Gingival swelling and diffuse mandibular osteolysis in a 57-year-old woman

Abstract

A 57-year-old woman was referred from her hematologist for evaluation of a left mandibular gingival swelling of 1 week's duration. The hematologist expressed concern about odontogenic infection owing to the patient’s prolonged immunosuppressive chemotherapy for the management of treatment-resistant multiple myeloma (MM). The diagnosis of MM had been made in 2017, and since then she had received multiple rounds of chemotherapy, undergone autologous stem cell transplantation, and received intravenous zoledronic acid (Zometa; Novartis). Her health history was also significant for type 2 diabetes mellitus, hypertension, and a distant history of mandibular orthognathic surgery. Results of the extraoral examination did not indicate any pathology. The intraoral examination revealed a firm, sessile, nonmobile, 1-cm mass on the buccal gingiva between teeth nos. 21 and 22 (Figure 1). The results of pulpal and periapical testing of adjacent teeth were unremarkable. No evidence of purulent drainage or hemorrhage from the lesion was seen. A cone-beam computed tomographic scan revealed multiple missing teeth in the maxillary and mandibular right quadrants as well as hardware in place from a bilateral sagittal split osteotomy. In addition, multiple ill-defined radiolucencies were notable across the mandible, with cortical perforation apparent in the anterior and left mandible (Figures 2 and 3) without evidence of tooth resorption or displacement. An excisional biopsy was performed of the gingival soft-tissue lesion in the area of teeth nos. 21 and 22 under local anesthesia. The histopathologic examination revealed a gingival soft-tissue lesion composed of an unremarkable superficial squamous mucosa with extensive and diffuse submucosal infiltrates of mature plasma cells (Figure 4). Immunohistochemical staining showed that the plasma cells were positive for cluster of differentiation 138, and in situ hybridization for κ and λ light chains showed that the plasma cells were κ-restricted (Figure 5). 1 O’Connell F.P. Pinkus J.L. Pinkus G.S. CD138 (syndecan-1), a plasma cell marker: immunohistochemical profile in hematopoietic and nonhematopoietic neoplasms. Am J Clin Pathol. 2004; 121: 254-263https://doi.org/10.1309/617DWB5GNFWXHW4L Crossref PubMed Scopus (214) Google Scholar Dr. Barawi is a resident, Department of Oral and Maxillofacial Surgery, University of Illinois at Chicago, Chicago, IL. Mr. Shah is a student, College of Dentistry, University of Illinois at Chicago, Chicago, IL. Dr. Cabay is an associate professor of clinical pathology, Department of Pathology, College of Medicine; a clinical associate professor, Department of Otolaryngology, College of Medicine; and an associate professor, Department of Oral Medicine and Diagnostic Sciences, College of Dentistry, University of Illinois Hospital, University of Illinois at Chicago, Chicago, IL. Dr. Callahan is an assistant professor, Department of Oral and Maxillofacial Surgery, University of Illinois at Chicago, Chicago, IL.