Legs ripe for harvest – Part 2

I still have to head back to pick up my venous doppler scans, but the clinic receptionist kindly faxed me the report.  I find it somewhat perplexing that none of these high tech medical centres, including Dr P’s office at Macquarie University Hospital, can email documents to me.  Indeed, I hear horror in their voice when I am even so bold as to suggest such a thing.

Again, it seems to be good news on the blood flow in my leg veins.  There is no clot in the deep vein (deep vein thrombosis) or inflammation and clot in the surface vein (superficial thrombophlebitis).  Rock and roll then.

Report

Bilateral legs doppler venous study

Normal flow and compressibility were demonstrated in the deep and superficial systems of the legs bilaterally.  There was therefore no evidence of DVT or superficial thrombophlebitis.  No other specific finding.

Legs ripe for harvest – Part 1

I was back again for more doppler ultrasounds yesterday, this time on the arteries in my leg.  Again uncomfortable but painless.  This time, he turned up the sound so I could listen to the soothing sound of triphasic arterial flow.

I returned to pick up the images and reports this afternoon.   Unfortunately I didn’t check the envelope until we got home.  It turns out they’d forgotten to include the venous scans and report from last week.  Rookie error by someone who ought to know better.  We were doing a 2-hour mad dash around Bondi Junction – shopping is not AJ’s favourite thing – but my whole experience with this disorganised crowd suggested I should check.  I’ll have to chase them up.

The writer of the report (not my sonographer) is a man of few words, as you’ll see below.  In short, there’s no evidence of narrowing of the artery vessels (stenosis) or thickening of the artery walls (artherosclerosis).

The ultrasound scans also included various readings for the blood flow speed.  Just for fun, I’ve added below the report the averaged readings are for the right leg.  That’s the leg from which Dr A proposes to do the fibula harvest.

Report

Bilateral doppler arterial leg studies

All vessels were demonstrated bilaterally and showed normal triphasic flow throughout.  There was no evidence of stenosis or atherosclerosis.

Right leg artery readings

Rt CFA 92.2 cm/s

Rt PFA -55.5 cm/s

R SFA prox -102.1 cm/s

R SFA mid -120.9 cm/s

R SFA dist -96.7 cm/s

R Pop prox 59.6 cm/s

R Pop dist -109.4 cm/s

Details

Now of course, nowhere does the report say it’s not cancer.

Let me see what sense I can make of it.

The radiologists and the pathologists were concerned about the way the tumour had grown.

For the radiologist, it was the tumour’s proliferative activity, the buccal and lingual expansion and the perforation of the lingual cortex and the focal buccal perforation.  That, I think, just means the way the cheek and tongue had expanded and the way the tumour had penetrated their outer layers.

The pathologists were concerned about the way the tumour’s cells looked: somewhat basaloid appearance, apoptotic cells and scattered mitoses.  From what I took in speaking to Dr P this morning, this means the way the tumour had infiltrated surrounding tissue.

The two properties that separate cancer from your garden variety benign tumour are metastasis and invasiveness.  Metastasis is the ability of the tumour to spread from one organ to another and to start the growth of a secondary tumour.  This is the aspect of cancer that really scared me.  Invasiveness is the ability to infiltrate and destroy surrounding tissue.  Benign tumours are more visually defined than malignant tumours.

We already knew my tumour is aggressive and destructive.  It has eaten away at my jaw bone (mandible) until paper thin in sections and it has eaten into the surrounding tissue.

It seems the degree of invasiveness was an ‘unusual finding in a straightforward benign ameloblastoma’.  But it lacks ‘frank malignant features’.

So yes, they will have to remove a great deal of my jaw.  Yes, they will have to take a large margin around it to be sure they get all the cells from the tumour that have invaded the surrounding tissue.  But this aggressive resection will mean it is really unlikely that the tumour will grow back in my jaw.  Possible, but very unlikely.  And because it is not malignant, a related tumour is not going to pop up elsewhere unannounced.

Back to The Plan – Part 2.  Never did I think I would be so thankful.

If you haven’t had your fill of big medical words, feel free to read on…

Macroscopic

1.  ‘Left lateral mandible’.  The specimen consists of portion of grey soft tissue 11mm in maximum dimension.

2.  ‘Periosteum left mandible’.  The specimen consists of a portion of cream soft tissue 14mm in maximum dimension.

3.  ‘Deep mandible’.  The specimen consists of a portion of firm cream soft tissue 10mm in maximum dimension.

Microscopic

I’ll spare you this bit.

Comment

The histologic appearances in all of the three biopsies predominantly reflect organising fibrosis and granulation tissue with occasional strips of reactive bone all of which could reflect a reaction to prior biopsy.  In specimens 1 and 2, rare islands of odontogenic epithelial cells persist and although a suggestion of basal palisading certainly prompts consideration of a residuum of an ameloblastomatous process.

I have taken this case in conjunction with the imaging to the Royal Prince Alfred bone and soft tissue tumour meeting which is attended by Professor H who reported the original biopsy.  He has sent the initial material to Dr C in the USA in consultation as he had some concerns regarding its proliferative activity.

Professor H kindly brought recuts of the histology to the meeting,  The images were reviewed in which the presence of a destructive radiolucent lesion of the left posterior mandible with perforation of the lingual cortex and focal buccal perforation.  The lesion had focally multiloculated appearance and it extended into the ramus of the mandible.  On MRI it had a heterogenous appearance with soft tissue extension on the buccal and lingual aspect.  Overall the radiology had a somewhat aggressive appearance which could fit for a large ameloblastoma.

I have reviewed the sections originally reported by him in which the presence of an ameloblastoma with a partly cystic and partly solid infiltrative appearance is confirmed.  As noted by Dr H, much of the ameloblastomatous component has a somewhat basaloid appearance, apoptotic cells are seen and scattered mitoses are noted, an unusual finding in a straightforward benign ameloblastoma.  While these findings are of some concern, frank malignant features are not seen.

Professor H did inform me that he 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.  Within the current material as receive by me. scattered islands of residual epithelium consistent with residual ameloblastoma are noted in speciment 1 and 2.  Residual tumour is not seen in specimen 3.

This is not good

The CT and MRI results from Tuesday are in.

They are not good.

We have a telephone conference tonight with Dr P and they are scheduling me for a second biopsy on Saturday afternoon.

They need to find out more than the MRI can show them.  They need to exclude malignancy.

Malignancy.

The next step might be a CT PET scan to determine whether my ameloblastoma is in fact cancer.

Cancer.

Read on below if you can.  We hope Dr P can explain it tonight.

CT scan

Report: There is an expansile unilocular lesion involving the posterior left mandible and ramus. The second and third left mandibular molars are absent. There is no evidence of an unerupted tooth. The mandibular canal is displaced inferiorly and its roof is dehiscent. There is thin remodelled bone peripherally with areas of focal dehiscence through the buccal and lingual cortex and inferior border of the mandible. There is periosteal reaction seen anteroinferiorly over the buccal cortex. No osteoid matrix is present. Extraosseous extension is better demonstrated on the MRI performed today. No other bone lesions are seen.

Conclusion: There is an expansile lesion within the posterior left mandibular body and ramus, consistent with the histological diagnosis. There is extension through the cortex into the soft tissues. The periosteal reaction is atypical and may represent secondary infection. A malignant ameloblastoma should also be considered.

MRI scan

Report: There is a expansile mass involving the posterior left mandible body and ramus. The mass is largely isointense to muscle on T1 and slightly hyperintense on T2. Centrally there is an area measuring of T11T2 hyperintensity.The mass demonstrates avid enhancement, with a small central non enhancing component measuring 8mm.

There is dehiscence of the buccal conex medially and the lesion extends into the submandibular space abutting the mylohyoid muscle. There is periosteal reacti0n anteriorly over the lingual cortex and the mass extends through the cortex and perlosteum, buccal gingival sulcus and buccinator msucle. The mass surrounds the facial artery and is limited faterally by the facial muscles. There is edema and enhancement seen around the anteror border of the masseter muscle.

Posteriorly there is involvement of the mandibular ramus and the lesion abuts the anterior border of the medial pterygoid muscle. Inferiorly the inferior areolar canal is dehiscent and displaced. The tumor breaches the lower border of the mandible to project into the submandibular space.

There is normal fat within the pterygoid palatine fossa. There is no evidence of perineural tumour spread along the trigeminal nerve. There is no denervation of the muscles of mastication. There is a left retropharyngeal lymph node measuring 6mm. There are non enlarged lymph nodes in level 1B.

Conclusion: There is an enhancing mass within molar ramus region of the left hemi-mandible, corresponding to the the histologically diagnosed ameloblastoma. There is extraosseus extension into the soft tissues as described and inferior displacment and dehiscence of the inferior alveolar canal. Periosteal reaction is an atypical finding and may indicate secondary infection. Infection could account for some of the soft tissue changes laterally. A malignant ameloblastoma should also be considered.