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Bone tumors (tumors 14

and cysts of the jaws)

INTRODUCTION neck region. These t u m o r s m a y arise f r o m t h e jaws or any other


bone of the s k u l l . In a d d i t i o n lo this, tumors that arise from the
upper and lower alveolus may he of odontogenic origin. The
Bone tumors form a very small c o m p o n e n t in the total spectrum
histologic classification of n o n - o d o n t o g e n i c tumors of the jaws
of neoplastic diseases requiring surgical treatment in the head a n d
and skull is listed in l i g . 1 4 . 1 .
In a d d i t i o n to the above, fibrous dysplasia is quite often seen in
Fig. 14.1 The histologic classification of non-odontogenic tumors of the facial skeleton, particularly i n v o l v i n g the mandible. The clinical
jaws and skull.
and radiographic findings of fibrous dysplasia are similar to other
fibro-osseous lesions of the facial skeleton. A thorough workup is
Tissue of origin Benign Malignant
therefore essential in a r r i v i n g at an accurate diagnosis to facilitate
Chondrocytes Chondroma, Chondrosarcoma treatment p l a n n i n g .
Chondroblastoma Lesions of o d o n t o g e n i c o r i g i n form a large number of clinical
Osteochondroma, entities r e q u i r i n g appropriate understanding of their etiology to
Chondromyxoid
facilitate management. These lesions may be cystic or solid and
fibroma
may arise in the m a x i l l a or the m a n d i b l e . A variety of epithelial
Osteocytes Osteoma, Osteogenic sarcoma
Osteoid osteoma, (endosteal,
Osteoblastoma parosteal,
periosteal) Fig. 1 4 . 2 The histologic classification of tumors of odontogenic origin.
Fibroblasts Fibroma - ossifying Fibrosarcoma,
and non-ossifying Malignant fibrous Epithelial odontogenic M e s o d e r m a l odontogenic
histiocytoma tumors tumors
Myxoma Myxosarcoma
Ameloblastoma Myxoma, fibromyxoma
Vascular tissue Hemangioma Hemangiopericytoma
Ameloblastic fibroma Odontogenic fibroma
Aneurysmal bone Hemangioendothelioma
Ameloblastic fibrosarcoma Cementoma, cementoblastoma
cyst
Adenomatoid odontogenic Cementifying fibroma, periapical
Nervous tissue Neurilemoma, Neurogenic sarcoma
tumor cemental dysplasia, familial
Neurofibroma
multiple (gigantiform)
Histiocytes Histiocytosis Plasmacytoma,
cementoma
Myeloma,
Squamous odontogenic tumor
Lymphoma
Calcifying epithelial
odontogenic tumor
Miscellaneous
Odontoma (compound or
Giant cell granuloma Malignant giant cell tumor, complex)
Ewing's sarcoma Ameloblastic odontoma
Giant cell tumor Metastatic tumors to the skull (fibrodontoma)

Fig. 1 4 . 3 Classification of odontogenic cysts.

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BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S ) 14

CJ Head and neck • Pelvis B Other


S Upper limb D Lower limb
Fig. 14.6 Site distribution for osteogenic sarcomas.

Fig. 14.4 Classification of fissural cysts.

Fig. 14.7 Site distribution for chondrosarcomas.

Fig. 14.S Distribution of ameloblastomas among the jaws.

and mesodermal tumors arise from the odontome. However, their


surgical management in most instances is similar. The histologic
classification of tumors of odontogenic origin in shown in Fig. 14.2,
Epithelial cysts of the jaws may be of odontogenic or fissural
origin. Odontogenic cysts are periodontal (apical, lateral, residual),
dentigcrous, gingival, primordial or keratinizing and calcifying
(Fig. 14.3). On the other hand, fissural cysts may be lateral
(nasolabial, globulomaxillaryl, medial (nasopalatine, median
palatal) or median mandibular (Fig. 14.4). The most frequently
seen odontogenic tumor is ameloblastoma. The mandible is the
site of origin in over three-quarters of all patients (Fig. 14.5).
Fig. 14.8 Site distribution for osteogenic sarcomas of the head and
neck.
SITE DISTRIBUTION OF BONE TUMORS
the mandible is shown in Fig. 14.10. The most frequent mode of
Only 5% of all bone sarcomas in adults arise in the head and neck presentation is a mass lesion or symptoms secondary to pressure
region (Figs 14.6 and 14.7). Osteogenic sarcoma and chondro- on contiguous neurovascular structures or viscera or the adjacent
sarcoma are the most common histologic variants. The silc distri- dentition. Symptoms may also arise for tumors of the maxilla due
bution of the most frequently encountered adult bone sarcomas in to compression of Ihc orbit or obstruction of the nasal passages.
the head and neck region is shown in Figs 14.8 and 14.9. As can The diagnosis of a bone tumor is usually suspected by an adequate
be seen, sarcomas can arise from almost any of the craniocervical clinical examination although for surgical treatment planning,
bones although the mandible and maxilla arc the most frequently additional workup, including thorough radiographic evaluation
encountered sites. The relative distribution of various lesions in and tissue diagnosis, is mandatory.

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BONE T U M O R S ( T U M O R S A N D CYSTS O F THE ) A W S )

Fig. 14.11 CTscan of a


patient with an
osteoblastoma of the
infratemporal fossa.

CH Calvarium O Mandible B Vertebrae


Fig. 14.12 MRI scan of
LJ Maxilla EH Other sinuses the same patient as in
Fig. 14.9 Site distribution for chondrosarcomas of the head and neck. Fig. 14,11 confirming
the soft tissue extent
of the tumor.

Fig. 14,13 Three-


Fig. 14.10 The relative distribution of various lesions in the mandible.
dimensional
reconstruction of the
CT scan showing the
lesion.
RADIOGRAPHIC EVALUATION

Accurate assessment of the anatomic extent of a bone tumor of


the head and neck area requires its evaluation in all three
dimensions. Plain films of the mandible and skull often provide
satisfactory radiographic evaluation of the bony architecture and
the pathologic process in the involved bone. However, for detailed
evaluation of the mandible it is necessary to obtain additional
studies including a panoramic x-ray of the mandible. For more
accurate details of the bony architecture of the mandible as it
relates to the dentition, occlusal film of the mandible and
periapical dental x-rays are most satisfactory. A special CT evaluation
of the mandible ('Dentascan') provides serial tomographic axial like conditions have characteristic radiographic appearances almost
cuts of the mandible and is very helpful in select circumstances to pin-pointing the diagnosis However, tissue diagnosis is mandatory
study accurate bone details at the site of the pathologic process. prior to implementation of therapy.
CT and MR1 scans provide the most comprehensive assessment of Whenever a CT scan is requested for evaluation of a neoplastic
the entire facial skeleton in a three-dimensional fashion. In addition process with invasion of bone as well as soft tissue, the scan
to this, virtual three-dimensional reconstruction of CT or MR should be obtained with contrast enhancement and with a special
images is now feasible, enabling the surgeon to appreciate the true request to obtain both soft tissue and bone windows. The patient
anatomic location and extent of a bone tumor in the head and whose CT scans of the upper alveolus are shown in Figs 14.14
neck region. For example, representative views of a CT scan, MRI, and 14.15 has a myxoma of the alveolus extending into the
and three-dimensional reconstruction of a patient with an maxilla. The soft tissue window shown in Fig. 14.14 gives
osteoblastoma of the infratemporal fossa are shown in Figs excellent soft tissue detail, but the fine architectural detail of the
14.11-14.13. The radiographic appearances of several other bone bone is obscured. On the bone window shown in Fig. 14.15, the
lesions are shown later in this chapter. Many tumors and tumor- soft tissue detail is obscured and the fine architecture of the bone

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BONE T U M O R S ( T U M O R S A N D CYSTS OF THE J A W S )

Fig. 14.14 Soft tissue window of an axial CT Fig. 14.15 Bone window of the axial CT scan Fig. 14.16 Three-dimensional CT reconstruction
scan through the upper alveolus demonstrating demonstrating an expansile bone destructive showing an expansile lesion of the mandible.
a hypodense expansile bone destructive lesion. lesion of the upper alveolus.

Fig. 14.17 Posterior Fig. 14.18 Axial view


view of the of the CT scan (bone
three-dimensional window) shows the
CT reconstruction featureless 'ground-
demonstrates the full- glass' appearance of
thickness invovlement the pathologic bone.
of the mandible.

and the lesion are vividly demonstrated. Therefore, for adequate present, three-dimensional reconstructions of the CT scans are
evaluation of bone invasion by a neoplastic process, both soft valuable for accurate assessment and documentation of the extent
tissue and bone windows of the CT scan are required. of invasion and for planning reconstructive surgery.
Three-dimensional reconstructions of the CT scan are often
valuable in assessing the true extent of the tumor, particularly
BIOPSY
with reference to planning reconstructive procedures. Three-
dimensional cast models can also be fabricated with computer
software which provide cast models of the bony defect to be It is vitally important that accurate tissue diagnosis be established
reconstructed, thus facilitating the ability of the reconstructive prior to definitive surgical treatment in patients who present with
surgeon to accurately fabricate a graft or flap to achieve accurate lesions suspicious of being a neoplastic process involving the
contour and symmetry. A three-dimensional reconstruction of the facial skeleton. Several bone lesions arc often benign or of a low-
craniofacial skeleton of a young patient with fibrous dysplasia of grade malignant histology and their treatment is significantly
the mandible is shown in Fig. 14.16. Note the shape and dimensions different than for high-grade bone tumors. Since needle biopsy is
of the pathologic mandible in relation to the remaining facial often not satisfactory, an open biopsy with a generous volume of
skeleton. In a posterior view of the reconstructed CT scan the representative tissue should be submitted for pathologic analysis.
thickness of the mandible involved by fibrous dysplasia is vividly Frozen section diagnosis is sometimes not possible and should not
demonstrated (Fig. 14.17). An axial view of the same patient be requested when a bone tumor is suspected. Extraction of a
tooth near lesions of the upper or lower jaw should be avoided
shows the thickening of the cancellous bone with thinning out of
and a biopsy obtained from an adjacent area to prevent im-
the mandibular cortex. The normal architecture of the cancellous
plantation of malignant tumor into the marrow cavity of the
bone is lost and replaced by a ground glass appearance of fibrous
affected bone, increasing the risk of tumor dissemination.
dysplasia (Fig. 14.18). Thus, when complex bony pathology is

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14 BONE T U M O R S ( T U M O R S A N D CYSTS O F THE | A W S )

FACTORS A F F E C T I N G C H O I C E O F T R E A T M E N T The operative procedures in this chapter are not discussed by


tissue of o r i g i n , as was done in the chapter on soft tissue tumors.
Instead, the management of osseous tumors is described by bone
Surgical excision is the preferred m o d a l i t y of therapy for nearly all of o r i g i n , starting f r o m the c a l v a r i u m . Thus, tumors of the vertex,
bone tumors arising in the head and neck region. Most b e n i g n calvarium, skull base, maxilla, mandible a n d cervical spine are
lesions can be adequately treated by a relatively conservative discussed in that order.
excision hut preferably in a m o n o b l o c fashion by an appropriate
surgical approach depending u p o n the size a n d location of the
tumor. In a similar fashion, low-grade malignant t u m o r s such as TUMORS OF THE CALVARIUM
low-grade chondrosarcoma a n d low-grade fibro-osseous lesions arc
also managed by a relatively conservative surgical resection. On
Primary bone t u m o r s of the calvarium are exceedingly rare.
the other hand, high-grade malignant tumors require an aggressive
Osteoma a n d h e m a n g i o m a are, however, the most frequently seen
surgical approach for satisfactory resection w i t h adequate b o n y benign lesions. I'aget's sarcoma, osteogenic sarcoma, and metastatic
and soft tissue margins. Histologically aggressive tumors w i l l require lesions are the most frequently seen malignant tumors. The
multimodal therapy i n c l u d i n g radiotherapy a n d chemotherapy to indications for surgery are related to histologic diagnosis and
improve local c o n t r o l and reduce the risk of distant metastases. symptoms. Some benign lesions are asymptomatic and may be
Metastatic tumors to the craniofacial skeleton f r o m p r i m a r y car- simply kept under observation.
cinomas of the kidney, t h y r o i d , l u n g , a n d breast may occasionally
require surgical resection. Some lesions such as fibrous dysplasia
are polyostotic. Involvement of m u l t i p l e bones w o u l d clearly H E M A N G I O M A OF THE FRONTAL B O N E
influence surgical treatment. Appropriate w o r k u p should therefore
be undertaken to rule out m u l t i p l e bone i n v o l v e m e n t .
Hemangiomas of (he craniofacial skeleton are usually asymptomatic
Lesions of odontogenic o r i g i n are usually managed in a c o n -
a n d present s i m p l y as a b o n y mass. On occasion the lesions get
servative fashion. Ameloblastoma is a locally malignant process
large and produce skeletal deformity requiring surgical intervention.
which is usually treated by 'complete excision' to avoid local
Some patients do have s y m p t o m s due to progressive growth of the
recurrences. Curettage a n d marsupialization are u n l i k e l y to be
lesion, w a r r a n t i n g the need for surgical i n t e r v e n t i o n . Occasionally
successful and almost u n i f o r m l y result in recurrent disease. W h e n -
h e m a n g i o m a in a stress bearing bone may require surgical inter-
ever major resection of the upper or lower jaw is planned, appropriate
v e n t i o n to avoid a pathologic fracture. The most c o m m o n site of
consultation from a reconstructive surgical team and maxillofacial
hemangiomas in the craniofacial skeleton is the calvarium. A CT
prosthodonlic team s h o u l d be obtained to develop an o p t i m a l
scan in axial view w i t h soft tissue w i n d o w of a patient w i t h
therapeutic strategy. This is particularly i m p o r t a n t for patients in
hemangioma of the parietal region is shown in F i g . 14.19. Note
w h o m the floor of the o r b i t or hard palate is to be resected.
(he well-demarcated b o n y defect w i t h a h o n e y c o m b appearance of
Similarly preoperative photographs a n d facial moulage s h o u l d also
the i n v o l v e d outer cortex of the c a l v a r i u m . The bone w i n d o w of
be obtained for fabrication of facial orbital prostheses. Lesions
the same patient s h o w n in F i g . 1 4 . 2 0 demonstrates a punched
i n v o l v i n g the calvarium or the skull base require neurosurgical
out area of (he frontoparietal region i n v o l v e d by hemangioma.
consultation for a c o m b i n e d craniofacial approach for adequate
surgical resection. Fig. 1 4 . 1 9 Axial view
of the CT scan (soft
tissue w i n d o w )
PREOPERATIVE P R E P A R A T I O N d e m o n s t r a t i n g the
well-demarcated defect
in the outer table w i t h
a 'honeycomb'
Most patients requiring surgery for t u m o r s of the jaws or facial
appearance.
skeleton do not need any specific preoperative preparation other
than satisfactory radiographic studies a n d accurate tissue diagnosis.
If a massive resection is c o n t e m p l a t e d , leading to significant b l o o d
Fig. 1 4 . 2 0 Bone
loss, then sufficient quantities of b l o o d should be available for w i n d o w of CT scan of
replacing operative b l o o d loss. H i g h l y vascular lesions may be the same patient as in
considered for preoperative e m b o l i z a t i o n p r i o r to surgical Fig. 14.19 shows the
resection. If the upper alveolus or m a x i l l a is to be resected, then punched out defect in
the f r o n t a l bone.
preoperative consultation f r o m the dental prosthetic d e p a r t m e n t
should be obtained for preoperative dental impressions a n d
fabrication of a dental obturator. If m a n d i b u l c c l o m y is planned,
then appropriate consultation from a microvascular reconstructive
surgical team should be obtained and the patient should be prepared
for a microvascular free flap reconstruction f r o m an appropriate
donor site. Patients requiring craniofacial resections need to be
started on preoperative a n t i b i o t i c s and steroids to reduce the risk
of postoperative sepsis a n d brain edema. Surgical resection of
vertebral bodies requires adequate stabilization of the spine. This
may require either neurosurgical or orthopedic c o n s u l t a t i o n for
posterior stabilization of the spine or for availability of a halo
splint for postoperative i m m o b i l i z a t i o n .

553
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S ) 14

Surgical excision of the lesion requires a full-thickness craniectomy 14.23 and 14.24). The scalp incision is then closed over the
and appropriate cranioplasty. The entire operative procedure is cranioplasty in the usual manner. Alternatively, a titanium mesh
extradural. The patient is placed under general endotracheal anes- can be used to provide the matrix for support to the bone cement
thesia and the scalp is shaved and prcpped in the usual fashion. A or special cranioplasty plates may be used wilhout the bone
U-shaped incision is taken over the scalp around the palpable cement to repair small surgical defects (Fig. 14.2S).
tumor with the pedicle of the flap based anteriorly. The scalp flap
is elevated deep to the pericranium exposing the outer cortex of
the frontoparietal region (Fig. 14.21). Note the purplish color of
the hemangioma involving the bone. Two burr holes are placed,
one anterior and the other posterior to I he lesion. Using ap-
propriate dural elevators the underlying dura is separated from the
inner cortex of the bone to free up the area of bone involvement.
Using a Midas Rex side-cutting power saw the craniectomy is
completed by connecting the burr holes around the visible and
palpable tumor. The surgical specimen is removed in a monobloc
fashion (Fig. 14.22). Accurate hemostasis is secured by using
bipolar cautery for control of bleeding from the dura and using
bone wax over the cut edges of the calvarium.
Cranioplasty of the craniectomy defect can be performed by a
variety of different techniques. The simplest technique is to use a
braided wire and bone cement. The wire criss-crossed between the
edges of the surgical defect and bone cement is used to fill the
surgical defect. The wire acts as a matrix over which the bone Fig. 14.23 Braided wire is criss-crossed between the edges of the
cement provides a shell to repair the craniectomy defect (Figs surgical defect.

Fig. 14.21 The scalp flap is elevated to expose the hemangioma. Fig. 14.24 The wire acts as a matrix over which the bone cement
provides a shell to repair the craniectomy defect.

Fig. 14.25 A titanium


mesh or cranioplasty
plate can be used to
reconstruct the
craniectomy defect.

METRICll 2| 31 4
. .1.. .
Fig. 14.22 The surgical specimen.

554
Postoperative care for this patient is relatively simple. The The patient shown here has Paget's disease involving the skull.
patient is maintained on antibiotics until satisfactory primary He presented to a local surgeon with an enlarging mass on the
healing of the scalp wound is manifested. forehead of approximately six months' duration. A generous open
Hemangiomas of the bone are benign lesions which are often biopsy was performed with a transverse incision in the skin of the
asymptomatic and may not require surgical resection in every forehead which confirmed the diagnosis of osteogenic sarcoma
instance. Unless there is demonstrable growth over a short period (lig. 14.26).
of time, or the patient has symptoms, or if there is suspicion of A CT scan of the head in an axial plane with soft tissue window
malignancy, surgical treatment is usually not undertaken. The lesion shows significant intracranial extension of disease with displacement
can simply be followed clinically or radiographically and surgical and/or involvement of the dura and the frontal lobe on the left-
intervention may be considered if any of the above indications hand side (Fig. 14.27). A representative axial view of the CT scan
become manifest. with a bone window shows the entire skull involved with Paget's
disease (Fig. 14.28). The tumor involves the frontal bone on the
left-hand side with extension of disease to involve the medial part
SARCOMA OF THE FRONTAL BONE
of the frontal bone on the right-hand side. There is significant soft
tissue extension in an extracranial fashion. A coronal view of the
Malignant tumors of the calvarium which arc adherent to the CT scan shows direct extension of the tumor in the orbit through
overlying scalp and underlying dura require through-and-through its roof, displacing the globe interiorly and laterally (Fig. 14.29).
monobloc resection. However, when these tumors involve the The tumor does not extend to involve the contents of the nasal
anterior cranial fossa, a craniofacial resection becomes necessary. cavity however.
If the tumor involves one orbit, then orbital exenteration in Operative procedure in this clinical setting demands involvement
conjunction with formal craniectomy and en bloc excision are of two surgical teams. A neurosurgical team which will begin with
indicated. the craniotomy and the head and neck team which will

Fig. 14.26 A patient Fig. 14.28 Axial CT


with a bony lesion on scan of the head with
the forehead. The scar bone window showing
of an open biopsy is the bone destructive
visible. tumor and involvement
of the cranium with
Paget's disease.

Fig. 14.27 Axial CT Fig. 14.29 Coronal


scan with soft tissue view of a CT scan
window showing a showing extension of
massive tumor with the tumor into the
intra- and extracranial orbit.
extension.

555
T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS) TT
accomplish the facial aspect of the procedure and reconstruction
of the surgical defect with appropriate scalp flaps. A third surgical
team for microvascular free tissue transfer may he required if free
flap reconstruction of the surgical defect is planned. The technical
details of craniofacial resection are discussed in Chapter 4. An artist's
rendering of the extent of tumor resection is shown in Fig. 14.30.
The surgical specimen shows the orbit, frontal hone with the
tumor and overlying skin excised in a monobloc fashion (Fig.
14.31). The posterior view of the specimen shows the excised
portion of the dura and frontal lobe (Fig. 14.32). The surgical
delect of the craniectomy is continuous with (he lower half of the
orbital socket and the contents of the frontal fossa with exposed
brain in that region. A close-up view of the surgical defect shows
exposed brain of the left frontal lobe with a large dural defect due
to its resection with the specimen (Fig. 14.33). Laterally, the
stump of the temporalis muscle is visible in the temporal region.
A large segment of the periosteum from the posterior aspect of
Fig. 14.32 Posterior view of the specimen showing the intracranial
the skull is now excised and used as a free graft to repair the delect tumor and the resected portion of the dura.
in the dura. The periosteum is sutured to the dura with 4-0
Neurolon sutures. A watertight closure is obtained to prevent any
cerebrospinal fluid leakage (Fig. 14.34).

Fig. 14.33 Close-up view of the surgical defect showing the exposed
brain and the dural defect.
Fig. 14.30 An artist's rendering of the proposed extent of surgical
resection.

Fig. 14.31 Anterior view of the surgical specimen. Fig. 14.34 A watertight closure is obtained.

556
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S )

Fig. 14.36 The appearance of the patient three


months following surgery. Patient is now ready
for fabrication of a facial and orbital prosthesis.

Fig. 14.37 Postoperative CT scan.

Fig. 14.35 The scalp flaps are rotated to cover


the surgical defect.

Fig. 14.38
A massive defect such as this is best reconstructed with a composite Anteroposterior view
free Flap. A rectus abdominis or latissimus dorsi free flap arc ideal of the plain x-ray of
the skull.
for this purpose. If a composite free flap is loo bulky, then simply
a latissimus dorsi muscle flap may be used and a split-thickness
skin graft is applied over it for skin coverage. However, if a free
flap is not available, then closure can be achieved with multiple
scalp flaps. This requires proper planning of incisions to resect the
tumor and elevate the flaps at the beginning of the operation. The
defect in this patient was repaired using multiple scalp flaps based
on superficial temporal and occipital arteries (Fig. 14.35).
The postoperative appearance of the patient approximately three
months following surgery shows primary healing of all the scalp
flaps (Fig. 14.36). An external prosthesis will now be fabricated lo
rehabilitate the patient for esthetic appearance.
A postoperative CT scan demonstrates lotal excision of the tumor
of the frontal region with satisfactory margins (Fig. 14.37).

METASTATIC TUMOR OF THE CALVARIUM

Tumors of the calvarium which involve the overlying scalp require


a through-and-through resection often including the underlying
dura. Primary tumors of the scalp invading the skull, and primary
tumors of or metastatic tumors of the calvarium warrant this type
of surgical resection.
The plain x-rays of the skull of the patient shown here demon-
strate a bone destructive lesion involving the cranial vault in the
parieto-occipital region on the right-hand side (Figs 14.38 and
14.391. CT scans clearly demonstrale the lesion which involves the
overlying scalp with extension through the cranium to involve the
underlying dura (Figs 14.40 and 14.41). Needle aspiration biopsy
of (his lesion confirmed the diagnosis of a metastatic renal cell
carcinoma. This was a solitary metastasis.
The patient is placed under general endotracheal anesthesia in
the supine position on the operating table with the head resting
on the left parietal region on a standard U-shaped head rest (Fig.
14.42). The shaved scalp clearly shows the gross dimensions of
the lesion. An indwelling spinal catheter is placed to monitor Fig. 14.39 Lateral view of the plain x-ray of the skul

557
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S )

cerebrospinal fluid pressure as well as to facilitate withdrawal of


cerebrospinal fluid to slacken the brain if necessary.
The incisions are outlined on the scalp (Fig. 14.43). The extent
of scalp that would have to be sacrificed with resection of I he
tumor is shown. A parietal scalp flap is outlined; this scalp flap is
based on the left-hand side with the entire scalp elevated from the
pinna of the ear on the right-hand side all the way up to the pinna
of the ear on the left-hand side (Fig. 14.44). The blood supply to
this flap is derived from the superficial temporal, posterior
auricular, and occipital arteries of the left-hand side. The scalp flap
is elevated all the way up to the pinna of the ear and the mastoid
process on the left-hand side. The flap is elevated in a subgaleal
plane remaining superficial to the pericranium which will be used
later for repair of the deled. A circumferential incision is now
made through the periosteum remaining at least 1.5-2 cm away
from the edges of the scalp to be sacrificed with the specimen Fig. 14.42 The patient in position.

Fig. 14.40 CT scan of


the skull with a bone
window shows a
punched out area of
bone destruction.

Fig. 14.43 The incisions are outlined on the scalp.

Fig. 14.41 CT scan of


the skull with a soft
tissue window shows
the extra- and
intracranial component
of the tumor.

Fig. 14.44 The parietal scalp flap is elevated in a subgaleal plane,


remaining superficial to the pericranium.

558
14 BONE T U M O R S ( T U M O R S A N D CYSTS O F THE | A W S )

(Fig. 14.45). The skull is now exposed subperioslcally in a circum- 14.47). During this phase of the operation it is necessary to
ferential fashion around the tumor. Multiple burr holes are now withdraw approximately 30-40 ml of cerebrospinal fluid (CSF) to
made. Using a craniotome, a circumferential craniectomy is slacken the brain and prevent CSF leakage. Bleeding from the
completed around the gross tumor (Fig. 14.46). The plane of dural vessels is easily controlled with a bipolar cautery.
dissection is still extradural. Care and caution must be exercised The specimen is now removed showing the surgical defect (Fig.
during the performance of burr holes to stay well away from the 14.48). The brain is exposed as a result of sacrifice of the dura.
gross tumor in order to avoid compromising the adequacy of Complete hemostasis at this point must be secured prior to
resection. Using a dural dissector, an attempt is made to elevate beginning the closure of the dural defect. Bleeding from the edges
the dura from the undersurface of the parietal bone. The dura, of the craniectomy defect is controlled using bone wax.
however, is adherent to and involved by the tumor. It will therefore The previously elevated scalp flap is now elevated further
require resection. The dura is entered by making an incision with posteriorly to expose the left occipital region. The periosteum
a scalpel. Using scissors, it is excised circumferentially around the covering the skull in the occipital region on the left-hand side is
tumor to facilitate a monobloc resection. As the dura is incised, thus exposed (Fig. 14.49). A generous portion of the periosteum
the surgical specimen becomes more mobile permitting its rotation of the skull over the occipital region from the left side is now
externally to further facilitate exposure of the remaining dural elevated and excised for its use as a free graft lor repair of the dural
attachments and its division. defect. No attempt is made to remove the periosteum from the
The surgical specimen is now reflected posteriorly with the dura parietal region since that will be necessary to support the skin
attached to the tumor and exposing the underlying brain (Fig. graft. Sufficient periosteal graft should be harvested to repair the

Fig. 14.45 Circumferential incision is made in the periosteum around Fig. 14.47 The surgical specimen is reflected posteriorly with dura as its
the tumor. deep margin.

Fig. 14.46 A circumferential craniectomy is completed through multiple Fig. 14.48 The surgical defect following removal of the specimen.
burr holes and the dura is opened.

559
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S )

dural delect. This periosteal graft is sutured to the edges of the position with a bolster dressing. A suction drain is placed beneath
dura with 4-0 Neurolon suture (Fig. 14.50). A watertight closure the rotated scalp flap. The surgical specimen shows the intact
must be secured to prevent CSF leakage. portion of the scalp resected with the tumor (Fig. 14.53). Its
After satisfactory repair of the dural defect, the sharp edges of deeper surface shows intact dura providing a monobloc resection
the craniectomy defect are smoothed out. The previously elevated of the tumor (Fig. 14.54).
scalp flap is now rotated posteriorly in order to cover the craniectomy The postoperative appearance of the patient approximately nine
defect (Fig. 14.51). Closure of the scalp edges is performed in two months following surgery shows .satisfactory restoration of the
layers using interrupted chromic catgut subcutaneous sutures and scalp defect (Fig. 14.55). Although there is no bony support at
3-0 nylon sutures for the skin. The donor site defect in the scalp the site of the craniectomy, the defect is covered with full-
of the parietal region still has its periosteum intact (Fig. 14.52). A thickness scalp while the split-thickness skin graft covers the skull
split-thickness skin grail harvested from the thigh is now applied at the donor site of the scalp flap. Rotated scalp flap in this fashion
to the exposed periosteum. The skin graft is secured with continuous provides a very satisfactory coverage for craniectomy defects
absorbable sutures to the edges of the scalp. It is retained in following resection of primary or metastatic tumors of the calvarium.

Fig. 14.49 The periosteum covering the skull in the occipital region is Fig. 14.51 The scalp flap is rotated posteriorly to cover the craniectomy
exposed and a pericranial graft is harvested. site.

Fig. 14.52 The donor site defect has its periosteum intact over which a
split-thickness skin graft is applied.

560
BONE T U M O R S ( T U M O R S A N D CYSTS O F THE | A W S )

TUMORS OF THE FACIAL SKELETON AND


PARANASAL SINUSES

The most frequently seen benign tumors ot the facial skeleton and
paranasal sinuses are osteomas and fibro-osseous lesions.
Osteomas are most frequently seen in the frontal/ethmoid sinuses.
Chondrosarcomas a n d osteogenic sarcomas are I he most
predominant malignant lesions of this region.

OSTEOMAS OF THE FACIAL SKELETON

Osteoma is a benign tumor of osseous origin which can arise in


any facial bone. The mandible is the most commonly involved
bone. Among the paranasal sinuses, the frontal and ethmoid
sinuses are most frequently involved. Patients present with
symptoms secondary to obstruction of the involved sinus cavity
with secondary mucocele formation or occasionally an expansile
lesion with distortion of the facial contour. Surgical treatment
requires total excision via an appropriate surgical approach
depending upon the site of presentation. Osteomas grow very
slowly and small lesions are often not symptomatic. In some
patients, osteomas present as a component of Gardner's syndrome.
Patients with multiple osteomas of the facial skeleton should
therefore be investigated for Gardner's syndrome in particular.
Small osteomas may be left alone but larger lesions are
symptomatic and require surgical treatment.
The CT scan of a patient with an osteoma of the ethmoid is
shown in Figs 14.56 and 14.57. An axial view with bone windows
demonstrates a bony lesion involving the right ethmoid region
with displacement of the left globe anteriorly. The lesion does not
show any soft tissue invasion or bone destruction, but does show
an expansile lesion filling up the ethmoid complex with displace-
ment of the lamina papyraecea of the right orbit. The coronal view
shows the tumor completely replacing the right ethmoid complex
with extension into the right orbit by displacement of the lamina
papyraecea. The tumor extends into the floor of the frontal sinus
Fig. 14.54 The deep surface of the surgical specimen. on the right-hand side, but there is no intracranial extension. The
surgical approach for this lesion required an external elhmoidectomy
approach via a lateral rhinotomy with a Lynch extension. The
medial wall of the orbit and the nasal bone are exposed. A facial
disassembly is performed by removing the nasal bone as well as the
medial wall of the orbit, which will be used later for reconstruction.
Following removal of these, adequate exposure of the ethmoid
region and the floor of the frontal sinus is obtained. Adequate
exposure is a key to the success of this surgical procedure. The
osteoma is inspected and its pedicle is identified. Using a high-
speed burr the pedicle of the tumor is burred down to a very
narrow margin. Eventually small osteotomes arc used to fracture
the tumor from its remaining attachments, allowing its delivery in
a monobloc fashion. The surgical defect demonstrates complete
excision of the tumor (Fig. 14.58). The surgical specimen shows
a multilobulated osteoma arising from the frontoethmoidal region
removed in a monobloc fashion (Fig. 14.59). The previously
excised facial bones are repositioned in their proper place and fixed
with microplalesand screws (Fig. 14.60). Postoperative appearance
of the patient approximately three m o n t h s following surgery
shows satisfactory healing of the skin incision with repositioning
of the globe and restoration of binocular vision (Fig. 14.61). A CT
scan obtained postoperatively shows the extent of bony resection
and complete removal of the tumor (Fig. 14.62).

561
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE ) A W S ) 14

Fig. 14.56 Axial view of the CT scan (bone window) shows a dense Fig. 14.57 Coronal view (bone window) shows that the tumor displaces
lesion of the right ethmoid pushing the globe anteriorly. the right lamina papyraecea laterally without involvement of the globe.

Fig. 14.58 The surgical defect after the tumor Fig. 14.59 The surgical specimen, Fig. 14.60 The facial bones are repositioned
has been excised through a right lateral using microplates and screws.
rhinotomy and facial disassembly procedure.

Fig. 14.61 Early postoperative view of the patient showing the healed Fig. 14.62 Coronal view of the postoperative CT scan shows complete
incision and normal position of the right globe. excision of the tumor.

562
TT BONE TUMORS (TUMORS AND CYSTS OF THE |AWS)

OSSIFYING FIBROMA OF THE ETHMOID

The patient shown in Fig. 14.63 is an 11-year-old hoy who had


previously undergone lateral rhinotomy and attempted excision
of an obstructing lesion from the left nasal cavity which on
histologic analysis was said to be an ossifying fibroma. Some
residual lesion was left behind and the patient was asked to seek
further consultation with the author for definitive treatment. CT
scans in axial and coronal planes demonstrate a bone destructive
expansile lesion filling up the entire nasal cavity between the two
orbits and extending from the cribriform plate cephalad to the
floor of the nasal cavity caudad (Figs 14.64 and 14.65). A lesion
Fig. 1 4 . 6 5 Coronal views of the CT scans show the t u m o r extending up
of this magnitude requires a craniofacial approach for total removal.
t o t h e c r i b r i f o r m p l a t e a n d i n t o t h e s p h e n o i d sinus.
The technical details of craniofacial resection are described in
Chapter 4. Postoperative CT scans of the same patient (Figs 14.66,
14.67) demonstrate complete removal of the tumor.

Fig. 1 4 . 6 6
Postoperative CT scan
t h r o u g h the maxillae
shows complete
removal of the t u m o r
f r o m the nasal cavity.

Fig. 14.63 This p a t i e n t had previously u n d e r g o n e lateral r h i n o t o m y f o r


excision of an o b s t r u c t i n g lesion f r o m the left nasal cavity.

Fig. 1 4 . 6 7 CT scan
t h r o u g h the orbits
shows complete
clearance of the t u m o r
f r o m the ethmoids.

Fig. 14.64 Axial CT scans show a h y p o d e n s e fibro-osseus lesion of t h e


ethmoids.

563
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S )

OSTEOGENIC SARCOMA OF THE ETHMOID The surgical defect shows a massive cranio-orbital resection with
excision of the dura at the floor of the anterior cranial fossa in
conjunction with orbital exenteration, maxillectomy and ex-
The patient whose CT scan is shown in Fig. 14.68 had an
enteration of Ihc nasal cavity (Fig. 14.69). The surgical specimen
osteosarcoma of the ethmoid region which was initially attempted
from the anterior view shows the left orbit and the skin of the
to be resected elsewhere by a lateral rhinotomy approach. Incomplete
frontal region resected with the tumor en bloc (Fig. 14.70). The
resection was performed, following which ihc patient was placed
posterior view of the surgical specimen shows the intracranial
on chemotherapy and radiation therapy. In spite of these treatments,
component of the tumor with craniectomy of the frontal bone
the tumor progressed and lie presented with a massive tumor
and the floor of the anterior cranial fossa accomplished in a
filling up the nasal cavity, left maxillary antrum, and the ethmoid
monobloc fashion (Fig. 14.71). The surgical defect in this patient
region, with extradural extension into the anterior cranial fossa.
was reconstructed using a rectus abdominis myocutaneous free
The tumor had infiltrated the periorbita of the left-hand side and
flap. Postoperative appearance of the patient approximately three
had displaced the globe in the right orbit.
months following surgery shows satisfactory primary healing of
A craniofacial resection with orbital exenteration was performed the wound (Fig. 14.72). Although the esthetic appearance of the
in a monobloc fashion. For technical details of Ihc operative patient is not optimal, the massive surgical defect has been
procedure, please refer to Chapter 4. A standard bifrontal repaired in a single stage operation with primary healing. However,
craniotomy is performed and the floor of the anterior cranial fossa further reconstructive efforts and restoration of the contour of the
is approached in an extradural fashion. Since there was invasion face will be required. Eventually an external facial prosthesis will
of the dura by the tumor, dura of the frontal fossa was resected. be fabricated for esthetic rehabilitation of the face.

Fig. 14.68 Coronal Fig. 14.69 The defect


view of the CT scan after surgical excision
shows a massive tumor of the tumor.
filling up the nasal
cavity, left maxillary
antrum, and the
ethmoid region, with
extradural extension
into the anterior
cranial fossa.

Fig. 14.70 Anterior view of the surgical Fig. 14.71 Posterior view of the surgical Fig. 14.72 Postoperative view of the patient
specimen. specimen. three months following reconstruction with a
rectus abdominis myocutaneous free flap.

564
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS)

LOW-GRADE CHONDROSARCOMA OF THE NASAL patient was secured through a biopsy performed through the nasal
CAVITY cavity. Surgical resection for a lesion of these dimensions and in
this location requires a craniofacial approach. The details of the
technique of craniofacial resection are described at length in
The patient whose MRI scan is shown in Fig. 14.73 presented
Chapter 4.
with a six-month history of progressive nasal obstruction and slight
Postoperative MRI scans of the same patient in the axial, sagittal
proptosis on the right-hand side. MRI scans in the axial, sagittal
and coronal planes demonstrate total resection of the tumor from
and coronal planes demonstrate a well-demarcated bone destructive
the nasal cavity and right maxillary antrum all the way from the
lesion with speckled calcification occupying the entire nasal cavity
base of the skull cephalad lo the floor of the nasal cavity caudad
and the right maxillary antrum, approaching the floor of the orbit
(Figs 14.76-14.78). Since this is a low-grade lesion, no additional
and the cribriform plate al the base of the skull (Figs 14.74 and
treatment is necessary.
14.75). Tissue diagnosis of low-grade chondrosarcoma in this

Fig. 14.73 Axial view of the MRI scan shows a Fig. 14.74 Sagittal view of the MRI scan shows Fig. 14.75 Coronal view of the MRI scan shows
honeycomb-like tumor in the nasal cavity and the tumor extending upto the cribriform plate. tumor of the nasal cavity and maxilla extending
right maxilla. up to the skull base.

Fig. 14.76 Axial view of the postoperative MRI Fig. 14.77 Sagittal view of the postoperative Fig. 14.78 Coronal view of the postoperative
scan. MRI scan. MRI scan.

565
BONE TUMORS (TUMORS AND CYSTS OF THE |AWS) 14
HIGH-GRADE CHONDROSARCOMA OF THE ORBIT demonstrates a massive tumor involving the medial portion of the
left orbit with extension into the nasal cavity (Fig. 14.82). This
patient required a craniofacial resection with orbital exenteration
The patient shown in Fig. 14.79 had previously undergone a
and resection of a portion of the frontal bone and the roof of the
conservative surgical approach for excision of a chondrosarcoma
orbil to excise the tumor in a monobloc fashion. The surgical
of the frontal ethmoid region through a supraorbital incision but
specimen is shown in Fig. 14.83. Technical details of the surgical
the tumor had promptly recurred. Biopsy of the excised tumor
procedure of craniofacial resection are discussed at length in
proved this to be a high-grade chondrosarcoma. The plain x-ray of
chapter 4.
the skull shown in Fig. 14.80 demonstrates bone destruction of
the superior medial quadrant of the left orbit with extension of
tumor to destroy a portion of the frontal bone and the adjacent
skull base. A conventional coronal tomogram of the skull further Fig. 14.81
demonstrates the bone destructive lesion involving the medial Conventional coronal
portion of the left orbit with destruction of the cribriform plate tomogram of the skull
and extension of tumor into the anterior cranial fossa (Fig. 14.81). showing bone
destruction at the
An axial CT scan through the level of the mid-orbit vividly cribriform plate.

Fig. 14.82 Axial CT


scan showing tumor in
the ethmoids and
orbit.

Fig. 14.79 This patient had previously undergone an attempt at surgical


excision of chondrosarcoma of the frontal ethmoid region, through a
supraorbital approach.

Fig. 14.80 Plain x-ray Fig. 14.83 The surgical


of the skull showing specimen.
bone destruction of the
frontal ethmoid
complex.

566
14 BONE T U M O R S ( T U M O R S A N D CYSTS O F THE | A W S ]

LOW-GRADE CHONDROSARCOMA OF THE PREMAXILLA MYXOMA OF THE MAXILLA

The patient whose upper alveolus is shown in Fig. 14.84 had a Myxomas and fibroniyxomas are benign lesions of the facial
nodular firm lesion arising from the midline of the upper alveolus skeleton which usually present as expansile lesions with minimal
in the premaxillary region. The lesion had been present for several soft tissue component. The dentition at the site of the tumor is
years but had shown recent growth. She was unable to wear her usually loose or the teeth have spontaneously extruded. The
upper denture as a result of the presence of this lesion. Open patient whose upper alveolus is shown in Fig. 14.87 presented
biopsy of this lesion showed that this was a low-grade chondro- with a fullness of the left cheek, and spontaneous extrusion of the
sarcoma. A preoperative CT scan of the patient (Fig. 14.85) upper teeth on the left-hand side. CT scans of the paranasal sinuses
demonstrates a bone destructive lesion of the premaxilla with a in the axial and coronal planes demonstrate a homogeneous
honeycomb-like appearance which is classic for a chondrosarcoma. tumor mass causing expansion of the alveolus with minimal bone
This patient's tumor was excised through a per oral approach destruction (Figs 14.88-14.91). The lesion extends into the
with resection of the premaxilla and upper alveolus with satisfactory maxillary antrum with its expansion to produce obstruction of the
bony and soft tissue margins in all three dimensions. The surgical left nasal cavity and displacement of the contents of the orbit
defect was left open to heal by secondary intention since it did not cephalad without any soft tissue invasion by tumor. In spite of
communicate with the nasal cavity or maxillary antrum on either this being a histologically benign tumor, due to its dimensions
side. The postoperative appearance of the patient approximately total maxillectomy would be required for treatment.
six months following surgery is shown in Fig. 14.86. Note the
absence of the alveolar process in the anterior half of the upper
alveolus. This patient required a specially fabricated upper denture
to provide protrusion of the upper lip to fill the defect created by
the surgical resection.

Fig. 14.84 Upper


alveolus showing a
muitilobulated hard
tumor.

Fig. 14.87 Upper alveolus showing an expansile lesion.

Fig. 14.85
Preoperative CT scan
showing a bone
destructive lesion of
the premaxilla.

Fig. 14.86
Postoperative view of
the upper alveolus six
months following
1 surgery.

Fig. 14.88 Axial view of the CT scan showing an expansile lesion with
bone destruction.

567
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S )

OSTEOGENIC SARCOMA OF THE MAXILLA

The maxilla is the second most frequent site of origin for osteogenic
sarcoma in the craniofacial skeleton. The patient whose oral cavity
is shown in Fig. 14.92 is a 19-ycar-old man with the history of
having noted pain, discomfort and swelling of the posterior part
of the left upper gum for three months. He also complained of a
loosening of his molar teeth al that site. CT scans of the paranasal
sinuses in the axial and coronal planes show a bone forming and
hone-destructive expansile lesion of the left maxilla (Figs 14.93
and 14.94). The lesion appears to be contained within the confines
of the maxillary antrum with minimal soft tissue component
anterolateral!}'. Surgical treatment for osteogenic sarcoma of the
maxilla requires a true total maxillectomy. The resection includes
the entire maxilla including the left half of the hard palate, the
floor of the orbit, the zygomatic process and the pterygoid plates,
as well as the nasal process of the maxilla and the lateral wall of
the nasal cavity. When a maxillectomy is undertaken for a sarcoma
in contrast to an epithelial carcinoma, very generous true en bloc-
Fig. 14.89 Axial view of CT scan showing displacement of the medial
wall of the maxilla into the nasal cavity.
total resection of the maxilla should be undertaken, with generous
soft tissue margins around the maxilla in all directions. Every

Fig. 14.90 Coronal


view of the CT scan
showing destruction of
the alveolus and lateral
wall of the maxilla.

Fig. 14.92 Intraoral view showing tumor of the left maxilla causing
expansion of the left upper alveolus.

Fig. 14.91 Coronal


view of the CT scan Fig. 14.9J Axial view
showing the tumor of the CT scan shows
confined to the an expansile bone-
maxilla, causing its forming tumor of the
expansion. left maxilla.

568
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS)

attempt must he made (o achieve monobloc excision of the lunior Fig. 14.94 Coronal
to ensure adequacy of resection. Extreme care should be exercised view of the CT scan
shows a well-
during the course of Ihe operation not to fracture the specimen circumscribed tumor of
and avoid removing the lunior piecemeal. Removal of the tumor the left maxilla without
in a piecemeal fashion significantly increases the risk of leaving soft tissue involvement.
residual tumor behind. Since this is a neoplastic lesion of osseous
origin, ils monobloc removal is not that difficult. The technique
of total maxillectomy is described in Chapter 3.
The lateral view of Ihe specimen shows transected zygoma and
intact posterolateral wall of the maxilla (Fig. 14.95). The medial
view of the specimen shows Ihe transected hard palate and lateral
wall of the nasal cavity (Fig. 14.96). The left half of the hard
palate forms the inferior margin of the specimen (Fig. 14.97). The
anterosuperior view of the specimen clearly shows the tumor
contained in the maxillary antrum (Fig. 14,98). This patient will
need a dental obturator to obliterate the maxillectomy defect and
facilitate his ability to speak and swallow by mouth.

Fig. 14.95 Lateral view of the specimen shows the transected zygoma Fig. 14.96 Medial view of the specimen shows the intact lateral wall of
and intact posterolateral wall of the left maxilla. the nasal cavity.

Fig. 14.97 The palatal surface of the specimen shows the intact hard Fig. 14.98 The anterosuperior view of the specimen shows the upper
palate with an expansile lesion of the alveolus. border of the tumor in the maxillary antrum.

569
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS)

TUMORS OF THE MANDIBLE patient's symptoms, and radiographic appearance of the lesion.
The patient shown in Fig. 14.99 is a 14-ycar-old boy who
presented with the history of a fullness on the left side of his face
The mandible is the most frequent site of odontogenic and non-
noted by his parents several years ago. He had experienced
odontogenic tumors of bone in the head and neck region. The
intermittent discomfort on the left side of the mandible with
most frequent non-odontogenic benign tumors are fibro-osseous
progressive tenderness and pain within the past year. A plain x-ray
lesions. Osteogenic sarcoma and chondrosarcoma are the most
of the mandible (Fig. 14.100) demonstrates a periosteal reaction
common malignant tumors. Ameloblastoma is the most common
over the ascending ramus of the mandible on the left-hand side
odontogenic tumor seen in the mandible; the mandible is more
signifying an active neoplastic process. A panoramic x-ray of the
often involved by ameloblastoma compared to the maxilla. A variety
mandible (Fig. 14.101) demonstrates an irregular osteolytic lesion
of odontogenic cystic lesions are also more commonly seen in the
involving the ascending ramus and the posterior part of the body
mandible.
of the mandible. Due to progressive symptoms of pain and
discomfort, surgical excision of the lesion was recommended.
Exposure of the lesion is obtained through an upper neck incision
OSSIFYING FIBROMA OF THE MANDIBLE
through a skin crease remaining deep to all the soft tissues and
directly over the periosteum of the mandible since this is a benign
The histologic diagnosis between mono-ostotic fibrous dysplasia lesion and truly a subperiosteal process (Fig. 14.102). The
and ossifying fibroma of the mandible is difficult. A decision mandible is exposed from the temporomandibular joint to the
regarding treatment should therefore be based on physical findings, menial foramen on the left-hand side. Soft tissue attachments

Fig. 14.99 This patient presented with a history of pain and a fullness
on the left side of his face.
Fig. 14.101 Panoramic x-ray of the mandible showing an ill-defined
osteolytic lesion.

Fig. 14.100 Plain x-ray of the mandible shows periosteal reaction. Fig. 14.102 The upper neck incision with exposure of the mandible.

570
BONE TUMORS (TUMORS AND CYSTS OF THE |AWS)

including the masseter muscle and the temporalis and pterygoid LOW-GRADE OSTEOGENIC SARCOMA OF THE
muscles are detached with the use of an electrocautery. The MANDIBLE
mandible is divided just posterior to the mental foramen on the
left-hand side and the temporomandibular joint is disarticulated.
The surgical specimen is shown in Fig. 14.103. A sagittal section Osteogenic sarcomas may be endosteal, parosteal, or periosteal.
through the mandible demonstrates the fibrous nature of the They may also be histologically low-grade lesions or high-grade
lesion replacing bone in the entire involved hemimandible (Fig. tumors. The patient shown in Fig. 14.105 presented with the
14.104). A surgical defect of this magnitude requires mandible history of a slowly enlarging bony mass near the angle of the
reconstruction with a fibula free flap with the added consideration mandible on the left-hand side for eight months. On physical
that this patient is a growing child and will probably require examination, there was a bony hard mass involving the region of
further revision surgery as he grows. It is also important that the angle of the mandible with expansion of the lateral cortex and
the upper and lower teeth be kept in intermaxillary fixation to overlying soft tissues. He had anesthesia of the skin of the chin on
maintain alignment and occlusion to prevent progressive facial the left-hand side. Intraoral examination showed the presence of
deformity. a granular polypoid lesion adjacent to the retromolar gingiva in
the gingivobuccal sulcus (Fig. 14.106). Biopsy of this lesion

Fig. 1 4 . 1 0 3 The surgical specimen of left h e m i m a n d i b u l e c t o m y . Fig. 1 4 . 1 0 5 This p a t i e n t h a d a slowly e n l a r g i n g b o n y mass near the
angle of the m a n d i b l e .

Fig. 14.104 W h o l e o r g a n section s h o w i n g a dysplastic f i b r o u s lesion. Fig. 1 4 . 1 0 6 I n t r a o r a l v i e w shows a p o l y p o i d lesion near the retromolar
gingiva.

571
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS)

through the oral cavity c o n f i r m e d t h e diagnosis of a low-grade HIGH-GRADE OSTEOGENIC SARCOMA OF THE
osteogenic sarcoma. A panoramic x-ray of the m a n d i b l e shows MANDIBLE
bone destruction in the edenliilous m a n d i b l e on Hie left-hand
side ( F i g . 14.107). Surgical treatment for a low-grade osteogenic
The patient s h o w n in Fig. 14.109 had previously undergone
sarcoma requires total excision of the clinically palpable a n d
chemotherapy and radiation therapy for a biopsy-proven osteogenic
radiographically demonstrable t u m o r w h i c h can be achieved
sarcoma of the mandible. The t u m o r had s h o w n slight response
through segmental m a n d i b u l e c t o m y . This patient underwent a
but was persistent at w h i c h p o i n t he presented for consideration
segmental resection of the entire ascending ramus of the m a n d i b l e
of surgical resection. Physical e x a m i n a t i o n showed Ihc tumor to
from the c o n d y l o i d process cephalad up to the m i d b o d y of the
be arising from the body of Ihc m a n d i b l e adjacent to the
mandible anterior to the mental foramen on the left-hand side.
symphysis on Ihc left-hand side, presenting as a submental and
The surgical specimen is s h o w n in F i g . 14.108. M a n d i b l e recon-
submandibular f i r m b o n y mass arising from the mandible w i t h
struction f o l l o w i n g such a resection is desirable. However, in this
fixation of the overlying soft tissues and skin. Intraoral examination
elderly gentleman, microvascular free flap reconstruction was not
showed significant expansion of the buccal and lingual cortex of
undertaken due to medical contraindications. Therefore a p r i m a r y
(he m a n d i b l e e x t e n d i n g f r o m t h e region o f t h e right f i r s t molar
closure of the mucosal defect was performed w i t h o u t any bone
l o o t h to t h e last molar t o o t h on the left-hand side (Fig. 14.110).
reconstruction.

Fig. 14.107 Panoramic x-ray showing a bone destructive lesion. Fig. 14.109 This patient had undergone previous chemotherapy and
radiation therapy for osteogenic sarcoma of the mandible.

Fig. 14.108 The surgical specimen of segmental mandibulectomy with


generous soft tissue margins.

572
-? A
I -' I BONE T U M O R S ( T U M O R S A N D CYSTS OF THE ) A W S )

The panoramic x-ray of the mandible shows a classic sun-ray mandible, to encompass the entire tumor. The specimen shown in
appearance of a bone destructive and bone forming lesion of the Fig. 14.113 demonstrates a monobloc resection of the tumor
mandible (Fig. 14.111). A CT scan of the mandible with bone with the mandible resected from angle-to-angle. The surgical
window demonstrates a new bone-forming neoplastic lesion defect shown in Fig. 14.114 demonstrates the stumps of the
involving the body of the mandible with sun-ray appearance mandible on both sides with a soft tissue and skin delect in the
within the tumor, a classic picture for osteogenic sarcoma (Fig. anterior floor of the mouth and the chin. Massive resections such
14.112). as this require a major reconstructive effort with a composite
Surgical resection for this tumor required resection of the mandible microvascular free flap of bone, soft tissues and skin. The technical
from angle-to-angle with a through-and-through resection of the details and the choices of reconstructive surgery in this setting are
skin and soft tissues of the chin near the symphysis of the discussed in Chapter 15.

Fig. 14.111 Panoramic x-ray of the mandible showing an osteoblastic


osteogenic sarcoma.

Fig. 14.113 The surgical specimen of subtotal mandibulectomy.

Fig. 14.112 CT scan


with bone window
showing the extent of
bone invasion.

Fig. 14.114 The surgical defect following resection of the tumor.

573
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS)

AMELOBLASTOMA OF THE MANDIBLE taken inlraorally with curettage and placement of a non-
vascularizcd bone graft (Fig. 14.116). Although it appeared that
the bone graft had healed, a recurrent lytic lesion was noted two
Ameloblastoma is an epithelial odontogenic tumor which is histo- years following the last surgical procedure in the body of the
logically benign but is biologically aggressive. The lesion is most mandible (Fig. 14.117). By the time of presentation for treatment
often seen in the mandible but it may also arise in the maxilla. this time, the patient had developed further bone destruction,
The surgical treatment of ameloblastoma requires its 'total now extending across the midline to the body of the mandible on
excision' if cure is to be achieved. Very small localized lesions can
be excised through the oral cavity with marginal mandibuleclomy
or, occasionally, by per oral excision and curettage. However, lesions
of significant size are seldom cured by intraoral excision and curettage
since they invariably develop local recurrence and require a more
aggressive surgical resection down the road. Therefore, the optimal
treatment for ameloblastoma is its total excision at initial pre-
sentation. The patient whose recurrent ameloblastoma is shown
here vividly demonstrates the inadequacy of intraoral resection
and the need for eventual mandibulectomy of a larger segment of
the mandible due to local recurrences.
This patient gave the history of spontaneous extrusion of her
lower premolar and first molar teeth due to a bone destructive
lesion eight years prior to this presentation. The panoramic x-ray
at that time showed a bone destructive lesion in the body of the
mandible on the right-hand side (Fig. 14.115). An intraoral
excision and curettage was attempted but the lesion recurred three
years later. At that point a second surgical procedure was under- Fig. 14.117 Further local recurrence.

Fig. 14.115 Panoramic x-ray showing a lytic lesion of the mandible on Fig. 14.118 Progressive bone destruction of the mandible.
the right-hand side.

Fig. 14.116 Per oral re-excision for recurrence and placement of a non-
vascularized bone graft. Fig. 14.119 Intraoral view shows an expansile lesion at the symphysis of
the mandible.

574
1
14 BONE T U M O R S ( T U M O R S A N D CYSTS O F THE ( A W S )

the left-hand side (Fig. 14.118). Intraoral examination demonstrated hemimandibulectomy, reconstruction with a fibula free flap, and
an ulcerated granular exophytic expansile lesion near the eventual osseointegrated implants for dental rehabilitation are
symphysis of the mandible with expansion of both the labial and shown in Fig. 14.122. Note the ameloblastoma presenting in the
lingual cortex (Fig. 14.119). Surgical resection of this tumor region of the body and retromolar trigone of the right-hand side
required excision of the anterior arch of the mandible from the of the mandible. A segmental mandibulectomy up to the lateral
region of the first molar tooth on the left-hand side to the first incisor teeth was necessary for resection of this tumor. Recon-
molar tooth on the right-hand side. The surgical specimen is struction of the resected mandible was performed with a fibula
shown in Fig. 14.120. The lesion did not extend beyond the bone free flap. The fibula required multiple osteotomies and fixation
and therefore there is minimal soft tissue loss in the oral cavity or with several miniplatcs and screws. Approximately one year
the chin. The surgical defect is shown in Fig. 14.121. Recon- following reconstruction the screws and plates in the region of the
struction of the anterior arch of the mandible in this patient will reconstructed body of the mandible were removed and osseo-
require a microvascular fibula free flap with appropriate osteotomies integrated implants were placed for dental rehabilitation. Post-
to recreate the shape, size, and configuration of the resected operative appearance of the patient shown in Fig. 14.123 shows
mandible. The technical details of mandible reconstruction are excellent esthetic restoration of the right hemimandible with
discussed in Chapter 15. dental rehabilitation accomplished through the osseointegrated
Serial panoramic x-rays of another patient who underwent implants.

Fig. 14.120 The surgical specimen from resection of the anterior arch of
the mandible.

Fig. 14.121 The surgical defect following arch resection. Fig. 14.123 Postoperative appearance of the patient.

575
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS) 1 Z|

Fig. 14.124 This Fig. 14.126 Axial CT


patient presented with scan showing
fullness of the right expansion of the
cheek. anterior wall of
maxilla.

Fig. 14.125 Axial CT Fig. 14.127 Axial CT


scan through the scan showing further
upper alveolus shows a expansion of the
thin-walled, expansile maxilla.
bone-destructive
lesion.

ODONTOGENIC CYSTS AND TUMORS marsupialization. In such an event, the patient will require a
dental obturator.
The surgical treatment for cystic lesions of odontogenic origin is
usually conservative. If the etiology is of inflammatory nature, ODONTOGENIC CYST OF THE MANDIBLE
then the inflammatory process should be appropriately addressed.
In other situations, the cystic lesion is usually approached intraorally The patient shown in Fig. 14.128 is a 67-year-old female who
and is widely opened for curettage and complete removal of its presented with a six-year history of a slowly expanding mass in the
epithelial lining. The surgical defect occasionally requires a bone region of the angle of the mandible on the left-hand side. She had
graft but is usually packed open and allowed to heal by secondary no symptoms from this mass. A panoramic x-ray of the mandible
intention. Most odontogenic tumors are benign, and have charac-
teristic clinical features and radiographic appearance. A conservative
surgical approach with excision of these tumors is recommended.

ODONTOGENIC CYST OF THE UPPER ALVEOLUS

The patient shown in Tig. 14.124 is a 21-year-old male who


presented with a four-year history of fullness of the right cheek.
Sensations of the skin of the cheek were normal. However, on
physical examination a bony hard mass could be palpated on the
upper alveolus and anterior wall of the maxilla. CT scans in an
axial plane vividly demonstrate an expansile lesion of the upper
alveolus extending into (he anterior wall of the maxilla with a
hypodense lesion signifying a fluid-tilled cystic process (Figs
14.125-14.127). Excision of the cystic lesion is not required but
its marsupialization with removal of its epithelial lining is
accomplished through an intraoral approach. The bony defect is
packed open and the patient is given a temporary dental obturator
until reorganization and tilling of the cavity takes place.
If significant bone destruction of the alveolus has taken place,
then an oroanlral fistula may result following curettage and Fig. 14.128 A patient with a slowly expanding mass of the left cheek.

576
14 BONE T U M O R S ( T U M O R S A N D CYSTS O F THE ) A W S )

secondary intention. If the periosteum and lateral or inferior


cortex of the mandible is intact, then a bone graft is not required.
A simple Xcrolorm gauze packing is introduced into the empty-
space in the ascending ramus and body of the mandible. A
postoperative panoramic x-ray approximately six weeks after
surgery shows a large defect in the posterior part of the body of
the mandible and Ihc ascending ramus of the mandible (Fig.
14.130). The patient required regular packing and irrigations of
Ihc defect for approximately three months. At that time, secondary
healing had completely obliterated the cystic space. A follow-up
panoramic x-ray approximately one year after surgery shows
adequate filling of the defect and recalcification of the ascending
ramus and posterior part of the body of the mandible (Fig. 14.131).

DENTICEROUS CYST
Fig. 14.129 Panoramic x-ray of the mandible shows a multiloculated
cystic lesion of the left-hand side of the mandible. A dentigerous cyst is a developmental cystic lesion around an
unerupted tooth, lined by an epithelium. The radiographic
appearance is similar to an odontogenic cyst but the characteristic
presence of an uneruplcd tooth in the cystic lesion is confirmatory
of its diagnosis. The panoramic x-ray of a patient with a dentigerous
cyst involving the ascending ramus and the body of the mandible
on the right-hand side is shown in Fig. 14.132. The surgical
treatment for a dentigerous cyst is essentially similar to that for an
odontogenic cyst. The lesion is approached intraorally. The unerupted
tooth is extracted al the time of curettage and marsupialization of
the cyst. Postoperative management is similar with daily packing
of the surgical defect until adequate obliteration of the dead space
lakes place by healing with secondary intention.

Fig. 14.130 Panoramic x-ray six weeks after surgery.

Fig. 14.131 Follow-up panoramic x-ray one year following surgery Fig. 14.132 Panoramic x-ray shows a multiloculated cystic lesion with an
shows good healing with new bone formation. unerupted tooth.

shows an expansile multiloculated smooth thin-walled cystic GIANT CELL REPARATIVE GRANULOMA
lesion involving the ascending ramus of the mandible (Fig.
14.129). Hie sensations of the skin of the chin and the tongue are
within normal limits. This lesion is approached intraorally through Giant cell reparative granuloma is a bone-destructive rapidly
an incision in the mucosa of the retromolar gingiva to expose the expanding lesion, usually seen in (he young. It is a self-limiting
anteromedial cortex of the ascending ramus of the mandible. The lesion and it may show spontaneous regression. The classic-
cyst wall is entered into with an osteotome and its epithelial appearance of a giant cell reparative granuloma is shown in Fig.
lining is carefully elevated with a periosteal elevator and excised. 14.133. The clinical, radiologic and histologic differential diagnosis
Meticulous attention should be paid to completely excise all the rests between giant cell granuloma and giant cell tumor of bone.
epithelial lining of the cyst wall or local recurrence is likely to The latter occurs in adults and does not show spontaneous regression
develop. The surgical defect thus created is left open to heal by and often manifests recurrence after treatment, these lesions have

577
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S ) TT
to be differentiated from the 'brown' tumor of hyperparathyroidism. Fig. 14.135 Axial view
Therefore, when a lesion of this nature is demonstrated in the of the CT scan (bone
window) demonstrates
mandible, then appropriate tissue diagnosis should be supple- an osteolytic lesion in
mented by studies for serum calcium, parathormone and a skeletal the posterior part of
survey to rule out involvement of other bones. Surgical treatment the body of the
for giant cell granuloma is usually undertaken by an intraoral mandible on the right-
hand side.
approach with curettage and marsupialization. The surgical defect
is left open and is allowed to heal by secondary intention.

Fig. 14.133 Giant cell


reparative granuloma.

An intraoral view of the right lower gum of a patient with a


giant cell granuloma is shown in Fig. 14.134. Note the granular
fleshy lesion arising from the alveolar process of the mandible.
This patient had a slightly painful lesion at that site. A CT scan of
this patient demonstrates an osteolytic lesion in the posterior part
of the body of the mandible on the right-hand side (Fig. 14.135).
Surgical treatment for this lesion is accomplished via a per oral
approach. A circular incision is placed on the mucosa of the right
lower gum around the primary tumor (Fig. 14.136). The mucosal
incision is deepened down to the underlying bone. Thereafter
using appropriate periosteal elevators and currcttes, the lesion is
excised as far as possible in a monobloc fashion. This is usually
possible for small lesions, however, larger lesions may not be able
to be excised in one piece. The surgical defect following excision
of the lesion shows a well-demarcated area of bone destruction
Fig. 14.136 The mucosa around the tumor is incised circumferentially.
(Fig. 14.137). Hemostasis is secured with electrocautery and bone
wax. A xeroform gauze packing is applied snug to assure hemostasis
in the immediate postoperative period. The mucosal incision is

Fig. 14.134 This patient presented with a slightly painful, granular Fig. 14.137 A well-demarcated bony defect remains after surgical
fleshy lesion of the right lower gum. excision of the tumor.

578
14 B O N E T U M O R S ( T U M O R S A N D CYSTS O F THE JAWS)

Fig. 14.140 Cementifying fibroma of the left side of the mandible.

SURGICAL ACCESS TO CERVICAL VERTEBRAL


BODIES

Surgical access to the vertebral column in the cervical region is


indicated in patients who require excision of primary tumors or
metastatic tumors to the vertebral bodies. The surgical approaches
described in this chapter are all anterior approaches for access to
the vertebral column. Standard posterior approaches for
decompression laminectomy or exposure of the spinal cord fall
within the realms of orthopedic or neurologic surgery and are
deliberately excluded from this chapter. However, anterior exposure
of the vertebral column is sometimes required for resection of
tumors involving the vertebral bodies or soft tissue tumors
secondarily extending to the vertebral column. These procedures
are usually performed in collaboration with a neurosurgeon.
Primary benign or malignant tumors, and occasionally metastatic
tumors to the vertebral bodies, producing neurologic symptoms
require surgical treatment. Posterior laminectomy is often adequate
Fig. 14.139 A fleshy, granular surface on bisection is consistent with the for decompression and immediate relief of symptoms. However, it
pathologic diagnosis of a giant cell granuloma. does not address the problem of the presence of intraspinal tumor
anteriorly or of progressive destruction of the vertebral body
leading to recurrent spinal cord compression and/or an unstable
not closed, but left open to heal by secondary intention. The spine. The operation of resection and replacement of the involved
xeroform gauze packing is removed in 48 hours and irrigations of vertebral body not only provides decompression of the spinal cord
the surgical defect are begun with a solution of baking soda and but achieves removal of the intravertebral tumor and allows
salt in warm water. The patient is instructed to re-pack the defect immediate stabilization of the vertebral column. The surgical
at least twice a day on a daily basis for several weeks. The healing approaches to cervical vertebral bodies can be described under
of the defect begins from the floor of the surgical defect, three categories, based on the level of involvement: (1) the cranio-
eventually leading to filling of the bony defect with granulation cervical junction for lesions of the ciivus and first two cervical
tissue and epithelialization over the soft tissues. The surgical vertebrae; (2) the mid-cervical region for vertebral bodies C3 to
specimen of the giant cell granuloma removed in a monobloc C6; and (3) the cervicothoracic junction for lesions of lower
fashion is shown in Fig. 14.138. The mucosal surface shows the cervical and upper thoracic vertebral bodies.
previous biopsy site and irregular nodularity on the alveolar process.
On bisecting the specimen a fleshy, granular lesion is seen, consistent
SURGICAL APPROACH TO CRANIOCERVICAL JUNCTION
with the pathologic diagnosis of a giant cell granuloma (Fig.
AND UPPER CERVICAL VERTEBRAE
14.139).

CEMENTIFYING FIBROMA Lesions of the craniocervical junction and first two cervical
vertebrae present very special surgical challenges for approach and
exposure. Small lesions can be approached through the open
Cementifying fibroma is a benign neoplasm of fibrous origin with mouth. A patient with a craniocervical chordoma presented with
calcium deposition which usually presents in the adult in the a bulging posterior pharyngeal wall. An MRI scan in sagittal plane
molar region of the mandible (Fig. 14.140). Surgical treatment shows the lesion arising from the region of the first and second
for symptomatic lesions consists of local excision of the lesion, cervical vertebrae (Fig. 14.141). This lesion is approached through
usually performed through a per oral approach. Most incidentally the oral cavity under general endotracheal anesthesia. A Dingman
found asymptomatic lesions are left alone. mouth retractor is used to open the oral cavity and expose the

579
BONE T U M O R S ( T U M O R S A N D CYSTS O F THE | A W S )

Fig. 14.144 The vertebral bodies are exposed by incising the


prevertebral fascia and muscles.

the nasopharynx and extending caudad up to the region of the


arytenoids. The mucosal incision is deepened through the pharyngeal
muscles to expose the prevertebral fascia. The prevertebral muscles
are similary incised in the midline and the vertebral bodies are
exposed (Fig. 14.144). Appropriate resection of the vertebral
bodies is then undertaken to expose the tumor which is resected
in a monobloc fashion. This procedure is generally conducted in
cooperation with a neurosurgical team who will assume the
responsibility of the surgical procedure at this juncture. Thus, a
two team surgical approach to cranioccrvical chordomas and
similar tumors of the cranioccrvical junction is desirable for safety
Fig. 14.142 A Dingman mouth retractor is used to open the oral cavity and completeness of the surgical resection. The head and neck
and expose the oropharynx. team provides the necessary exposure for the neurosurgical team
to accomplish resection of the tumor. If, however, adequate
exposure is not felt to be achieved through this approach, then a
mandibulotomy should be considered for wider exposure. A
detailed description of a mandibulotomy approach for excision of
a cranioccrvical chordoma is presented in Chapter 13.

SURGICAL APPROACH TO MIDCERVICAL VERTEBRAE

Lesions of the midcervical vertebrae are easily approached through


a transverse midcervical incision along an upper neck skin crease
at the level of the upper border of the thyroid cartilage. The
patient shown in Fig. 14.145 has a chordoma arising from the
vertebral bodies of the third and fourth cervical vertebrae
presenting as a mass lesion deep to the sternocleidomastoid
muscle in the left side of the neck. The clinically palpable extent
of the tumor is shown on the patient along with the placement of
the incision, which begins along an upper neck skin crease at the
Fig. 14.143 Division of the soft palate in the midline.
level of the mastoid process and extends anteriorly across the
midline. After elevation of the upper and lower skin flaps a plane
of dissection is developed between the carotid sheath laterally and
region of the oropharynx (Fig. 14.142). The soft palate is divided the laryngotrachcocsophageal visceral compartment medially
in the midline to get exposure of the posterior wall of the (Fig. 14.146). Three structures need to be deliberately divided.
oropharynx and nasopharynx (Fig. 14.143). Retracting sutures They are: (I) the superior thyroid artery; (2) the middle thyroid
are applied to the two halves of the soft palate and lateral vein; and (3) the omohyoid muscle. The superior laryngeal nerve
retraction provides satisfactory exposure. Alternatively, Cloward is at risk of being divided or injured due to stretch neuropraxia
retractors may he used to retract the two halves of the soft palate secondary to its retraction cephalad to gain exposure. Similarly,
to expose the posterior pharyngeal wall. A vertical incision is fibers of the sympathetic chain are at risk of injury in the
placed in the posterior pharyngeal wall, beginning at the roof of prevertebral plane. The sympathetic chain should therefore be

580
14 BONE T U M O R S ( T U M O R S A N D CYSTS O F THE | A W S )

carefully dissected and retracted laterally along with the carotid expose Ihc tumor. The prevertebral muscles, thus exposed, are
sheath. Injury lo Ihc sympathetic chain will lead to the incised vertically and dissected off Ihc anterior surface of the
development of Horner's syndrome. The larynx and esophagus are vertebral bodies providing the necessary exposure. In this patient
retracted medially and the carotid sheath is retracted laterally to the tumor has destroyed the anterior aspect of the vertebral bodies
on the left-hand side with the tumor projecting into the
prevertebral plane. Appropriate retraction of the larynx,
esophagus and the carotid sheath provide the necessary exposure
to deliver the tumor into Ihc wound (Fig. 14.147). Following
complete excision of tumors of this magnitude, stabilization of
the cervical spine is essential. This may be accomplished either by
fusion of the cervical spine by a poslerior approach or
reconstruction of the vertebral bodies anteriorly and internal
fixation through the anterior approach. As discussed before,
resection of the chordoma or similar tumors of Ihc cervical spine
should be accomplished by a multidisciplinary surgical team of
head and neck surgeons and neurosurgeons. The role of the head
and neck surgeon in this joint approach would be to provide
satisfactory exposure and the role of the neurosurgeon would be
to accomplish a satisfactory resection of the tumor and
reconstruction of the vertebral column with either anterior or
poslerior fusion. Assistance from a third surgical team of orthopedic
surgeons may be required in certain circumstances. Transient post-
Fig. 14.145 Outline of the clinically palpable extent of the tumor and operative swallowing difficulties are to be expected and Iherefore
the skin incision.
a nasogastric feeding tube is required for Ihrcc to four days following
surgery. A tracheostomy is usually not necessary.

SURGICAL APPROACH TO LOWER CERVICAL AND


UPPER THORACIC VERTEBRAE

Special technical considerations are necessary for the cervicothoracic


junction due to the confined space of the thoracic inlet and the
presence of major neurovascular structures as well as the trachea
and esophagus. The details of the operative procedure are discussed
here. A lateral radiograph of the cervical spine of a patient (Fig.
14.148) demonstralcs a destructive bone lesion of the body of the
first thoracic vertebra. A myelogram in an anlcroposterior projection
shows complete spinal block at the level of the involved vertebral
body (Fig. 14.149).

Fig. 14.148 Lateral


Fig. 14.146 A plane of dissection is developed between the carotid radiograph of the
sheath laterally and the laryngotracheoesophageal visceral compartment cervical spine showing
medially. a lesion of the first
thoracic vertebra.

Fig. 14.147 The tumor is delivered into the wound.

581
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S ) 14
The surgical approach for exposure and resection of this vertebral Fig. 14.153. The left sternocleidomastoid muscle is now detached
body needs two surgical teams: a head and neck surgeon for ex- from its insertion on the manubrium as well as the clavicle and is
posure of the vertebral column and a neurosurgeon for resection allowed to retract cephalad. Likewise, the strap muscles on the left-
and replacement of the vertebral body. hand side are divided close to the sternum and are allowed to retract
The surgical incisions necessary for exposure are shown in Fig. cephalad. The exposure thus oblained is depicted in Fig. 14.154.
14.150. A T-shaped incision with its transverse component The actual surgical field exposed by dividing the sternomastoid
extending from the posterior triangle of one side of the neck to the muscle and the strap muscles is shown in Fig. 14.155. The internal
posterior triangle of the other side of the neck is necessary. The jugular vein can be seen deep to the sternomastoid muscle. The
vertical incision is in the midline extending from the transverse middle thyroid vein and the inferior thyroid artery are thereafter
incision over the sternum. The patient is shown on the operating doubly clamped, divided and ligated. The thyroid gland, larynx,
table under general endotracheal anesthesia in the supine position trachea and esophagus can now be retracted towards the right-hand
(Fig. 14.151). Upper and lower skin flaps are elevated to expose the side and the carotid sheath towards the left-hand side (Fig.
strap muscles in the midline and the sternocleidomastoid muscles 14.156). The medial third of the clavicle is now cleared
as depicted in Fig. 14.152. The lower skin flaps should be elevated circumferentially of all its muscular and ligamentous attachments.
enough to expose the entire manubrium. Use of an electrocautery The periosteum of the medial third of the clavicle is incised and
expedites clearance of the anterior surface of the sternum by elevated circumferentially. Using a Gigli or power saw, the clavicle
detaching the origin of the pectoralis major muscle from the is divided at the junction of its medial and middle thirds. The
manubrium. The surgical field exposed up to this point is shown in sternoclavicular joint on the left-hand side is opened by incising its

Fig. 14.149 Myelogram (anteroposterior Fig. 14.150 The surgical incisions necessary for
projection) shows blockage at the level of C I . exposure of the cervico-thoracic vertebral
column.

Fig. 14.151 The incisions are outlined on the


patient.

Fig. 14.152 Elevation of upper and lower skin Fig. 14.153 The surgical field after elevation of Fig. 14.154 The sternomastoid muscle is
flaps. the skin flaps. detached and the strap muscles on the left side
are divided. The clavicle is now ready to be
divided.

582
14 BONE TUMORS (TUMORS AND CYSTS OF THE |AWS)

capsule and the medial third of the clavicle is disarticulated and exposure up to this point is shown in Fig. 14.158. The larynx,
preserved for subsequent use as a bone graft. Removal of the medial trachea and esophagus are mobilized by blunt dissection in the
third of the clavicle requires division of the dense capsule of the prevertebral plane and are retracted to the right-hand side.
joint, the ultra-articular disc and the costoclavicular ligament on Similarly, the common carotid artery and internal jugular vein are
the lower border of the clavicle. This is best done with an mobilized from the prevertebral fascia and are retracted laterally,
electrocautery. Now using a high-speed drill with an olive-shaped exposing the vertebral column at the root of the neck as shown in
burr, the manubrium is scored along its periphery, coring through Fig. 14.159. A self-retaining Cloward retractor is employed to keep
its anterior cortex and the cancellous part of the manubrium up to the anterior surface of the vertebral column exposed for further
its posterior cortex. Finally, using a I.ebsche knife, the manubrium work of resection of the vertebral body (Fig. 14.160). The accurate
is excised to gain exposure of the superior mediastinum as shown in placement of the Cloward retractor is depicted in Fig. 14.161. The
Fig. 14.157. The excised cancellous bone from the manubrium is operative procedure beyond this point may be taken over by the
also preserved for subsequent use as a bone graft. The surgical neurosurgical team.

Fig. 1 4 . 1 5 5 The strap muscles a n d t h e Fig. 1 4 . 1 5 6 The t h y r o i d g l a n d , larynx, trachea Fig. 1 4 . 1 5 7 Exposure of the superior
sternomastoid muscle on t h e left side a r e a n d esophagus a r e r e t r a c t e d t o w a r d s t h e r i g h t - mediastinum.
divided. h a n d side a n d the carotid sheath t o w a r d s t h e
l e f t - h a n d side.

Fig. 1 4 . 1 5 8 The surgical exposure of t h e Fig. 1 4 . 1 5 9 Exposure of t h e v e r t e b r a l c o l u m n Fig. 1 4 . 1 6 0 Placement of the Cloward
mediastinum after resection o f t h e m a n u b r i u m . a t t h e r o o t o f t h e neck. retractor.

583
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS) 14

Fig. 14.161 The Fig. 14.163 The


anterior surface of the surgical defect after
vertebral column is excision of the
exposed. vertebral body.

Fig. 14.164 The


vertebral column is
reconstructed with
methyl methacrylate.

Fig. 14.162 Excision of the involved vertebral body and placement of a


bone graft.

The neurosurgical aspects of the operative procedure are described Reconstruction and internal stabilization of the spine requires
here briefly. Excision of the involved vertebral body is generally insertion of stainless steel wires or pins in the healthy vertebral
done in a piecemeal fashion using appropriate rongeurs and body above and below. Following this, the remaining surgical
curettes as depicted in Fig. 14.162. If the surface of the vertebral defect created by resection of the vertebral bodies is filled with
body in question does not show any abnormality, then appropriate bone cement (methyl methacrylate) as depicted in Fig. 14.164.
localization films should be obtained to ensure that the vertebral Alternatively the previously harvested bone grafts (segment of
body exposed is indeed the one involved by I he disease process, clavicle and cancellous bone from manubrium) may be used
and not the one cephalad or caudad. This is vitally important additionally to complete the reconstruction. Extreme caution must
since accurate localization of the involved vertebral body can be exercised to prevent excessive projection of the reconstructed
sometimes be difficult in the surgical field. The involved vertebral vertebral column posteriorly or else it may create impingement on
body is completely curetted out to remove all grossly abnormal the spinal cord. The reconstructed vertebral column is shown in
bone. If the dura is involved by tumor, or if there is intraspinal Fig. 14.165. The upper part of the surgical field shows the upper
tumor, then it is removed at this time and the spinal dura border of the bone cement aligned against the undersurface of the
appropriately repaired, following complete curettage of the involved vertebral body of the seventh cervical vertebra. Further retraction
vertebral body and 'excision' of all gross tumor, the surgical defect caudad in the mediastinum shows adequate alignment of the
is irrigated with antibiotic solution. Complete hemostasis must be reconstructed vertebral column with the third thoracic vertebra.
secured before reconstruction of the vertebral column begins. The The wound is irrigated at this point with Bacitracin solution.
surgical defect after excision of the vertebral body is shown in Fig. Suction drains are placed in the field and the incision is closed in
14.163. In this patient, the vertebral bodies of T, and T2 were layers (Fig. 14.166).
resected because of involvement by the tumor. Postoperative care requires bed rest until satisfactory healing of

584
TT BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S )

Fig. 14.165 Close-up Fig. 14.167


view of the Postoperative x-ray
reconstructed vertebral (lateral view) showing
column. the reconstructed
vertebral body.

Fig. 14.166 Closure of


the incision with
suction drains in place.

MISCELLANEOUS BONE TUMORS

EXTRAOSSEOUS OSTEOGENIC SARCOMA

Osteogenic sarcomas generally arise from bones, but these tumors


can occasionally arise from soft tissues. The natural history of
extraosseous osteogenic sarcomas is similar to those of osseous
origin. The patient shown in Fig. 14.168 has a soft tissue tumor
arising in the superior mediastinum presenting at the root of the
neck. The palpable extent of the tumor is shown in the patient
along with its relation to the innominate artery, the common
carotid artery, and the subclavian artery (Fig. 14.168). A coronal
view of the MRI scan of the patient demonstrates the lesion with
a tumor thrombus in the innominate vein (Fig. 14.169). Axial
view of the CT scan at the level of the superior mediastinum
demonslrates the classic appearance of an osteogenic sarcoma
with areas of osteolytic and osteoblastic features. The tumor is
situated anterior to the trachea and the great vessels (Fig. 14.170).
the wound is achieved. Since the vertebral column is internally Surgical approach to this tumor requires a T-shaped incision.
stabilized, external immobilization is usually not necessary. The The transverse incision is taken along a lower neck skin crease
postoperative x-ray in a lateral view of the reconstructed vertebral extending from the anterior border of the trapezius muscle on the
column shows the metallic wires in position with the bone cement right-hand side up to the clavicular head of the sternocleidomastoid
replacing the resected vertebral bodies (Fig. 14.167). Resection muscle on the left-hand side. The vertical incision is in the midline
and replacement of the lower cervical and upper thoracic vertebral overlying the manubrium slerni. The skin incision is deepened
bodies causing spinal cord compression can thus be adequately through the platysma and upper and lower skin flaps are elevated
performed through this approach. Tumors of the vertebral bodies (Fig. 14.171). The sternocleidomastoid muscle on the right-hand
which arc likely to produce an unstable spine are also optimally side is detached from the manubrium as well as the clavicle. The
treated by resection and replacement of the vertebral body as strap muscles are resected. This provides exposure of the superior
described. The surgical procedure should ideally be undertaken as surface of the tumor at the thoracic inlet. At this juncture a
a team effort with co-operation between a head and neck surgical 'clam-shell' thoracotomy is performed, dividing the manubrium
team and a neurosurgical team. slerni just medial to the left sternoclavicular joint up to the

585
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS) 14
Fig. 14.168 The manubriosternal junction. A lateral extension of the sternotomy is
palpable extent of the taken up to the second intercostal space on the right-hand side
tumor is shown along
with its relation to the (Fig. 14.172). Retraction of the divided manubrium provides
innominate artery, the satisfactory exposure of the superior mediastinum. I5y alternate
common carotid artery, blunt and sharp dissection the tumor is carefully mobilized from
and the subclavian the great vessels in the superior mediastinum. At this juncture it
artery.
becomes apparent that a contiguous tumor thrombus is present in
the innominate vein on the right-hand side (Fig. 14.173). Therefore,
a segment of the innominate vein on the right-hand side is
resected in a monobloc fashion. The surgical specimen shown in
Fig. 14.174 demonstrates monobloc resection of the intact tumor
along with tumor extension into the innominate vein. The
bisected specimen clearly shows the tumor growing through the

Fig. 14.169 A coronal


view of the MRI scan
demonstrates the
lesion with a tumor
thrombus in the
innominate vein.

Fig. 14.170 Axial view of the CT scan at the level of the superior
mediastinum.

Fig. 14.171 The exposure obtained after Fig. 14.172 The manubrium sterni is divided Fig. 14.173 A contiguous tumor thrombus is
elevation of the skin flaps of the T-shaped just medial to the left sternoclavicular joint and seen in the innominate vein on the right-hand
incision. a lateral extension of the sternotomy is taken side.
up to the second intercostal space on the right-
hand side.

586
•R BONE T U M O R S ( T U M O R S A N D CYSTS OF THE ) A W S )

| Fig. 14.176 The


surgical defect
demonstrates the
internal jugular vein
and the subclavian vein
with the stump of the
resected innominate
vein on the right-hand
side.

Fig. 14.174 The surgical specimen showing monobloc resection of the


tumor and the thrombus in the innominate vein.

RESULTS OF TREATMENT

Nearly all benign cystic or solid lesions of the cranial-facial-cervical


skeleton are cured by adequate total resection. Incomplete removal
is often followed by local recurrence, making subsequent surgical
undertaking hazardous and much more debilitating. This is
particularly important in tumors with a high potential for local
recurrence.
Ameloblastomas of the mandible and maxilla are generally
cured by initial adequate total excision. Curettage, however, is
doomed lo failure and results in an unacceptably high rate of local
recurrence. Subsequent resection is successful in a high proportion
of patients but requires sacrifice of a larger segment of the
mandible or maxilla (Figs 14.177 and 14.178). Long-term control
of osteogenic sarcoma of craniofacial bones is not as good as that
Fig. 14.175 The bisected specimen clearly shows the tumor growing seen in osteogenic sarcomas of the extremities. Similarly, the long-
through the wall of the innominate vein and presenting in the lumen as term prognosis in adult osteogenic sarcomas is not as good as
a tumor thrombus.
observed in children. The cure rates for osteogenic sarcomas of the
mandible, maxilla, and other cranial bones are shown in Fig.
14.179. Chemotherapy is not as effective in adult osteogenic
sarcomas of the head and neck region as is seen in osteogenic
sarcomas of the extremities in the pediatric age group. Significant
predictors of local control include tumor size smaller than 4 cm
tumor thrombus (Fig. 14.175). The surgical field alter excision of and negative margins of surgical resection while positive margins
the tumor demonstrates the internal jugular vein and the subclavian are the only predictors of disease-specific survival.
vein with the stump of the resected innominate vein on the right- Prognosis in c h o n d r o s a r c o m a s of the craniofacial bones
hand side (Fig. 14.176). After complete hemostasis, suction drains depends on the histologic grade of the lesion and the status of
are placed and the wound is closed in layers. margins of resection (Fig. 14.180). l.ow-grade chondrosarcomas,
As demonstrated in this procedure, resection of osteogenic if adequately excised, offer excellent control rates. On the other
sarcomas of skeletal origin or extraosseous origin require a wide hand, high-grade chondrosarcomas and those lesions which are
three-dimensional resection with adequate soft tissue and bony incompletely excised with positive margins fail in a significant
margins. Wide exposure is essential for safe conduct of the surgical number of patients. The risk of local recurrence is very high in
resection, preserving as many vital structures as possible without patients with high-grade chondrosarcomas and those who have
compromising a satisfactory oncologic resection. positive margins.

587
BONE TUMORS (TUMORS AND CYSTS OF THE JAWS)

Fig. 1 4 . 1 7 7 Disease c o n t r o l by t r e a t m e n t for a m e l o b l a s t o m a of t h e Fig. 1 4 . 1 7 8 Disease c o n t r o l by t r e a t m e n t f o r ameloblastoma of the


mandible. maxilla.

Fig. 1 4 . 1 7 9 Five-year overall survival f o r osteogenic sarcomas of t h e Fig. 1 4 . 1 8 0 Five-year survival f o r chondrosarcomas of the head and
head and neck by site. neck by histological g r a d e a n d m a r g i n s .

588

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