for malignancy. Biopsy at the general pathology lab depicted parakeratotic lining with dense inflammation. No evidence of osteomyelitis, necrosis, dysplasia, or malignancy was noted. All margins were free from malignancy. Lymph nodes dissected showed reactive morphology. ZN, PAS, and Gram stain were all negative. Later, a 5 × 2 cm ulceroinfiltrative lesion redeveloped in the region of teeth 32 to 42 slowly progressing toward tooth 45. Positron emission tomography/computed tomography of the lesion showed focal FDG uptake in the anterior mandibular region. Because of increased suspicion of malignancy, white-light examination up to tooth 47 was carried out. Histopathology showed degenerated bony fragments and flakes of lamellated keratin. No evidence of dysplasia or malignancy was noted. The lesion continued to spread even after successful surgical intervention with an adequate surgical margin. The patient was eventually lost because of severe cardiac arrest during her last surgical intervention for mandibular arch reconstruction. This could be a case of a lifetime in which multiple consultations with oral and general pathologists failed to reach a conclusive diagnosis.