Clinical–Pathological Conference: Case 6

Abstract

Clinical PresentationA 47-year-old male presented with a 5 cm, firm, painfulswelling over the left mandibular ramus that had progres-sively enlarged and was associated with limitation ofmandibular opening and trismus. He related that he firstnoted symptoms from the area shortly after dental treat-ment involving a tooth in his left lower jaw 2 monthspreviously. He indicated a 72 pack-year history of cigarettesmoking and currently smoked two packs of cigarettes perday. He reported minimal alcohol consumption.Since the swelling was initially believed to represent alesion of the soft tissues, a fine needle aspiration biopsywas performed. When this did not yield diagnostic infor-mation, a computed tomographic (CT) scan was obtained.At the time of the scan, paresthesia of the left lower lip wasobserved.The CT scan revealed an expansile, aggressive-appear-ing process with a sunburst-type periosteal reaction sur-rounding the angle and ramus of the left mandible withextension into the infratemporal fossa just below themandibular condyle (Figs. 1, 2) and overlying soft tissueinvolvement. Neoplastic growth was highly suspect.Differential DiagnosisBased on the clinical history, particularly the presence ofpain, swelling and paresthesia, along with available imag-ing, the differential diagnosis is heavily swayed towards amalignancy capable of inducing calcified matrix produc-tion. The most likely considerations include osteosarcoma,chondrosarcoma, and metastatic disease.Osteosarcoma of the jaws typically presents in the 4thdecade as a bony swelling that may also elicit pain andoccasionally causes a neurologic deficit [1, 2]. Mandibularlesions most often affect the posterior body and ramus andoften show extension into soft tissues [2]. Radiographi-cally, lytic lesions are most often observed [1] followed bya sclerotic or mixed appearance. The classic ‘‘sunburst’’pattern noted in lesions of the long bones is uncommon inthe jaws [1]. While this patient is a little older than thetypical average age at presentation, the signs, symptoms,location and radiographic features all support a clinicaldiagnosis of osteosarcoma.Chondrosarcoma of the jaw is a rare tumor which mostoften affects the maxilla and is most often reported in the5th decade with a wide age range [3]. Clinically, the tumoris characterized by swelling; pain is an unusual complaint[3]. Radiographs often show an ill-defined radiolucentmass exhibiting bone destruction, with variable calcifica-tion and soft tissue extension [3]. The age of the patientand location in this case could be consistent with a diag-nosis of chondrosarcoma but the presence of pain andparticularly paresthesia would generally be less likely forthis tumor.