CASO CLÍNICO

 

Condroma maxilar

Chondroma of the maxilla

 

 

J.P. Crestanello Nese¹, C. Fernández Luzardo¹, C. Arismendi²

1 Cirujano Buco-Maxilofacial.
2 Odontólogo.
Servicio de Cirugía Buco Maxilofacial. Hospital Maciel. Montevideo, Uruguay.

Dirección para correspondencia

 

 

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ABSTRACT

Chondromas are benign tumours, rare in the head and neck area. The aim of this article is to present an anterior maxillary chondroma and a review of the literature about its clinical, radiological and histological features among with its treatment is done. An emphasis in the differential diagnosis is done because of its similarity with some osteolitic lesions in the area.

Key words: Chondroma; Premaxilla; Head and neck; Radiolucent lesions.

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RESUMEN

Los condromas son tumores benignos raros en la región de cabeza y cuello. El objetivo de este artículo es presentar un condroma de la premaxila junto con una revisión de la literatura sobre sus características clínicas, radiográficas, histológicas y terapéuticas. Además, se enfatiza el diagnóstico diferencial con otras lesiones osteolíticas de la región.

Palabras clave: Condroma; Premaxila; Cabeza y cuello; Lesiones radiolucidas.

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Introduction

Cartilaginous tumors of the head and neck area are rare, but when they are presented, it is necessary to differentiated them from true chondrosarcoma or other lesions of more frequent presentation. In this report a case of chondroma involving the premaxilar area is presented and a clinical pathologic differential diagnosis is done.

 

Case report

In August 2003, a 75 year old white female was seen in the Oral and Maxillofacial Surgery Clinic at Maciel Hospital. Her chief complain centered around an asymptomatic mass on the right maxilla and the inability to wear her upper denture. She also noted that her upper lip was elevated. The lesion had been growing slowly for over 2 months (Figs. 1 and 2).

 

The medical history was non-contributory. She reported taking no medications and no know drug allergies. Her social history was negative for smoking, alcohol or narcotics. The review of systems was negative for the current complaint. Her general physical examination was within normal limits.

There is a history of an inflammatory odontogenic cyst being enucleated from this area approximately seven years before this presentation.

Clinical examination of the oral cavity revealed a firm, well demarcated sessile nodule approximately 2.0 cm in diameter in the right anterior maxilla, mobile to the underlying tissues. The overlying mucosa appeared erythematous. Several small traumatic ulcers on the area due to her complete upper denture were noted. The were no nasal obstruction and the floor of the nose appeared symmetrical. There was no suggestion of fluctuance or crepitance (Fig. 3). The cranial nerves were intact. There was no lymphadenopathy.

 

A panoramic radiograph revealed a bilateral irregularly shaped lucent area with sclerotic margins. The radiological features were non specific but suggested a benign lesion (Fig. 4).

 

A working diagnosis of a residual inflammatory cyst was made. Due to its location differential diagnosis includes nasopalatine cyst. The odontogenic keratocyst was also consider due to the possibility of a recurrent lesion.

An excisional biopsy was planned under local anesthesia. During the procedure the maxillary cortex was found to be thin and absent in the area. A well encapsulated nodule was found suggesting a mass instead of an inflammatory cyst. The capsule was broken reavealing a pale gray gelatinous mass having the consistency of wet sand. The lesion was also found to be more extensive than originally expected. So instead of a excisional an incisional biopsy was completed.

Healing was unremarkable. Histopathologic examination revealed a chondroma.

CT scan were obtained to fully assess the extent lesion. Axial scans showed an irregular radiolucency that involved the buccal and palatine cortices. The lesion extended from approximately the maxillary right cuspid to the left lateral incisor. There was no evidence of soft tissue spread (Fig. 5).

 

On November 2003, the patient was taking to the operating room and under general anesthesia underwent a wide local excision. Free margins were confirmed by frozen section. Microscopic examination of the surgical specimen showed a well circumscribed benign tumor of mature hyaline cartilage showing a homogeneous mass of uniform chondrocytes with small nuclei. The final diagnosis of chondroma was made (Fig. 6).

 

The postoperative course was uneventful. The patient is seen regularly for follow up. There has been no sing of recurrence of the tumor after more than 2 years and 7 months from the excision. Because of previous report of malignant transformation in a benign chondroma, long term follow up is planned.

 

Discussion

Chondroma is a benign tumor of unknown etiology. A hamartomatous origin has been postulated. It is composed of mature cartilage cells with no bone.^1-4 It is one of the more commonly encountered tumors in the long bones and bones of the hand. In a review of 8542 bone tumors by Dahlin and Unni, chondromas were 12% of benign tumors and 2.8% of all tumors.^{1, 5}

The chondroma is rarely reported in the jaws.^{6, 7} Most examples have been found in the anterior maxilla of adult patients. Chaundry in a review of the literature from 1912 to 1959 found a total of 18 cases of combined osteochondromas and myxochondromas of the jaws.^{1, 3} In over 10.000 bone lesions reviewed at the Mayo Clinic, there were no cases of chondromas in the jaw or facial bones. Among 1243 chondromas in 4 large series, only four (0.32%) were in the head and neck region.⁸ Potdar and Srikhande reported a series of 15 cases of chondrogenic tumors of the jaws over a period of 27 years^.3

Chondromas of head and neck (H&N) region are diagnosed so infrequently that in some maxillofacial radiology or pathology texts, they are not described.^2,3,9,10 Thes lesions do not have a sex predilection. They are usually discovered in the third or fourth decade of life, although have been found from the first to eighth decade of life.^1,2,8,11 Sixty-one percent (61%) of the patients fall between the ages of 10 to 39. The patient presented is 75 years old.

Most chondromas in the craniofacial complex arise in the nasal septum and ethmoid sinuses developed from vestigial cartilaginous rests. Lesions of the maxilla are located in the anterior region adjacent to the nasal spine and nasal septum. Mandibular chondromas have been observed in the symphysis, body, coronoid process and mandibular condyle.^{1, 2,7,8,13} Oral soft tissue chondromas have been found in the tongue, the cheek, on the nasal surface of the soft palate and arising in hyperplastic tissue in denture-bearing areas.^3,6,12,14-16 Chondroma could be a manifestation of Maffucci’s syndrome.¹⁸ The chondroma usually is slow growing painless swelling of the jaw. The patient could know the presence of a mass or have moderate symptoms for several years previous to diagnosis. True chondromas could likely be no more than chance findings as firm, smooth – surfaced nodules. The overlying skin or mucosa is seldom involved due to the gradual expansion of the lesion. If arising in dentate regions, tooth mobility and root resorption are possible.^1,2,7,8,17

The radiographic findings of the chondroma is not characteristic. An irregular, radiopaque and radiolucent mottled mass may be seen.¹ However the lesion most often presents as an irregular radiolucent area² that it could mimicked a mesiodens or other lesions.⁴ The absence of cortical destruction and soft tissue extension favor a benign diagnosis.⁸

The chondroma should be clinically, radiologically and histologically differentiated from the chondrosarcoma. Clinical and radiographic features often provide little useful information to distinguish the chondroma from the well differentiated chondrosarcoma. The size of the lesion is a helpful feature. Most chondromas have been reported in the range of 1 to 3 cm. Most chondrosarcomas have measured more than 5.5 cm.^2,18 Additional signs of persistent, unrelenting pain along with radiographic evidence of cortical erosion and soft tissues extension are foreboding signs of malignancy. ^1,5,6

Distinction between chondroma and chondrosarcoma may be difficult because of overlapping histologic features.² Distinguishing chondroma from high grade chondrosarcoma presents no difficulty. However the distinction from low grade chondrosarcoma is among the most difficult problems in bone pathology. So an argument has been proposed that all symptomatic cartilaginous lesions be considered and treated as chondrosarcomas. Many pathologists regard the diagnosis of chondroma as representing a potential chondrosarcoma. ^1,6

The differentiation of the benign versus the malignant lesion is based on evidence of invasion and the finding of more than a rare mitotic figure. The presence of one of those signs indicates a high probability of malignacy.^8,16 Conversely, mitotic figures are extremely rare to nonexistent in the bening chondroma.¹ Finally, some authors suggest the examination of multiple blocks for all cartilaginous tumors due to areas diagnostic of a chondrosarcoma may be only focal.⁷

Because of the possible clinical and histological overlap and consideration that twenty percent (20%) of H&N chondrosarcomas may be initially diagnosed as benign the treatment of the chondroma is a wide, although not radical, excision. The resection with a margin of normal soft tissue and bone is preferred. Curettage has resulted in local recurrence in a significant number of cases.^1,2,6,7,11 Radiotherapy is contraindicated because the tumor is not radiosensitive. In adittion, potential malignant transformation is possible.^1,11

Prolonged follow – up is essential. If recurrence occurs, the original diagnosis should be reconsider for the possibility of low grade malignancy.^{2, 7}

 

Conclusions

A new case of maxillary chondroma was presented. The lesion presented similar in appearance to, and in an area of previous enucleation of an inflammatory odontogenic cyst. An initial incisional biopsy confirmed the diagnosis of chondroma. Once the histologic diagnosis of chondroma is given, the possibility of a low grade chondrosarcoma should be considered.

Differential diagnosis in this particular location may include any osteolitic benign lesion. In the maxillary region, one should consider that the same tumors of the other bones could be found together with lesions of odontogenic origin. The history, physical examination and the appropriate analysis by imaging must be done and the final diagnosis should be obtained under biopsy to define the more appropriate diagnosis and treatment.

Several clinical and radiographic signs may be helpful in distinguishing this case from chondrosarcoma. First, the tumor size was 2.0 cm and at biopsy a capsule was found. Histologic examination of the final surgical specimen showed hyaline mature cartilage with some amount of cellular architecture without bone and absence of invasion of the surrounding tissue in the wide but not radical margins. Mitotic figures were absent.

Long term follow up is planned. There has been no recurrence of the tumor in 2 years and 7 months since its removal.

 

 

Correspondencia:
Dr. Jose P. Crestanello Nese
C/ Alfredo Navarro 3012, Apto 116
Montevideo 11600, Uruguay
e-mail: jpcresta@adient.com.uy

Recibido: 06.07.2005
Aceptado: 04.07.2006

 

 

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