Malignant Tumours Involving the Jaws










Atlas of Oral and Maxillofacial Radiology, First Edition. Bernard Koong.
© 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.
178
11.1 Imaging ofmalignancies
involvingthejaws
Multidetector computed tomography (MDCT) is often the
imaging modality of choice (at least initially) in the evaluation
of malignancies involving the jaws, often with intravenous
contrast. Magnetic resonance imaging (MRI) is also essential.
Single‐photon emission computed tomography and positron
emission tomography/computed tomography may be required.
Radiological malignant features can be identified on intraoral
radiographs, panoramic radiographs and cone beam computed
tomography (CBCT), which are commonly applied tech-
niques in dentistry. The presence of a malignancy may well be
first discovered by one of these techniques. However, if there
is clinical suspicion for a malignancy in the maxillary or man-
dibular regions, 2D radiography is inadequate. CBCT is also
insufficient as the adjacent soft tissues are poorly demon-
strated, which may be important.
Malignant lesions in the jaws share common features.
Section 11.2 describes these while section 11.3 highlights
some of the specific features of malignancies which more
commonly involve the jaws.
11.2 Radiological features ofmalignancies
involving thejaws
(Figures11.1–11.18)
Borders.
Most demonstrate poorly defined invasive borders, which
may demonstrate irregular lucent extensions into the
adjacent marrow spaces. Occasionally, several small, ill‐
defined lucencies may be seen not far from the main
lesion.
Occasionally, multiple ‘punched out’ lucencies with slightly
more defined borders may be seen. Most commonly associ-
ated with multiple myeloma.
Some malignancies may sometimes not demonstrate
aggressive borders, e.g. mucoepidermoid carcinoma and
prostate and breast metastases.
Internal appearances.
Usually lucent. There may occasionally be residual bone
remnants within.
Osteoblastic metastatic lesions are usually sclerotic.
Breast and prostate metastatic lesions are typically scle-
rotic. There may be associated aggressive‐appearing
lucencies or destruction of adjacent cortices. However,
these sclerotic lesions may be relatively benign in
appearance.
Multiple sclerotic foci involving several visualised
bones of the head and neck should raise the suspicion
for metastatic disease. However, similar appearances
may be seen in patients who have been or are on related
drug therapies.
Osteogenic sarcomas variably produce tumour bone.
Mucoepidermoid carcinoma involving bone often presents
as a multilocular lesion.
Maxillary or mandibular cortices.
When a malignant lesion extends to or is centred at a bony
boundary, there is usually cortical destruction, often with
irregular edges.
Periosteal response at the involved cortex.
Most do not demonstrate a periosteal response, unless
there is secondary infection. However:
sometimes the edges of the destroyed cortex may be
slightly raised; this is considered a type of periosteal
response associated with aggressive lesions (Codman
triangle)
occasionally there is a lamina periosteal response
adjacent to the cortical lesion; the periosteal
response over the destroyed cortex is usually also
destroyed
occasionally spiculation (sunburst appearance) is
seen, i.e. multiple linear opacities extending out-
wardly from the site of cortical involvement;
this is a form of periosteal response classically
described in association with the osteosarcoma;
prostate metastases may also demonstrate this
feature.
CHAPTER 11
Malignant Tumours Involving theJaws

Malignant Tumours Involving theJaws 179
There is usually variable soft tissue mass over the region of
involved/destroyed cortex (demonstrated on MDCT or MRI).
Dentoalveolar structures.
Irregular widening of the periodontal ligament spaces of
the teeth. There may be focal regions of widening of the
periodontal ligament spaces with relatively normal appear-
ances between.
Destruction of the lamina dura of tooth roots. This is often
seen with the irregular widening of the periodontal liga-
ment spaces. There may be focal destruction of the lamina
dura interspersed with regions of relatively normal‐appear-
ing lamina dura.
This malignant widening of the periodontal ligament
spaces and destruction of the lamina dura may involve any
surface of any tooth root.
Destruction of follicular cortices of unerupted teeth. There
may be displacement of the calcified dental structures
within the follicle.
Tooth displacement and root resorption are not typically
seen. However:
root resorption is occasionally seen
teeth may occasionally appear to be in a displaced posi-
tion if a significant amount of surrounding bone is
destroyed; this is usually related to a lack of alveolar bone
support rather than displacement by the malignant lesion.
Sometimes, all or most of the alveolar bone around the
teeth is destroyed, giving the classically described appear-
ance of ‘teeth floating in space.
Mandibular canal.
Where a malignant lesion extends to this canal, the borders
are usually destroyed.
A malignant lesion may traverse along, largely/partly within,
the mandibular canal. There is usually lobulated or irregular
widening with focal regions of canal border destruction.
11.3 Features ofsome malignancies which
more commonly involve thejaws
Squamous cell carcinoma (SCCa) (Figures11.1 and 11.2).
When it involves the jaws, SCCa usually presents as a lytic
destructive lesion with invasive borders (refer to sec-
tion11.2). Teeth are not usually affected and may appear to
be ‘floating in space. Early bony involvement may appear as
a focal erosion of the cortex.
Within the oral cavity, it most commonly occurs at the lat-
eral border of the tongue. It also occurs on the lip, floor of
the mouth and over the alveolar processes. SCCa can very
rarely arise from odontogenic epithelium within bone,
including odontogenic cysts.
Lytic and destructive lesion with
invasive and ill-defined borders
Soft tissue mass
(a) (b)
(c)
Figure11.1 Squamous cell carcinoma of the left maxilla: coronal and axial soft tissue (a,c) and coronal bone (b) MDCT images.

180 Atlas of Oral and Maxillofacial Radiology
Metastatic lesions (Figures11.3 and 11.4).
More often in the older age group.
Occasionally, a metastatic lesion involving the jaws is the first
identified evidence of the presence of malignant disease.
Usually present as lytic lesions with aggressive features
(refer to section11.2).
Osteoblastic metastatic lesions (e.g. breast and prostate) are
often sclerotic in appearance. Prostate metastases may
demonstrate a spiculated periosteal response.
Lymphomas and leukaemias (Figures11.5–11.10).
Malignancies involving white blood cells.
Leukaemia usually arises from within bone marrow. Four
main types.
Lymphoma arises from lymphoid tissue. Two main
types.
When these malignancies involve the jaws, there are similar
radiological features.
Lytic destructive or infiltrative lesions with ill‐defined bor-
ders which demonstrate invasive features.
In some cases the marrow spaces may be replaced
with tumour tissue while the trabecular and cor-
tical bone remains intact (as demonstrated on MRI or
MDCT).
May infiltrate along periodontal ligament spaces, with
irregular widening and destruction of the lamina dura.
May infiltrate into the follicular spaces of developing teeth,
displacing the calcified structures and destroying the
follicular cortices.
Some demonstrate irregular widening of the mandibular
canal with destruction of the borders.
May be associated with variable soft tissue mass (as demon-
strated on MDCT or MRI).
Periosteal response is sometimes seen. May be lamina or
spiculated.
Malignant widening of the 44
apical periodontal ligament
space
No postextraction new bone
formation. Note the adjacent
reactive sclerosis.
Focal destruction of the buccal
cortex and soft tissue mass
(a) (b)
(c) (d)
Figure11.2 Squamous cell carcinoma; secondarily infected, 45 region: axial, corrected sagittal and corrected coronal bone (a,c,d) and axial soft tissue
(b)MDCT images.

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Atlas of Oral and Maxillofacial Radiology, First Edition. Bernard Koong. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.17811.1 Imaging ofmalignancies involvingthejaws• Multidetector computed tomography (MDCT) is often the imaging modality of choice (at least initially) in the evaluation of malignancies involving the jaws, often with intravenous contrast. Magnetic resonance imaging (MRI) is also essential. Single‐photon emission computed tomography and positron emission tomography/computed tomography may be required.• Radiological malignant features can be identified on intraoral radiographs, panoramic radiographs and cone beam computed tomography (CBCT), which are commonly applied tech-niques in dentistry. The presence of a malignancy may well be first discovered by one of these techniques. However, if there is clinical suspicion for a malignancy in the maxillary or man-dibular regions, 2D radiography is inadequate. CBCT is also insufficient as the adjacent soft tissues are poorly demon-strated, which may be important.• Malignant lesions in the jaws share common features. Section 11.2 describes these while section 11.3 highlights some of the specific features of malignancies which more commonly involve the jaws.11.2 Radiological features ofmalignancies involving thejaws (Figures11.1–11.18)• Borders. ◦Most demonstrate poorly defined invasive borders, which may demonstrate irregular lucent extensions into the adjacent marrow spaces. Occasionally, several small, ill‐defined lucencies may be seen not far from the main lesion. ◦Occasionally, multiple ‘punched out’ lucencies with slightly more defined borders may be seen. Most commonly associ-ated with multiple myeloma. ◦Some malignancies may sometimes not demonstrate aggressive borders, e.g. mucoepidermoid carcinoma and prostate and breast metastases.• Internal appearances. ◦Usually lucent. There may occasionally be residual bone remnants within. ◦Osteoblastic metastatic lesions are usually sclerotic. ■ Breast and prostate metastatic lesions are typically scle-rotic. There may be associated aggressive‐appearing lucencies or destruction of adjacent cortices. However, these sclerotic lesions may be relatively benign in appearance. ■ Multiple sclerotic foci involving several visualised bones of the head and neck should raise the suspicion for metastatic disease. However, similar appearances may be seen in patients who have been or are on related drug therapies. ◦Osteogenic sarcomas variably produce tumour bone. ◦Mucoepidermoid carcinoma involving bone often presents as a multilocular lesion.• Maxillary or mandibular cortices. ◦When a malignant lesion extends to or is centred at a bony boundary, there is usually cortical destruction, often with irregular edges. ◦Periosteal response at the involved cortex. ■ Most do not demonstrate a periosteal response, unless there is secondary infection. However: ◆ sometimes the edges of the destroyed cortex may be slightly raised; this is considered a type of periosteal response associated with aggressive lesions (Codman triangle) ◆ occasionally there is a lamina periosteal response adjacent to the cortical lesion; the periosteal response over the destroyed cortex is usually also destroyed ◆ occasionally spiculation (sunburst appearance) is seen, i.e. multiple linear opacities extending out-wardly from the site of cortical involvement; this is a form of periosteal response classically described in association with the osteosarcoma; prostate metastases may also demonstrate this feature.CHAPTER 11Malignant Tumours Involving theJaws Malignant Tumours Involving theJaws 179 ◦There is usually variable soft tissue mass over the region of involved/destroyed cortex (demonstrated on MDCT or MRI).• Dentoalveolar structures. ◦Irregular widening of the periodontal ligament spaces of the teeth. There may be focal regions of widening of the periodontal ligament spaces with relatively normal appear-ances between. ◦Destruction of the lamina dura of tooth roots. This is often seen with the irregular widening of the periodontal liga-ment spaces. There may be focal destruction of the lamina dura interspersed with regions of relatively normal‐appear-ing lamina dura. ◦This malignant widening of the periodontal ligament spaces and destruction of the lamina dura may involve any surface of any tooth root. ◦Destruction of follicular cortices of unerupted teeth. There may be displacement of the calcified dental structures within the follicle. ◦Tooth displacement and root resorption are not typically seen. However: ■ root resorption is occasionally seen ■ teeth may occasionally appear to be in a displaced posi-tion if a significant amount of surrounding bone is destroyed; this is usually related to a lack of alveolar bone support rather than displacement by the malignant lesion. ◦Sometimes, all or most of the alveolar bone around the teeth is destroyed, giving the classically described appear-ance of ‘teeth floating in space’.• Mandibular canal. ◦Where a malignant lesion extends to this canal, the borders are usually destroyed. ◦A malignant lesion may traverse along, largely/partly within, the mandibular canal. There is usually lobulated or irregular widening with focal regions of canal border destruction.11.3 Features ofsome malignancies which more commonly involve thejaws• Squamous cell carcinoma (SCCa) (Figures11.1 and 11.2). ◦When it involves the jaws, SCCa usually presents as a lytic destructive lesion with invasive borders (refer to sec-tion11.2). Teeth are not usually affected and may appear to be ‘floating in space’. Early bony involvement may appear as a focal erosion of the cortex. ◦Within the oral cavity, it most commonly occurs at the lat-eral border of the tongue. It also occurs on the lip, floor of the mouth and over the alveolar processes. SCCa can very rarely arise from odontogenic epithelium within bone, including odontogenic cysts.Lytic and destructive lesion with invasive and ill-defined bordersSoft tissue mass(a) (b)(c)Figure11.1 Squamous cell carcinoma of the left maxilla: coronal and axial soft tissue (a,c) and coronal bone (b) MDCT images. 180 Atlas of Oral and Maxillofacial Radiology• Metastatic lesions (Figures11.3 and 11.4). ◦More often in the older age group. ◦Occasionally, a metastatic lesion involving the jaws is the first identified evidence of the presence of malignant disease. ◦Usually present as lytic lesions with aggressive features (refer to section11.2). ◦Osteoblastic metastatic lesions (e.g. breast and prostate) are often sclerotic in appearance. Prostate metastases may demonstrate a spiculated periosteal response.• Lymphomas and leukaemias (Figures11.5–11.10). ◦Malignancies involving white blood cells. ■ Leukaemia usually arises from within bone marrow. Four main types. ■ Lymphoma arises from lymphoid tissue. Two main types. ◦When these malignancies involve the jaws, there are similar radiological features. ◦Lytic destructive or infiltrative lesions with ill‐defined bor-ders which demonstrate invasive features. ◦In some cases the marrow spaces may be replaced with tumour tissue while the trabecular and cor-tical bone remains intact (as demonstrated on MRI or MDCT). ◦May infiltrate along periodontal ligament spaces, with irregular widening and destruction of the lamina dura. ◦May infiltrate into the follicular spaces of developing teeth, displacing the calcified structures and destroying the follicular cortices. ◦Some demonstrate irregular widening of the mandibular canal with destruction of the borders. ◦May be associated with variable soft tissue mass (as demon-strated on MDCT or MRI). ◦Periosteal response is sometimes seen. May be lamina or spiculated.Malignant widening of the 44 apical periodontal ligament spaceNo postextraction new bone formation. Note the adjacent reactive sclerosis.Focal destruction of the buccal cortex and soft tissue mass(a) (b)(c) (d)Figure11.2 Squamous cell carcinoma; secondarily infected, 45 region: axial, corrected sagittal and corrected coronal bone (a,c,d) and axial soft tissue (b)MDCT images. Malignant Tumours Involving theJaws 181Sclerotic metastatic lesions with periosteal responseAssociated soft tissue metastatic lesion(a) (b) (c)(d) (e)Figure11.3 Metastatic prostate carcinoma: axial (a,b,d) and coronal (c) bone and axial soft tissue (e) MDCT images.Multiple sclerotic foci(a)(b)(c)Figure11.4 Metastatic breast carcinoma: axial (a,b) and coronal (c) MDCT images. 182 Atlas of Oral and Maxillofacial Radiology(a) (b) (c)Lytic ill-defined lesion with destruction of the left maxillary antral cortical floor. Soft tissue density at the left maxillary antral base represents the tumour massFigure11.6 Lymphoma: cropped panoramic radiograph (a) and corrected sagittal (b) and cross‐sectional (c) CBCT images.Focal follicular cortex destructionSlightly displaceddeveloping crownFigure11.7 Leukaemia: cropped panoramic image.Irregular widening of the 17, 16, 15 and 14 periodontal ligament spaces indicative of the infiltrative nature of this lesion. Note the destruction of the buccal cortex and maxillary antral floor(a) (b) (c)Figure11.5 Lymphoma involving the right maxilla: cropped panoramic radiograph (a) and cross‐sectional MDCT images (b,c). Malignant Tumours Involving theJaws 183Widened mandibular canal with destruction of the bordersSoft tissue density of the lymphoma within the canal and adjacent marrow spaces(a) (b)(c)Figure11.8 Lymphoma: panoramic radiograph (a) and axial bone (b) and soft tissue (c) MDCT images.Multiple small lucent foci of the anterolateral wall of the left maxillary sinusFigure11.9 Lymphoma: corrected sagittal CBCT image. 184 Atlas of Oral and Maxillofacial Radiology• Osteosarcoma (Figure11.11). ◦Synonym: osteogenic sarcoma. ◦This bone‐forming malignant tumour is rarely seen in the jaws. ◦Usually presents as a lesion with aggressive permeative borders and cortical destruction. ◦Internally, it is variable, ranging from being lucent to various abnormal patterns of internal opacities which reflect tumour bone and related calcifications. ◦There is usually a prominent periosteal response, the ‘sunburst’ spiculated appearance being classically described. A Codman triangle (refer to section 11.2) is sometimes seen. Laminated periosteal reaction is less common. ◦When teeth are involved, there may be infiltrative irregular widening of the periodontal ligament spaces. ◦Usually associated with an enhancing soft tissue mass.Focal cortical destruction.Note focal destruction of the follicular corticesFocal corticaldestructionFocal lytic lesion with lamina dura and lingual cortical destruction(a) (b)Figure11.10 Leukaemia: axial MDCT images (a,b). Malignant Tumours Involving theJaws 185• Chondrosarcoma (Figure11.12). ◦Synonym: chondrogenic sarcoma. ◦Malignant cartilaginous tumour, rarely seen in the jaws. ◦Variable radiological appearances depending on subtypes and grade. ◦May be quite benign in appearance with well‐defined, even corticated borders. The expanded jaw cortices may be preserved. Higher grade lesions demonstrate invasive borders. ◦Internally may be lytic. Some demonstrate internal ring/arc‐shaped calcifications and the classically described ‘popcorn’ appearance. Others demonstrate multiple internal sclerotic‐appearing foci which may beirregular. ◦When affecting the teeth, tooth displacement and root resorption may be seen. Infiltrative irregular widening of the periodontal ligament spaces may be seen. ◦May involve adjacent muscles.Soft tissue tumour involvement of the maxillary sinus, nasal cavity and orbit, with bony destruction(a)(b)(c) (d)Opaque heterogeneousexpansile lesion with radiating opaque spicules Figure11.11 Osteosarcoma: cropped panoramic radiograph (a) with coronal (b) and axial (c,d) MDCT images. 186 Atlas of Oral and Maxillofacial Radiology• Mucoepidermoid carcinoma (involving the jaws) (Figures11.13 and 11.14). ◦Usually occurs in the salivary glands. ◦Rarely arises from within bone (central). Lesions arising from the major and minor salivary glands may invade the adjacent jaws. ◦Unlike most malignant lesions, this malignancy can dem-onstrate benign features. ◦Often presents as a multilocular expansile lesion with scle-rotic or heavily corticated borders. Can be very similar in appearance to the ameloblastoma but root resorption is less commonly seen with the mucoepidermoid carcinoma.Contrast-enhanced muscle with multiple calcifications, a few of which demonstrate ring/arc-like morphology(a)(b)Figure11.12 Chondrosarcoma from the skull base involving the left lateral pterygoid muscle: postcontrast axial bone (a) and soft tissue (b) MDCT images. Malignant Tumours Involving theJaws 187Multilocular lesionwith well-definedsclerotic bordersInternally, the attenuation is similar to that of soft tissue(a) (b)(c)Figure11.13 Intraosseous mucoepidermoid carcinoma: axial and corrected sagittal bone (a,c) and axial soft tissue (b) MDCT images.(a) (b)Opaque heterogeneous expansile lesion within the left maxilla with some regions demonstrating a multilocular appearance. Note destruction of the antral walls and palatal cortexFigure11.14 Intraosseous mucoepidermoid carcinoma: axial (a) and coronal (b) MDCT images. 188 Atlas of Oral and Maxillofacial Radiology• Multiple myeloma (Figures11.15 and 11.16). ◦A malignancy of the plasma cells. ◦Most common primary malignant neoplasm of bone. ◦In the jaws, most commonly seen in the posterior mandible. ◦Classically presents as multiple ‘punch‐out’ lytic lesions with borders which demonstrate variable degrees of inva-sive features. May coalesce in severe cases, and may appear multilocular on 2D radiography.Large lucency reflects coalescence of multiple lesionsLytic lesionsLytic lesionsFigure11.15 Multiple myeloma: panoramic radiograph.Multiple ‘punched out’ lytic skull lesionsFigure11.16 Multiple myeloma: lateral skull radiograph. Altered trabecular architecture withfocal cortical destructions and wideningof the mandibular foramenSoft tissue mass(a) (b) (c)(d)(e)Figure11.17 Ewing’s sarcoma of the right ramus and condyle: axial (a,b) and corrected sagittal (c) bone and axial soft tissue (d,e) MDCT images.Root resorption of the15 and 14 noted.This is rarely seen with malignant lesionsLytic lesion with destruction of the palatal and sinus corticesSoft tissue mass(a) (b)(c)Figure11.18 Malignant fibrous histiocytoma of the right maxilla: cropped panoramic radiograph (a) with axial soft tissue (b) and bone (c) MDCT images. 190 Atlas of Oral and Maxillofacial RadiologyDifferential diagnosis (non‐malignant lesions)Key radiological differencesPeriapical inflammatory lesionsMay appear similar. Inflammatory lesions are usually centred at the apical foramen (occasionally related to a lateral canal on other root surfaces). In contrast, malignan-cies demonstrate irregularly widened peri-odontal ligament spaces or periradicular lucencies, which tend to occur at any of the root surfaces. There are often infiltrative margins. There may be relatively normal‐appearing periodontal ligament space and lamina dura between abnormal foci.Vascular malformationsMay appear aggressive, especially larger lesions. Abnormal vascular channels at cortices may give the impression of an invasive or infiltrative lesion.Osteomyelitis May appear similar, especially when acute. Malignancies (e.g. SCCa) tend to demonstrate more aggressive borders. Periosteal response is often seen in osteo-myelitis but it can also be present in some malignancies, and oral malignancies which are exposed to the oral cavity are often secondarily infected.Osteoradionecrosis May appear similar. Malignant borders demonstrate more invasive features. Irregularly widened periodontal ligament spaces may be seen in osteoradionecrosis and also some malignant lesions.Fibrous dysplasia May rarely appear similar to osteosar-coma and chondrosarcoma. Fibrous dysplasia demonstrates a more benign appearance. When teeth are involved, fibrous dysplasia usually thins and/or alters the architecture of the lamina dura, while malignant lesions usually variably destroy the lamina dura.Ossifying fibroma May appear similar to osteosarcoma and chondrosarcoma. Ossifying fibroma dem-onstrates a more benign appearance.

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