Giant neglected ameloblastoma: single stage treatment and clinicopathological review

Defining giant mandibular ameloblastomas - Is a separate clinical sub-entity warranted?

Context:

The term giant mandibular ameloblastoma (GMAs) while being in popular usage in the medical literature remains largely equivocal. Although a few authors have in the past attempted to ascribe definite criteria to this entity, these are by and large arbitrary and without any benefit in decision-making or contributing to its management.

Aims:

The aim of this study is to propose a set of objective criteria for GMAs that can be clinically correlated and thereby aid in the management of this entity.

Patients and Methods:

Of a total of 16 patients with ameloblastoma of the mandible presenting at our institute from August 2012 to September 2016, 11 patients were identified as having GMAs as per the criteria proposed.

Results:

The defects in the mandible following segmental resection ranged from 7 to 11.5 cm in length (mean: 9.3 cm). No clinical or radiological evidence of tumour recurrence was found during a mean follow-up period of 10.7 months (range: 2–28 months).

Conclusions:

Defining GMA based on objective inclusion and exclusion criteria allows segregation of these lesions, thereby helping to remove ambiguity, simplify decision-making and facilitate communication among treating reconstructive surgeons. Inclusion criteria include: (i) The segmental bone defect following resection with a minimum 1 cm margin of healthy bone should exceed 6 cm (ii) The segmental bone defect should involve the central mandibular segment.

Retrospective Review of the Anaesthetic Management of Maxillectomies and Mandibulectomies for Benign Tumours in Sub-Saharan Africa

Background

Safe anaesthesia is a crucial component of safe surgical care, yet anaesthetic complications are common in resource-limited settings. We describe differences in anaesthetic needs for Mandibulectomy vs. Maxillectomy in three sub-Saharan African countries.

Materials and Methods

Retrospective review of patients undergoing minor Mandibulectomy, major Mandibulectomy, or Maxillectomy in Togo, Guinea and Republic of the Congo. Surgeries were performed on the Africa Mercy, an international non-governmental hospital ship. Primary outcomes were need for advanced airway management and intra-operative blood loss. Secondary outcomes were time under general anaesthesia and hospital length of stay. Multivariate regression determined the association between operation type and each outcome measure.

Results

105 patients were included (25 minor Mandibulectomy, 58 major Mandibulectomy, 22 Maxillectomy procedures). In-hospital mortality was 0%. 44/105 (41.9%) required an advanced airway management technique to achieve intubation, although in all cases this was anticipated prior to the procedure; no differences were noted between surgical procedure (p = 0.72). Operative procedure was a significant risk factor for intra-operative blood loss. Patients undergoing Maxillectomy lost on average 851.5 (413.3, 1289.8, p = 0.0003) mL more blood than patients undergoing minor Mandibulectomy, and 507.3 (150.3, 864.3, p = 0.007) mL more blood than patients undergoing major Mandibulectomy. Patients undergoing Maxillectomy had a significantly higher time under general anaesthesia than those undergoing minor Mandibulectomy. There was no significant difference in hospital length of stay between operation type.

Conclusion

Anaesthetic considerations for minor Mandibulectomy, major Mandibulectomy, and Maxillectomy differ with respect to intra-operative blood loss and time under general anaesthesia, but not need for advanced airway management or length of stay. Although advanced airway management was required in 41.9% of patients, there were no unanticipated difficult airways. With appropriate training and resources, safe anaesthesia can be delivered to patients from low-income countries requiring major head and neck surgery.

Recurrent giant mandibular ameloblastoma in young adults

BACKGROUND

The purpose of the study was to define the most appropriate management of the giant mandibular ameloblastoma (GMA) in young adults.

METHODS

A retrospective study was performed on patients with GMA <30 years old. The data collected included initial treatment, tumor margins, reconstruction, and follow-up. Patients evaluated speech, chewing, swallowing, and facial appearance after definitive treatment.

RESULTS

Thirteen patients were identified with recurrent solid/multicystic disease requiring further treatment. Definitive treatment involved segmental mandibulectomy and reconstruction with free fibular flap in all patients. Seven patients had immediate reconstruction (group A) and 6 had secondary (group B). Mandibular resection was planned at least 2 cm beyond the radiological limit, free margins were achieved in all patients, and all flaps were transplanted successfully. In group A, functional score was 13.7 ± 0.45 and facial appearance score was 4.5 ± 0.49, whereas in group B were 11.16 ± 0.37 and 3.3 ± 0.5, respectively (both p < .05).

CONCLUSION

Aggressive resection of the GMA and immediate reconstruction is strongly advised. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1947-E1954, 2016.

[Giant ameloblastoma of the mandible]

INTRODUCTION

Giant ameloblastomas are more common in developing countries. They raise a serious problem of management. We present the case of one of the largest ameloblastoma ever reported.

CASE REPORT

A 48-year-old Congolese female patient was referred for mandibular swelling having begun 23 years before and now inducing severe functional disorders. A cephalic CT scan revealed a multicystic mass, 30×18×10cm in size, with a typical "soap bubble" presentation, and with thinned and inflated cortical bone. The treatment was sub-total segmental mandibulectomy with immediate reconstruction using a fibular free flap, modeled on the sampling site by four ostectomies. The pathological examination confirmed the diagnosis of a benign follicular and plexiform ameloblastoma. The excess of soft tissue was treated with a right commissuroplasty on the 15th postoperative day. There was no complication.

DISCUSSION

Radical treatment followed by immediate reconstruction using a free flap is the treatment of choice for giant mandibular ameloblastomas, when considering immediate functional and esthetic benefits. This is a prime concern for patients with a difficult access to health care and for whom long-term follow-up is not feasible.

Rare giant granular cell ameloblastoma: a case report and an immunohistochemical study

Aims. The aim is to present a case of rare giant granular cell ameloblastoma and to review the pertinent literature highlighting the molecular aspects of its pathogenesis by analyzing the expression of CD-68, Bcl-2, and β -catenin. Methods. H and E stained sections showed large odontogenic islands showing peripheral ameloblast-like cells and central stellate reticulum-like cells with extensive granular cell transformation surrounded by fibrous stroma. Polyclonal rabbit anti-CD 68, anti-Bcl2, and anti- β -catenin were stained immunohistochemically. Results. CD-68 showed a moderate to strong staining intensity in granular cells. Moderate staining of Bcl-2 was expressed by the peripheral columnar cells of tumor islands and negative in the granular cells. Expression of β -catenin was generally weak, except for only the focal areas that showed a moderate staining intensity and weak in peripheral cells. Conclusion. The present case of giant granular cell ameloblastoma is a rare entity. Development of monstrous size is indicative of ameloblastomas persistent growth. Granular cell transformation in ameloblastomas probably occurs as a consequence of extensive molecular changes. Immunohistochemical studies help us to know the pathogenesis of this granular cell ameloblastoma. Therefore, an effort has been made here to study the expression of Bcl-2, CD-68, and β -catenin.

Giant neglected desmoplastic ameloblastoma: reconstruction with free fibula flap

The desmoplastic ameloblastoma (DA) is a rare variant of the conventional ameloblastoma. It accounts for only 4% to 13% of all ameloblastomas. In this article, we describe the case of a young child affected by a giant neglected DA of the jaw. Preoperative biopsy demonstrated the extremely rare osteoplastic variant of DA. The patient was submitted to segmental mandibulectomy and immediate reconstruction with a free fibula osseous flap. The postoperative period was uneventful. The patient was very satisfied with the functional and aesthetic results of the procedure. In case of such rare variants of ameloblastoma, it is mandatory to preoperatively recognize them to allow the adequate treatment modality to be provided.