The current paper summarizes the presentation given at the 39th and 40th Joint Workshop of Four Japanese Oral Societies (Japanese Society of Oral and Maxillofacial Surgeons, Japanese Society for Oral and Maxillofacial Radiology, The Japanese Society for Oral Pathology, and Japanese Academy of Maxillofacial Implants) held in 2013, and retouches by adding further findings after the presentation. In 2005, WHO put a recently advocated SIN (Squamous intraepithelial neoplasia) in the report with conventional dysplasia system, as the diagnostic criteria of early oral cancer and precancerous lesion. In Japan, we have two general rules: "General Rules for Clinical and Pathological Studies on Head and Neck Cancer 2012" and "General Rules for Clinical Studies on Oral Cancer 2010". And recently, The Japanese Society for Oral Pathology presented their original study (2014). Having various criteria for one specific field is causing confusion. Cytological examination is facing a similar phase. Starting with gynecology, a shift from the conventional Papanicolaou classification to Bethesda system that focuses more on presumed diagnosis is being considered. New criteria will be presented for oral cytological diagnosis as well (2015). This paper will cover the transitions of pathological diagnosis and the new movements in cytological examination for oral cancer.
Objectives: Cevimeline hydrochloride (CH) and pilocarpine hydrochloride (PH) are recognized as salivation-inducers with a high affinity for M3 muscarinic receptors. However, these drugs have a high frequency of side effects, including digestive symptoms and hyperhidrosis. We compared the effectiveness and side effects of these two drugs before and after a medication change. Materials and Methods: Seventy-six patients with Sjögren's syndrome were divided into the following four groups: 1) CH group, CH was administered for 12 months; 2) PH group, PH was administered for 12 months; 3) CH-PH group, CH was administered for 6 months followed by PH for 6 months; 4) PH-CH group, PH was administered for 6 months followed by CH for 6 months. We measured the salivary flow rate and recorded the subjective symptoms in each group. Results: In each group, stimulated whole saliva (SWS) and unstimulated whole saliva (UWS) significantly increased after 3 months and 6 months, respectively, and subjective symptoms improved after 3 months. The incremental changes in both SWS and UWS did not differ significantly between the groups. The CH and PH groups both had digestive symptoms (32.3% and 32.1%, respectively) and hyperhidrosis (29.0% and 39.3%, respectively). We found no significant difference in salivary flow rate or subjective symptoms after the medication change. However, the frequencies of side effects in the CH-PH and PH-CH groups decreased significantly for both digestive symptoms (9.7% and 10.7%, respectively) and hyperhidrosis (25.8% and 14.3%, respectively). Conclusions: After changing the salivation-inducing drug, there was no significant difference in salivary function or subjective symptoms, while the frequency of side effects markedly decreased. These results suggest that changing the salivation-inducing drug effectively reduces side effects.
Myoepithelial carcinoma commonly arises in the parotid and palatal glands and consists of spindleshaped, plasmacytoid, epithelioid, and glycogen-rich clear cells. Myoepithelial carcinoma is fairly rare and only accounts for approximately 0.4% of all salivary gland tumors. This report describes a case of myoepithelial carcinoma arising from myoepithelioma in the palate. However, the diagnosis made from a biopsy specimen was myoepithelioma, because the tissue taken from the tumor surface was composed of myoepithelial cells without atypia. The patient was an 83-year-old woman with a chief complaint of a painless swelling in the right side of the palate since November 2009. She was referred to our hospital for comprehensive examination and treatment by her physician in February 2010. Initial examination revealed an elevated mass approximately 17×15 mm in diameter with ulceration of the palatal mucosa. No enlargement of the corresponding lymph nodes was present. The mass was palpable without tenderness. Enhanced computed tomography showed a radiopaque lesion 15 mm in diameter, with no evidence of bone invasion. However, the lesion extended to the medial plate of the pterygoid process. A biopsy specimen showed the characteristics of myoepithelioma, without atypical tumor cells. The tumor cells were densely branched, but nuclear atypia and mitotic figures were not apparent. The lesion was resected, and the surgical defect was covered by a buccal fat pad with the patient under general anesthesia in March 2010. Histopathological examination revealed areas of myoepithelial carcinoma showing cellular atypia and high proliferative activity intermingled with myoepithelioma. A final diagnosis of myoepithelial carcinoma arising from myoepithelioma was established. The patient's postoperative course was uneventful with no functional disturbance, recurrence, or metastasis during 3 years of follow-up.
We report a case that was suspected to be a metastatic mandibular tumor of renal cell carcinoma, but was finally diagnosed as hemangiopericytoma (HPC)/ solitary fibrous tumor (SFT) of the mandible. The patient was a 79-year-old woman who was referred to our clinic because of a painful swelling in the lower right side of the mandible. She had a history of dementia and surgery for renal cell carcinoma. Panoramic radiography showed bone resorption extending from the mandibular body to the ramus of the mandible. The clinical diagnosis was a suspected metastatic tumor from renal cell carcinoma. On confirming the pulsation on the right mandibular gingiva, we predicted considerable bleeding during operation. Selective transcatheter arterial embolization was performed before surgical excision. Intra-arterial digital subtraction angiography showed remarkable tumor staining in the region of the right facial and inferior alveolar arteries. After selected embolization, the tumor was removed surgically. The histopathological diagnosis was a malignant HPC. Ten months after discharge, the patient died of advanced dementia and debilitation.
Organized hematoma is a rare progressive cystic lesion. In this paper, we report a case of organized hematoma developing in the oral floor of a 41-year-old woman. Intraoral examination revealed an elastic hard and mobile mass measuring 40 × 30 × 20 mm in the right side of the oral floor. Computed tomography showed a well-defined mass lesion. A high-density area was partially seen around the rim. On T1-weighted, coronal section MR images, the mass lesion appeared as a slightly high-signal area with a partially iso-signal area. On the T2-weighted images, the mass was seen as a low-signal area. The mass was entirely removed with the patient under general anesthesia. Histopathological examination of the specimen showed an old blood clot encapsulated by dense fibrous connective tissue without an epithelial lining. Granulation tissue with infiltration of macrophages and pathologic calcification was seen between the blood clot and fibrous capsule. On the basis of the above-mentioned findings, the mass lesion was finally diagnosed as an organized hematoma. No recurrence has occurred as of 5 years 6 months after surgical removal.
Mesothelioma is a rare neoplasm that arises from the pleura or peritoneum. Although malignant mesothelioma is known to spread hematogenously, causing metastasis to various organs, there have been few reports on oral metastasis. The patient was a 75-year-old man who had an elastic soft mass, measuring 38 × 20 mm, in the right upper jaw gingiva. On biopsy the lesion was histopathologically diagnosed as a malignant pleural mesothelioma with metastasis to the upper jaw. The lesion shrank in response to radiotherapy. We have described a case of malignant pleural mesothelioma arising in the upper jaw gingiva. We discuss the related literature and summarize our findings.
Carcinoma ex pleomorphic adenoma mainly occurs in the major salivary gland, and a tissue type of myoepithelial carcinoma is extremely rare in the minor salivary gland. We report a case of myoepithelial carcinoma ex pleomorphic adenoma of the hard palate in a 65-year-old man. At presentation, a tumor measuring 23 × 16 mm, which had a painless elastic hard, smooth surface and clear border, was found in the right side of the hard palate. Computed tomographic scanning and magnetic resonance imaging indicated the suspicion of malignancy. Histological examination suggested a myoepithelial carcinoma. A partial maxillectomy combined with a supraomohyoid neck dissection was performed. The histological diagnosis of the resected specimen was a myoepithelial carcinoma ex pleomorphic adenoma. There has been no sign of recurrence as of 2 years postoperatively.
Pleomorphic adenoma is the most common benign tumor of the salivary glands. Most cases develop in the region of the parotid gland, and few occur in the region of the sublingual gland. We describe our experience with a case of pleomorphic adenoma arising in the region of sublingual gland. Case patient: a 47-year-old man. Chief complaint: a tumor mass arising in the left side of the mouth floor. Facial expression: bilaterally symmetric, non-palpable regional lymph nodes. Present illness: a movable, elastically solid mass, measuring 25 × 14 mm, in the left side of the mouth floor. Findings on magnetic resonance imaging (MRI): on T2-weighted images, a slightly heterogeneous, high signal tumor mass in the left side of the mouth floor. Signal intensity as strong as muscle was observed on T1-weighted images. We diagnosed a sublingual gland benign tumor on MRI and suspected pleomorphic adenoma on fine-needle aspiration. We therefore performed extirpative surgery of the tumor, including the sublingual glands, from the oral cavity in May 2011. The histopathological diagnosis was pleomorphic adenoma. It has been 3 years since surgery, and no systemic or local abnormality has been found. A dequate follow-up for relapse and malignant transformation is considered essential.
Trigeminocardiac reflex (TCR) occurs rarely during oral and maxillofacial surgery. We report a case of sinus arrest caused by TCR during extraction of an impacted lower third molar in a 41-year-old woman referred to our department for tooth extraction. The preoperative electrocardiogram showed normal sinus rhythm. When the surgeon started luxation of the left impacted lower third molar with the patient under intravenous sedation with propofol, sinus arrest suddenly occurred. The surgery and propofol administration were discontinued immediately. The period of sinus arrest was 20 seconds, after which heart rate recovered to 70 beats per minute. The operation was resumed with the patient under propofol sedation, and no further sinus arrest occurred. It is likely that sinus arrest in this patient was caused by mechanical pressure on the inferior alveolar nerve. To prevent TCR, it is important to avoid invasive procedures and to use an appropriate local anesthetic during oral and maxillofacial surgery.
Pyoderma gangrenosum (PG) is serious skin disorder characterized by refractory ulcers. We report a rare case of PG arising in the oral cavity, posterior cervical region, and buttocks. A 54-year-old woman was referred to our hospital because of the swelling in the right lower gingival region. The patient had been treated for ulcerative colitis. The clinical diagnosis was pericoronitis of a wisdom tooth, and tooth extraction was performed. Four months after tooth removal, refractory ulcers appeared on the right buccal mucosa and the posterior part of the neck and expanded gradually. Two months later, a buttock abscess developed. No bacteria were detected on smear examinations or culture studies. Histologically, marked inflammation with predominant neutrophil infiltration was noted. The final diagnosis was PG. We immediately started treatment with high-dose corticosteroids and an anti-tumor necrosis factor- α agent. The ulcer and abscess disappeared 3 months after starting treatment.
A rare case of acute myelocytic leukemia that relapsed in association with the formation of a gingival tumor is presented. The patient was a 45-year-old man who had been referred to our department for oral examination before starting chemotherapy. No gingival swelling was found on the initial visit. However, about 4 months after complete remission was achieved, he noticed a gingival tumor arising in the left side of the mandible. The tumor was 47 × 32 mm in size and elastic hard, with a relatively well defined border. Pathologically, the lesion was diagnosed as leukemic cell infiltration, despite the hematologic remission. The patient died of respiratory failure about 3 months after presentation, with no response to chemotherapy.