Earlier this week, I emailed 45 questions to my oral & maxillofacial surgeon, Dr P.
He responded in a little under 2,000 words. By the next morning. While on holiday.
I read his email more than half a dozen times over the next day or so. His answers reassured me, as much by their existence as their content. Yes, they gave me a clearer picture in my head about how things would likely pan out but, more than that, they satisfied me he has this well in hand.
So here begins the three part Q&A series. Today diagnosis, tomorrow surgery, finally recovery. Enjoy.
How large is my tumour?
Your tumour is in the retromolar region of the mandible, extending forward to the body of the mandible and posteriorly to the ramus. The dimensions are approximately 4-7cms antero posteriorly, 3-4cms vertically and 2-4 cms transversely.
What has been destroyed other than the bone? Do you often see ameloblastomas this destructive of mandible etc?
The tooth roots have been eroded and this is indicative of the tumour process. The destruction of the jaw is similar in other people with this tumour. As a sub group the “Unicystic Ameloblastoma” is the only ameloblastoma that has a more innocuous and predictable outcome.
Do you often see ameloblastomas that have infiltrated the soft tissue? What does the infiltration of the soft tissue mean? Will it affect the surgery or prognosis?
Ameloblastomas erode mandible (bone), breaching the periosteum surrounding the mandible and may invade soft tissue. Although relatively unusual it depends primarily on the length of time you have had the tumour and also the aggressive local expansion of the tumour itself.
Infiltration of the soft tissue means we have to involve this in the resection (removal) as we want to minimise the chance of recurrence (Ameloblastomas have a high rate of recurrence). This will involve removal of adjacent muscle, fat, attached and free gingiva (gum) and associated nerves and blood vessels.
I do not believe we will need to remove external skin but this is predicated on soft tissue Frozen Sections (we cannot do bone frozen sections). Invasion of the soft tissue will mean more tissue is required to be removed, more tissue is required to replace it (Fibula Flap).
What does the pathologist in the second biopsy mean by: “a suggestion of basal palisading certainly prompts consideration of a residuum of an ameloblastomatous process”?
The description is that the 2nd biopsies showed a lot of reactive scar tissue and fibrosis from the first biopsy. The residuum confirms that Ameloblastoma was indeed found and concurs with the first biopsy and diagnosis.
The pathologist in the second biopsy wrote that the tumour has “a somewhat basaloid appearance, apoptotic cells are seen and scattered mitoses”. What does this mean? Is this the same as the pathologist in the first biopsy saying my tumour “exhibits basaloid features with evidence of apoptosis and occasional mitoses”?
Apoptotic cells are cells that are dead and dying, programmed as part of the tumour or living process. Mitoses indicate the tumour cells are dividing (ie. tumour is getting bigger)
The pathologist in the second biopsy wrote, “Overall the radiology had a somewhat aggressive appearance which could fit for a large ameloblastoma.” However, they also said, that the tumour’s appearance is an “unusual finding in a straightforward benign ameloblastoma”. What other diagnoses could the tumour’s appearance fit with?
The aggressive appearance is a term that denotes the expression of rapid growth, unusual features or a tendency towards malignancy. It is used by surgeons to convey to patients that a more aggressive approach to surgery is required In your case this essentially means mandibulectomy, resection of associated soft tissue and replacement with an autogenous flap (Fibula). This is aggressive surgery versus less aggressive surgery (enucleation or scooping out the tumour which we do for unicystic ameloblastoma).
Some other diagnoses that could be entertained include Pindborg Tumour (Calcifying Epithelial Odontogenic Tumour) but I rely on the pathologist for clarification, in your case they confirm it is an ameoblastoma.
The pathologist in the first biopsy said “unequivocal malignant features are not observed”. The pathologist in the second biopsy did not see “frank malignant features”. What would these features have been? How would they have differed from what the pathologists did see?
The pathologists confirm that in the biopsies noted they are clear and un-ambiguous that there is no process suggesting cancer (malignancy). Cancerous features may involve cellular atypia, bizarre or frequent mitoses, the absence of an ordered structure or other aspects histologically that do not resemble normal tissue.
The pathologist who undertook the first biopsy said had “done progesterone receptor on the tissue and found it to be strongly positive, raising the possibility of some degree of hormonal effect on this tumour”. What does this mean? Does the possible hormone effect suggest another or concurrent diagnosis?
He’ll get back to me on this.
In my notes, I wrote “if the biopsy results do not come back as clearly benign, I’ll likely have a CT PET scan”. Will I still have a CT PET scan?
You do not need a CT PET scan
*Disclaimer: He did not have access to my files and his answers are indicative only.