3 '78 ELLIS FISCHEL STATE CANCER HOSPI~L & CANCER RESEARCH CENTER

ORAL PATHOLOGY SEMINAR !70, O. P . S. 80-2064

DECEMBER 19, 1980

. Case •1 (1753872) contributed by Drs . Thomas M. Tarpley and

Russell Corio, NIH, Bethesda , ~larylond.

, 'his 58 year old white female with s t a tus , post r esection of right superficial lobe of the parotid gland in 1977 for a tumor in that region. The diagnosis at that time was Giant Cell Reparative Granuloma. The present admission has a recurrence of tumor in the right cheek ext.ending over the right periorbital and mandibular angle. The mass is f ixed, hard, non-tender, and fungating . The tumor also extends to the external auditory meatus, elevating the tragus .

Examination of the oral cavity r eve aled a hard smooth, well ­defined mass tha t was palpable ~the upper r i gh t cheek opposite t he maxi lla ana extending post erially to t he pterygo i ds .

Pre OP X-ray

Current X-ray

Current x- ray manidblc

- chest - ~egative - skull - Negative

- TMJ" and auditory canal bone destruction

-Absence of part of R ma ndjhl.e with psammoma bodies med i al to the angle suggestive of parotid tumor .

Lab data -Serum Ca. - 9. 7 and a l kaline phosphatase 154

case I 2 (SS0- 21734) Contributed by Dr. Bradley Arthaud, Boone County Hospital, Columbia, Missouri.

48 year old woman developed a lesion <o the right mid l ine in the mucosa of the hard palate. There has been t~o pr evious attempts prior to the present excision which extends down t o the bone. The slides are representative of the lesion.

Case ti 3 (12/80) Contr ibuted by Dr. Ri s t o-Pekka Hnpponen, Uni versity of Turku, Turku 52 Finland.

The patient is a 47 year old lady who has nothing special in her anamnesis . ln a routine x -ray examination a well demarqared radiolucency with sclerotic margins was found in her r ight ramus. The radiological diasnoais was ameloblastoma or keratocys t . The lesion was excised in one piece with the covering ~ucosa to which it was attached. During the operation the wal l s or the bone cavity were cleaned with a large drill .

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Case I 4 (77- 1008) Contributed by Dr. Carlos Perez- Mesa , Ellis Pischel State Cancer Hospital, Colwnbia, ~tissouri .

Fifty- four year old caucasian femal e had n lesion in t he ri<1ht tonsil which measured 6 x 6 cro ., Urml movable , and slightly ulcerated. Nith almost t o t al obliter a t ion o f the oral pharynx extending slight!~ into both mouth and pharynx . The rest of the physical examinat ion was negative.

case 1 5 (80- 944) Contributed by Drs. Charles Dunlap and Bruce Barker, University of Hissouri-Kansas City School of Dentistry, Kansas City, Nissouri.

This 56 year old male first noticed a growth o n the naxillary tuberosity one year ogo. A larg'e tumor mass was excised and s ubmi tted for microscopic study . There "'aG no radi ographic evidence o f intrabony disease.

case t 6 (80- 1212 ) Contributed by Drs. Charles Dunlap and Bruce Barker, oniversity of Missouti- Fansas City School of Dentistry, l<ansaa City, Nissouri

This 78 ~ar old male had painless enlargement of the buccal and palatal bone in the maxilla . Pertinent medical history inc l udes an accidental fall in July , 1978 . X-rays showed a subtrochanteric fracture and coincidentally , he was also found to have ~adiographic changes consistent with Paget's disease i n the pelvis and right f emur. At that t ime, hi s alkaline phosphatase was 350 units (normal 30-115) . Because of non-union of the fracture, bone grafting was performed in March 1979 at which time the alkaline phosphatase was reported to be 2,780 units.

DEPARTMENT OF SOCIAL SERVICES

ELUS FISCHEL STATE CANCER HOSPITAL O'fAAfEO 8Y TME OfVISION Of HEAl-TH Of: MIISOUfU

115 BUSINESS LOOP 70 WEST COLUMBIA, MISSOURI 65201

Nove~er 20, 1980

Juan Rosa i, ~1. D. University of Minnesota Med ical School Department o£ Laboratory Ncdicine & Pathology Box 609, ~layo ~lemorial Bldg. 420 Delaware Street S.c . ~linneapolis, ~IN 55~ 55

Dear Juan:

Ke missed your diagnoses for the pre>~ous oral pat hology semir.ar, particularly Case 11, from Honduras. During t he discussion of the case tlte diagnosis of ''histiocytoid hemangiona" was considered . Will you make sot:~.e conunents about this case from the p as t seminar BJid sand i t with your diagnoses Cor the pres eat otte.

Sincerely,

Car~~Mesa, M. D. Chief Pathologist

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Enclosure

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UNIVERSITY OF MINNESOTA nw cmrs

Dr . Carlos Perez-Mesa Deparlment of Pat hology Ellis Fischel State Cancer HOspital Co 1 ~obi a, lll 65201

Dear Carlos:

O~ptlrtment ol La!:lotalory Med1c:me .and PattroiOU)' Medlc~u School Box 609 ''3)10 \'tomo•lal Building ~20 f>f!ls.w3'o St1e:e1 s e tlin"c<:~poi1S Mlnne:solst 55455

Deccr.Cer 3, 1980

I apol ogize for not having sent you mY diagnostic impressions for the cases of the Oral Pathology Seminar 169. 1 bel ieve that case 1 is clearly a glandular neoplasm. It has nothing to do with histiocytoid hemangioca or, for that matter, with any vascular tumor . In view of the location, I would assurre that it is of minor salivary gland oriyin. l would liko to thi nk of this tumor as a very cellular pleooorphic adenoTA; I just don ' t know how mal i9nant It is .

Now as to the cases for the Oecc"lber seminar.

Case J: Malignant giant cel l tumor of salivary gland. I have seen two previous cases wi th a similar morphology. In one of them, there was clear cut evidence of a pre-exis ting pleomorphic aden~ . I think that this t umor is analogous to the ones that have been described in the pancreas and thyroid. I have the feeling that in most cases they represent metaplast ic carcinomas.

Case 2: Monomorphic adenoma of mi nor salivary gland origin. I have the suspic•on that most of the cells exhi bi t mYOepi thelial di fferentiation. This also reminds me of t he salivary gland tiJllOr that Azzopardi recently described as characteris t ica l ly composed of cells with an abundant "hya line• cytoplasm.

Case 3: low grade mucoepiden:D id t liiiOr.

Case 4: Squamous cell carc inoma with sarcoma-l ike stroma (so-c~l l ed pseudosarcooa).

Case 5: Extra asseous adaman ti noma. This i s a very interesti ng phenome­non, wh•ch reminds me of cases that I have seen of adamantinomas t n the leg , overlying the tibia but without osseous involve~ent .

Case 6: Paget's disease. The clinical hi story sugges ts to me the phen~~­non of rapid disolution of bone substance that has been reported in patients

Dr . Clrlos Perez llesa - 2 - Decenber 3, 1930

with Paget's disease following irrnoblllzation of a l ong bone because of fr.>cture (r:ew Engl . J . Hed . , 231 :343, 1944) .

1-t,y wife and 1 ~<ill be goi ng to 1\rgentina in two weeks lo spend the Christmas holidays ther e. I hope to have a stay as ple•sMt as the one you had t her·e t110 yea r-s ago.

JR/dm.i

Best persona l regards ,

~IJ-'-' -Juan Rosai , H.D. Professor, Labell" a tory t~di cine and Pathology Di rector of Ana lomic Pathology

"OFFICIAl " DIAGNOSIS

Elt!S FISCHEL ·sTATE CANCER HOSPITAL AND CAUCER RESEARCH CENTER ORAL PATHOLOGY SEMINAR §70

0. p .s. 80-2064

DECEMBER 19 , 1980

CASE #l (1753872 ) MAliGNANT GIANT CElL TUMOR OF SOFT PARTS Contribut ed by Drs. Thomas M. Tarpley and Russell Corio, NIH, Bethesda, Maryland

There was. diversity in the diagnostic impression among t he consultan ts . The majoritJ< recogni zed the malignant natur~ of the neoplasm, however, with variations concerning histogenesis and/or location, the mflnori ty felt i t was benign. A few col!lllents at rand0111 :

Pindborg from Copenhagen called it, "Mal ignant giant cell tumor- ­osteosarcoma~~ 1

Weathers from Emory stated , "Mal ignant giant cell tumor <>f soft par ts . A most unusua l l esion a.nd certainly an- osteosarcoma, or chondro­sarcoma of soft tissues must also be ruled out . I presume this is not primary i n bone •~tend ing outward." ·

Rowe from Michigan cal l ed it, "Giant cell variant of osteosarcoma . "

Abrams from .USC made the fo llowing commentary: "It is particularly di fficult. The clinica.l characteristics an·d behavior certainly indicate mali gnancy, t he precise origin of which seems difficult to i dent ify. The history suggests paroti d ori gin , but t he hi:stopathology is not compatibl e . Many areas resemble aneurysmal bone cyst but cel l ulari ty and areas of necros is indicate somet hi ng more ominous. Malignan~ giant cell tumor of a converted type is a pos·sibility. The presence of what s eems to be bone an~/or cart i llage would l ead me to prefer a diagnos is ·of osteosar coma. It could ~ave originated from the lateral aspect of th.e ramus to simulate a parotid tumor inHially. (We had a case that did· exact ly that.)"

Waterhouse f rom t he Un iversity of I llinois stated, "Giant cel l tumor, origi nall y j aw. Al ka line phosphatase 1.5 i mplies wider invol vement. "

Bat sak!s fr001 Maine cal led I t , "Chondroblast001a with aneurysma ] bone cyst. •

Berthrong from Co lorado Springs interpreted i t as "aneu rysmal l>one cyst. " Toto from Loyo 1 a ca 11 ed i t, "Chondrosarcoma."

Cornyn from San Antonio remarked, "Atypical Giant Cell tumor. Rule out ~hondroblastoma vs. pleomorphi c adenoma with Gi ant Cell EJ:ements ."

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White from Kentucky made the following comment , "If t his is trul y soft tissue in origin, then we feel this represents a malignant gi~nt cell tumor of the soft parts described by Gucclon and tnzinger . If primary in bone, malignant gia nt cell tumor of bone."

leGal from Strassbourg wrote, "1n spite of the classical saying there are no giant cell tumors of maxilla or mandible, I think this is. another e~ample of thi s rare lesion in this location. I have met the same diagnost i c problem at l east twice. Unfortunately, i have been unable to trace the post-operative evaluation. With this restriction, I shall call this lesion an aggres.sive or cytol ogically giant cell tumor of bone. u

Sprague from Nebraska made t he following considerations, "Although 1 bel ieve· this cas·e fi t s the general category of giant cell l es~on, I get a strong suggestio.n of osteoid formation in the midst of the stromal and giant cel l growth. 1 would favor a diagnosis of extraosseous osteo.sarcoma. '1

Rosai from Minnesota made the following commentary, "Mal ignant giant cell t~mor of salivary gland. I have seen two previous cases witfi · a ~imilar morphology. In one of them there was cl ear cut evidence of a pre-exist ing pl eomorphic adenoma . r think that t he ·tumor is analogous t o the ones that have been described in the pancreas and thyraid. I have the feel ing t hat in most cases they represent metaPlastic carcinomas. "

Cardona Lopez f rom Honduras , Centra l America, preferred to call it granuloma giganto cel ul ar del maxillar.

Tnls case was presented and discussed with the audience by Or. Dunl ap from University of Missouri at Kansas. City who preferred to call it "ma 1 i gnant fibrous hi st iocytoma (giant cell variant ). "

:ASE 12 (SS0-21734) MONOMORPHIC ADENOMA Contributed by Or. Bradley Arthaud, Boone County Hospital , Columbia, Missouri

This was the most popular diagnosis with minor semantic variations.

Rosai from Minnesota cal l ed it , "Monomorphfc adenoma of minor salivary gland region. I have the suspicion most of th~ cel ls exhibit myoepitnelial differentiation. This al so reminds me of the salivary gland tumor that Azzopardi rec'l!'t l y described as characteristically composed of cells· with an abundant "hyal i"ne" cytoplasm."

Happonen from Finland, Tarpley and Corio from NIH, Horl from West Virginia, .-.nong many, interpreted the l es i on as "monomorphic adenoma . "

Young and Glass from Oklahoma called it , "Monomorph ic adenoma with one or two areas suggestive of mixed tumor. •

Meyer from Jewi sh llospital, "Monomorphic adenQha. s ta tn as amyloid . "

Washington University, St. louis, called it, I wonder H the in t erstit i al materi al woul d

Bat saki s from Maine stated, • stain is poor but there are many (pajority) of cells that are plasmacytoid "hYaline• cells . Myoepithel i oma .•

The staff from Willtam Beaumont Anoy Hospital in Texas call ed t t , "Monomorph1 c adenoma--myoepithel ia 1 type. "

Abrams f rom USC said, " In spi t e of "two prev ious attempt s• I would classify Case 12 as benign mixed ttmOr."

Cos ta from NIH. Or Wesley from Detroit, and Drs. Dunlap and Barker f rom Kansas City call ed It, "Pleomorphic adenoma. "

There were some consultant s who consi dered the case as mal ignant:

White from Kentucky wrote the fo ll ow ing: "Adenocarci noma, the mali gnant expression of a pleomorphic adenoma. Has many areas of plasmacytoid myoepithelial cells. Does not l ook li ke t he t ypical carcinoma arising i n pl eomorphic adenoma. Would like to see the slides of the original surgical speci11en."

Pindborg fNm Copenhagen called it, "Carc inoma in pleomorphic adenoma."

Weathers frOCI Emory wrote the following, "I would have to call this a low grade adenocarc inoma, not otherwise specified. It doesn ' t l~ok too aggressive.•

lilly and the ent i r~ oral pathology staff from the University of Iowa call ed i t 11adenocarcinoma. 11

CASE 13 (12/80) WEll DIFFERENTIATED MUCOEP IDERMOID TUMOR Contr i buted by Or. Rlsto- Pekka Happonen, University of Turku, lurku 52, Finland

The predominant diagnosis was •mucoepidennoid carclnona , a low grade lllilllgnancy of probably central location." A few commentar ies are as follows:

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Drs. Tarpl ey and Corio stated, "Mucoepidermoid carc inoma arising in odontogenic cyst."

White frcn Kentucky called it, "Centra 1 m~co epldennoi d carcinoma."

Rosa! fl"OIII Minnesota called it, "low grade mucoepidermoid tumor."

Greer from Colorado cal led it, •central osseous mucoepidermoid tumor (carcinooa) . "

Others considered t he lesion as benign:

Batsakis fr0111 Maine called i t, "Salivary duct Inclusion cyst ."

Wesley from Detroi t stated, ' Odontogenic cyst possibly residual periapical wi t h t he epithelial lining exhi biting mucous di fferenti ation."

Plndborg from Copenhagen stated , ' Mucous cyst adenoma."

Sprague from Nebraska stat ed, "Odontogenic cysti c halllllartoma. Can' t agree with mucoepidermoid tUMor.•

Rose from Wichita called It , 'Embryonic cyst. •

LeGal fr0111 Strasbourg called It, ' Dentigerous cyst." Thi s was al so the diagnosis of Costa from HIC.

Weathers fr0111 Emory stated. "This 11ight be called a central. mucoepidermoid cyst or a cent ral mucoepidermoid t umor, although the distortion in the slide ~~akes interpretation somewhat diff icult. We have had the opportunity of seeing several central l esions of this type and whil e not overly aggressfve , they certainly wi l l recur i f inadequatel y removed."

Dr. Bruce Barker from the University of Mi ssouri at Kansas Ci ty presented and discussed t hi s case. He fe lt that all hi stopathological criteria for the diagnosis of mucoepidermoid <umor or carcinoma were not present and t hat this represented a benign cystic lesion with ~ucous different­ation. Dr. Barker had presented an almost identical case in Semi nar V60, Case #4. Diagnoses ranged froo ~coepidermol d carci noma to botyroid odontogenic cyst to odontogenic sialocyst. Dr. Barker prefers t he diagnosis of odontogenic sialocyst as coined by Dr. Shafer and Associates of t he University of Indiana. Botyroid odontogenic cyst was described by Weathers and Waldron in Oral Surgery 36: 235, 1973. This cyst, however. usua l ly does not show Mucous differentiation and the clear cells are glycogen rich. (See Attachment 61 for 160 seminar .)

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CASE #4 (77-1008) EPI DERMOID CARCINOMA, SPIHOLE CELL TYPE Contributed by Dr. Carlos Perez-Mesa , Ellis Fischel State Cancer Hospital, Col umbia , Missouri

Thi s wa s the overwhelming diagnosis. Du r ing t he presentation of the case, a biopsy from a metastatic lymph node in t he right supraclavicular lesion was shown demonstrat i ng the presence of areas with well-delineated, pOorly differentiated epider moi d carcinoma as well as areas with a sarcomatoid appearance.

A dissenting minority considered other diagnoses including malignant fibroxa ntho sarcoma , pl eomot•phi c l i posarcoma, histiocytic lympllc>ma, epi thelioid sarcoma, r habdomyosarcoma, angiosarcoma, etc.

CASE #5 (80·944) EXTRAOSSEOUS AHELOSLASTOHA Contri buted by Drs. Charles Dunl ap and Bruce Barker, University of ~issouri~Kansas City School of Dent istry, Kansas City, Missouri

This was the overwhelming diagnos is. A few commentaries:

Or. White from Kent ucky wrote, ' Per iphera l s pindle cell ameloblastoma. we had a case several years ago in the r etromol ar pad that histological ly resembles Charlie' s case very closely. It did not involve bone and after surg ical excision has not recurred."

Rosai from Minnesota sta ted , "Extraosseous ademantinoma. This i s a very interesting pheno~ena which reminds me of cases that I have seen ademanti nomas of t ho l eg, overlying the tibia but without osseous involvement.•

Tar pley and Corio fro~ HIH made the following conmentary, "Epi the lial odontogenic tuonor and an acan thomatous and basal cell ameloblastoma. Also one cannot rule out entirely the possibility of a pseudoadamantine advance of sa llvary gland. "

Weathers from Emory, "Thi s les ion does not fit readily into a chssif;cation I woul d have to say that it is definitely epithelial, It Is very likely odontogen ic . It is poss ibly an ameloblastoma and it might be malignant. My degree of certainty dissipates rapidly as 1 become more specific in labelling this lesion. If for ced into a corner, I would say that t his is probably a 11alignant at>eloblastoma."

Abrams from USC, • seems to represent ameloblast~a. History i ndicates it may be peri pheral , but I cannot tell from this slide. The hi stopa thology shows a pattern whi ch we have seen in ameloblastomas of the maxil la bu t not in the mandibl e ." •

Oxenhandler from Columbia. Hori from West Virginia. Weidner from Colorado Spr ings . Costa from IICI, Cardona Lope.: from Honduras called· it, .. amelobl astoraa . ••

:ASE !6 (80-1212) PAGET'S DISEASE Contributed by Dr. Charles Dunlap and Bruce Barker, University of Missouri·

Kansas City School of Dentistry , Kansas City , Mi ssouri

This was the overwhelm1ng diagnosis. A few commen taries :

Ta rpley and Cor io from UIH, "The histology is suggestive, i.e ., extreme vascularity, location of giont cel l s of early Paget' s Di sease.

Rosai from Minnesota, "Paget's Disease. The cl inical history suggests to me the phenomenon of rapid dissolution of bone substance t ha t has been repor ted in patients With Paget's Disease fol lowing immobil i zation of a long bone because of fracture. Hew England Journa l of Medicine, 231: 343. 1944.

Greer from Colorado, "Benign fibro-osseous lesion consi stent with Paget 's Disease.

Kreutzer frono llicllita called It •paget' s Disease. ''

Berthrong from Co lorado Springs. " ... probably it was Paget's recognizing the diffi culty of making that diagnosis definite in a COQpl etely decalcif ied specimen where the cement lines are largely lost. 1 had great difficul ty including osteitis fibrosa of hyperparathyroidls~ and felt that this had to be ruled out biochemical ly. The bone was entirely lamel lar bone which would be consistent with either of these two conditions. 1 believe the scalloping of the Ma rgins here is more irregular than most cases of hyperparathyro id bone disease and thus I woul d favor Paget's. I also suspect that t he alkaline phosphatase here Is far higher than would be seen in the vast 11ajority of hyperpara ­thyroidism, but is quite consistent with Paget's. MY favorite diagnosis is Paget 's Disease. but I would exclude hyperparathyroidism by ca lcium and phosphorous studies.

LeGal f rom St rasbourg, "This is not Paget's Disease . It could be primary or secondary hyperparathyroidiSm."

CASE 11

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CASE 12

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C.ASE 13

CAS£ 14

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Attachment Hl

CI\SB ~ I, {11-78-72) :BOTRYOI D ODONTOGB!IIC CYST {Contributed by Jlto. Bruae llarker, and D:r. Cho.:rlea Dull1!'3', D.D.S. , De~t. ot Oral Pathology, Univ. of Mo., K.o.n.s-a..e City. S~ol of Dentistry, 6~0 E. 25th St. , Kansas City, Mo.)

Dr. Waldl'on tram Emory RiJ&ted: "~'his bas t ile feaburea ot the eo called bo'bryoid oilontogenio eyat. I :tell tbiu is a multUooulu .r;>rilllOrdl.Ll c;rat. We oan•t 10elte llll!oloblaot"""" out ot' thin o~. U a fair llll!Ount of mcin = be dem<>mrb:r&ted, I lli.t;;;b.t lianL j:Ci •~Vise f1I1f 1!4snosio oo a variety of ....,t,l'!ll !IIIICoepidel'mOid tumor v:Lth, JM.rl<ed oysttc f<!&'tlurea. D:r. ll~ trcn D<> rqtt, Dr. Jfo:y an4 uaooi.o.teo frm '!l1.,nboli<U' M4d1cLL Conto•·, a.,, Dr, Sotubba and Aclt~rman 1'1:'~ toll8 Isl1111d eLll~d it "oynbin muooep~dermoid oo:cina:w.." Dr. Al>I.'GIIUr trom USC otated: "This 1M .U'I;her ;< ~aatia !:oUto..u&r O.)ct witb lmJCQ\t.a cell Pl'OaQl)~BB111 or .. oyatia mueoqoidermoid tumor. ! ;rr.<fe>:" tlJ..,. f.:o•""r pc>uibllit;r ~ut I wo\l.ld not l>~ao~rn> 1:oo ""otiona.l if ""' oM waate4 to aoneldo1· it ..., "" tuc:!J!f..,t muooepidenttllid tuwr." i;lr. 's •

m!.lr.i3 ud McCJe.Whey from !Uch:le;an ~tntetl: uiJilliY&r"J' i.aelWJlon eyat.-t. odol'ltlogenS.c :nucoep1tlf;trmo:id uarG.J..Aom. II nr. 'a Corio ana TU1'1le)" cBl.led

it O•lOilbOI!JOI>;Io {Bot,-;-oid) Oy"t. u Dr • Shafer !'l'Cill In~ abte'l: "II~ bGVO

tit.., •<OTarol oa.aee Yith this per.u.l18J:' Jlt!.xt.ure and hnV<! bc~D oe.l..Ung tilm rtal.o-odalltoseaia c,yst." ·

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