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BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S ) 14
550
BONE T U M O R S ( T U M O R S A N D CYSTS O F THE ) A W S )
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BONE T U M O R S ( T U M O R S A N D CYSTS OF THE J A W S )
Fig. 14.14 Soft tissue window of an axial CT Fig. 14.15 Bone window of the axial CT scan Fig. 14.16 Three-dimensional CT reconstruction
scan through the upper alveolus demonstrating demonstrating an expansile bone destructive showing an expansile lesion of the mandible.
a hypodense expansile bone destructive lesion. lesion of the upper alveolus.
and the lesion are vividly demonstrated. Therefore, for adequate present, three-dimensional reconstructions of the CT scans are
evaluation of bone invasion by a neoplastic process, both soft valuable for accurate assessment and documentation of the extent
tissue and bone windows of the CT scan are required. of invasion and for planning reconstructive surgery.
Three-dimensional reconstructions of the CT scan are often
valuable in assessing the true extent of the tumor, particularly
BIOPSY
with reference to planning reconstructive procedures. Three-
dimensional cast models can also be fabricated with computer
software which provide cast models of the bony defect to be It is vitally important that accurate tissue diagnosis be established
reconstructed, thus facilitating the ability of the reconstructive prior to definitive surgical treatment in patients who present with
surgeon to accurately fabricate a graft or flap to achieve accurate lesions suspicious of being a neoplastic process involving the
contour and symmetry. A three-dimensional reconstruction of the facial skeleton. Several bone lesions arc often benign or of a low-
craniofacial skeleton of a young patient with fibrous dysplasia of grade malignant histology and their treatment is significantly
the mandible is shown in Fig. 14.16. Note the shape and dimensions different than for high-grade bone tumors. Since needle biopsy is
of the pathologic mandible in relation to the remaining facial often not satisfactory, an open biopsy with a generous volume of
skeleton. In a posterior view of the reconstructed CT scan the representative tissue should be submitted for pathologic analysis.
thickness of the mandible involved by fibrous dysplasia is vividly Frozen section diagnosis is sometimes not possible and should not
demonstrated (Fig. 14.17). An axial view of the same patient be requested when a bone tumor is suspected. Extraction of a
tooth near lesions of the upper or lower jaw should be avoided
shows the thickening of the cancellous bone with thinning out of
and a biopsy obtained from an adjacent area to prevent im-
the mandibular cortex. The normal architecture of the cancellous
plantation of malignant tumor into the marrow cavity of the
bone is lost and replaced by a ground glass appearance of fibrous
affected bone, increasing the risk of tumor dissemination.
dysplasia (Fig. 14.18). Thus, when complex bony pathology is
552
14 BONE T U M O R S ( T U M O R S A N D CYSTS O F THE | A W S )
553
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S ) 14
Surgical excision of the lesion requires a full-thickness craniectomy 14.23 and 14.24). The scalp incision is then closed over the
and appropriate cranioplasty. The entire operative procedure is cranioplasty in the usual manner. Alternatively, a titanium mesh
extradural. The patient is placed under general endotracheal anes- can be used to provide the matrix for support to the bone cement
thesia and the scalp is shaved and prcpped in the usual fashion. A or special cranioplasty plates may be used wilhout the bone
U-shaped incision is taken over the scalp around the palpable cement to repair small surgical defects (Fig. 14.2S).
tumor with the pedicle of the flap based anteriorly. The scalp flap
is elevated deep to the pericranium exposing the outer cortex of
the frontoparietal region (Fig. 14.21). Note the purplish color of
the hemangioma involving the bone. Two burr holes are placed,
one anterior and the other posterior to I he lesion. Using ap-
propriate dural elevators the underlying dura is separated from the
inner cortex of the bone to free up the area of bone involvement.
Using a Midas Rex side-cutting power saw the craniectomy is
completed by connecting the burr holes around the visible and
palpable tumor. The surgical specimen is removed in a monobloc
fashion (Fig. 14.22). Accurate hemostasis is secured by using
bipolar cautery for control of bleeding from the dura and using
bone wax over the cut edges of the calvarium.
Cranioplasty of the craniectomy defect can be performed by a
variety of different techniques. The simplest technique is to use a
braided wire and bone cement. The wire criss-crossed between the
edges of the surgical defect and bone cement is used to fill the
surgical defect. The wire acts as a matrix over which the bone Fig. 14.23 Braided wire is criss-crossed between the edges of the
cement provides a shell to repair the craniectomy defect (Figs surgical defect.
Fig. 14.21 The scalp flap is elevated to expose the hemangioma. Fig. 14.24 The wire acts as a matrix over which the bone cement
provides a shell to repair the craniectomy defect.
METRICll 2| 31 4
. .1.. .
Fig. 14.22 The surgical specimen.
554
Postoperative care for this patient is relatively simple. The The patient shown here has Paget's disease involving the skull.
patient is maintained on antibiotics until satisfactory primary He presented to a local surgeon with an enlarging mass on the
healing of the scalp wound is manifested. forehead of approximately six months' duration. A generous open
Hemangiomas of the bone are benign lesions which are often biopsy was performed with a transverse incision in the skin of the
asymptomatic and may not require surgical resection in every forehead which confirmed the diagnosis of osteogenic sarcoma
instance. Unless there is demonstrable growth over a short period (lig. 14.26).
of time, or the patient has symptoms, or if there is suspicion of A CT scan of the head in an axial plane with soft tissue window
malignancy, surgical treatment is usually not undertaken. The lesion shows significant intracranial extension of disease with displacement
can simply be followed clinically or radiographically and surgical and/or involvement of the dura and the frontal lobe on the left-
intervention may be considered if any of the above indications hand side (Fig. 14.27). A representative axial view of the CT scan
become manifest. with a bone window shows the entire skull involved with Paget's
disease (Fig. 14.28). The tumor involves the frontal bone on the
left-hand side with extension of disease to involve the medial part
SARCOMA OF THE FRONTAL BONE
of the frontal bone on the right-hand side. There is significant soft
tissue extension in an extracranial fashion. A coronal view of the
Malignant tumors of the calvarium which arc adherent to the CT scan shows direct extension of the tumor in the orbit through
overlying scalp and underlying dura require through-and-through its roof, displacing the globe interiorly and laterally (Fig. 14.29).
monobloc resection. However, when these tumors involve the The tumor does not extend to involve the contents of the nasal
anterior cranial fossa, a craniofacial resection becomes necessary. cavity however.
If the tumor involves one orbit, then orbital exenteration in Operative procedure in this clinical setting demands involvement
conjunction with formal craniectomy and en bloc excision are of two surgical teams. A neurosurgical team which will begin with
indicated. the craniotomy and the head and neck team which will
555
T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS) TT
accomplish the facial aspect of the procedure and reconstruction
of the surgical defect with appropriate scalp flaps. A third surgical
team for microvascular free tissue transfer may he required if free
flap reconstruction of the surgical defect is planned. The technical
details of craniofacial resection are discussed in Chapter 4. An artist's
rendering of the extent of tumor resection is shown in Fig. 14.30.
The surgical specimen shows the orbit, frontal hone with the
tumor and overlying skin excised in a monobloc fashion (Fig.
14.31). The posterior view of the specimen shows the excised
portion of the dura and frontal lobe (Fig. 14.32). The surgical
delect of the craniectomy is continuous with (he lower half of the
orbital socket and the contents of the frontal fossa with exposed
brain in that region. A close-up view of the surgical defect shows
exposed brain of the left frontal lobe with a large dural defect due
to its resection with the specimen (Fig. 14.33). Laterally, the
stump of the temporalis muscle is visible in the temporal region.
A large segment of the periosteum from the posterior aspect of
Fig. 14.32 Posterior view of the specimen showing the intracranial
the skull is now excised and used as a free graft to repair the delect tumor and the resected portion of the dura.
in the dura. The periosteum is sutured to the dura with 4-0
Neurolon sutures. A watertight closure is obtained to prevent any
cerebrospinal fluid leakage (Fig. 14.34).
Fig. 14.33 Close-up view of the surgical defect showing the exposed
brain and the dural defect.
Fig. 14.30 An artist's rendering of the proposed extent of surgical
resection.
Fig. 14.31 Anterior view of the surgical specimen. Fig. 14.34 A watertight closure is obtained.
556
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S )
Fig. 14.38
A massive defect such as this is best reconstructed with a composite Anteroposterior view
free Flap. A rectus abdominis or latissimus dorsi free flap arc ideal of the plain x-ray of
the skull.
for this purpose. If a composite free flap is loo bulky, then simply
a latissimus dorsi muscle flap may be used and a split-thickness
skin graft is applied over it for skin coverage. However, if a free
flap is not available, then closure can be achieved with multiple
scalp flaps. This requires proper planning of incisions to resect the
tumor and elevate the flaps at the beginning of the operation. The
defect in this patient was repaired using multiple scalp flaps based
on superficial temporal and occipital arteries (Fig. 14.35).
The postoperative appearance of the patient approximately three
months following surgery shows primary healing of all the scalp
flaps (Fig. 14.36). An external prosthesis will now be fabricated lo
rehabilitate the patient for esthetic appearance.
A postoperative CT scan demonstrates lotal excision of the tumor
of the frontal region with satisfactory margins (Fig. 14.37).
557
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S )
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14 BONE T U M O R S ( T U M O R S A N D CYSTS O F THE | A W S )
(Fig. 14.45). The skull is now exposed subperioslcally in a circum- 14.47). During this phase of the operation it is necessary to
ferential fashion around the tumor. Multiple burr holes are now withdraw approximately 30-40 ml of cerebrospinal fluid (CSF) to
made. Using a craniotome, a circumferential craniectomy is slacken the brain and prevent CSF leakage. Bleeding from the
completed around the gross tumor (Fig. 14.46). The plane of dural vessels is easily controlled with a bipolar cautery.
dissection is still extradural. Care and caution must be exercised The specimen is now removed showing the surgical defect (Fig.
during the performance of burr holes to stay well away from the 14.48). The brain is exposed as a result of sacrifice of the dura.
gross tumor in order to avoid compromising the adequacy of Complete hemostasis at this point must be secured prior to
resection. Using a dural dissector, an attempt is made to elevate beginning the closure of the dural defect. Bleeding from the edges
the dura from the undersurface of the parietal bone. The dura, of the craniectomy defect is controlled using bone wax.
however, is adherent to and involved by the tumor. It will therefore The previously elevated scalp flap is now elevated further
require resection. The dura is entered by making an incision with posteriorly to expose the left occipital region. The periosteum
a scalpel. Using scissors, it is excised circumferentially around the covering the skull in the occipital region on the left-hand side is
tumor to facilitate a monobloc resection. As the dura is incised, thus exposed (Fig. 14.49). A generous portion of the periosteum
the surgical specimen becomes more mobile permitting its rotation of the skull over the occipital region from the left side is now
externally to further facilitate exposure of the remaining dural elevated and excised for its use as a free graft lor repair of the dural
attachments and its division. defect. No attempt is made to remove the periosteum from the
The surgical specimen is now reflected posteriorly with the dura parietal region since that will be necessary to support the skin
attached to the tumor and exposing the underlying brain (Fig. graft. Sufficient periosteal graft should be harvested to repair the
Fig. 14.45 Circumferential incision is made in the periosteum around Fig. 14.47 The surgical specimen is reflected posteriorly with dura as its
the tumor. deep margin.
Fig. 14.46 A circumferential craniectomy is completed through multiple Fig. 14.48 The surgical defect following removal of the specimen.
burr holes and the dura is opened.
559
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S )
dural delect. This periosteal graft is sutured to the edges of the position with a bolster dressing. A suction drain is placed beneath
dura with 4-0 Neurolon suture (Fig. 14.50). A watertight closure the rotated scalp flap. The surgical specimen shows the intact
must be secured to prevent CSF leakage. portion of the scalp resected with the tumor (Fig. 14.53). Its
After satisfactory repair of the dural defect, the sharp edges of deeper surface shows intact dura providing a monobloc resection
the craniectomy defect are smoothed out. The previously elevated of the tumor (Fig. 14.54).
scalp flap is now rotated posteriorly in order to cover the craniectomy The postoperative appearance of the patient approximately nine
defect (Fig. 14.51). Closure of the scalp edges is performed in two months following surgery shows .satisfactory restoration of the
layers using interrupted chromic catgut subcutaneous sutures and scalp defect (Fig. 14.55). Although there is no bony support at
3-0 nylon sutures for the skin. The donor site defect in the scalp the site of the craniectomy, the defect is covered with full-
of the parietal region still has its periosteum intact (Fig. 14.52). A thickness scalp while the split-thickness skin graft covers the skull
split-thickness skin grail harvested from the thigh is now applied at the donor site of the scalp flap. Rotated scalp flap in this fashion
to the exposed periosteum. The skin graft is secured with continuous provides a very satisfactory coverage for craniectomy defects
absorbable sutures to the edges of the scalp. It is retained in following resection of primary or metastatic tumors of the calvarium.
Fig. 14.49 The periosteum covering the skull in the occipital region is Fig. 14.51 The scalp flap is rotated posteriorly to cover the craniectomy
exposed and a pericranial graft is harvested. site.
Fig. 14.52 The donor site defect has its periosteum intact over which a
split-thickness skin graft is applied.
560
BONE T U M O R S ( T U M O R S A N D CYSTS O F THE | A W S )
The most frequently seen benign tumors ot the facial skeleton and
paranasal sinuses are osteomas and fibro-osseous lesions.
Osteomas are most frequently seen in the frontal/ethmoid sinuses.
Chondrosarcomas a n d osteogenic sarcomas are I he most
predominant malignant lesions of this region.
561
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE ) A W S ) 14
Fig. 14.56 Axial view of the CT scan (bone window) shows a dense Fig. 14.57 Coronal view (bone window) shows that the tumor displaces
lesion of the right ethmoid pushing the globe anteriorly. the right lamina papyraecea laterally without involvement of the globe.
Fig. 14.58 The surgical defect after the tumor Fig. 14.59 The surgical specimen, Fig. 14.60 The facial bones are repositioned
has been excised through a right lateral using microplates and screws.
rhinotomy and facial disassembly procedure.
Fig. 14.61 Early postoperative view of the patient showing the healed Fig. 14.62 Coronal view of the postoperative CT scan shows complete
incision and normal position of the right globe. excision of the tumor.
562
TT BONE TUMORS (TUMORS AND CYSTS OF THE |AWS)
Fig. 1 4 . 6 6
Postoperative CT scan
t h r o u g h the maxillae
shows complete
removal of the t u m o r
f r o m the nasal cavity.
Fig. 1 4 . 6 7 CT scan
t h r o u g h the orbits
shows complete
clearance of the t u m o r
f r o m the ethmoids.
563
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S )
OSTEOGENIC SARCOMA OF THE ETHMOID The surgical defect shows a massive cranio-orbital resection with
excision of the dura at the floor of the anterior cranial fossa in
conjunction with orbital exenteration, maxillectomy and ex-
The patient whose CT scan is shown in Fig. 14.68 had an
enteration of Ihc nasal cavity (Fig. 14.69). The surgical specimen
osteosarcoma of the ethmoid region which was initially attempted
from the anterior view shows the left orbit and the skin of the
to be resected elsewhere by a lateral rhinotomy approach. Incomplete
frontal region resected with the tumor en bloc (Fig. 14.70). The
resection was performed, following which ihc patient was placed
posterior view of the surgical specimen shows the intracranial
on chemotherapy and radiation therapy. In spite of these treatments,
component of the tumor with craniectomy of the frontal bone
the tumor progressed and lie presented with a massive tumor
and the floor of the anterior cranial fossa accomplished in a
filling up the nasal cavity, left maxillary antrum, and the ethmoid
monobloc fashion (Fig. 14.71). The surgical defect in this patient
region, with extradural extension into the anterior cranial fossa.
was reconstructed using a rectus abdominis myocutaneous free
The tumor had infiltrated the periorbita of the left-hand side and
flap. Postoperative appearance of the patient approximately three
had displaced the globe in the right orbit.
months following surgery shows satisfactory primary healing of
A craniofacial resection with orbital exenteration was performed the wound (Fig. 14.72). Although the esthetic appearance of the
in a monobloc fashion. For technical details of Ihc operative patient is not optimal, the massive surgical defect has been
procedure, please refer to Chapter 4. A standard bifrontal repaired in a single stage operation with primary healing. However,
craniotomy is performed and the floor of the anterior cranial fossa further reconstructive efforts and restoration of the contour of the
is approached in an extradural fashion. Since there was invasion face will be required. Eventually an external facial prosthesis will
of the dura by the tumor, dura of the frontal fossa was resected. be fabricated for esthetic rehabilitation of the face.
Fig. 14.70 Anterior view of the surgical Fig. 14.71 Posterior view of the surgical Fig. 14.72 Postoperative view of the patient
specimen. specimen. three months following reconstruction with a
rectus abdominis myocutaneous free flap.
564
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS)
LOW-GRADE CHONDROSARCOMA OF THE NASAL patient was secured through a biopsy performed through the nasal
CAVITY cavity. Surgical resection for a lesion of these dimensions and in
this location requires a craniofacial approach. The details of the
technique of craniofacial resection are described at length in
The patient whose MRI scan is shown in Fig. 14.73 presented
Chapter 4.
with a six-month history of progressive nasal obstruction and slight
Postoperative MRI scans of the same patient in the axial, sagittal
proptosis on the right-hand side. MRI scans in the axial, sagittal
and coronal planes demonstrate total resection of the tumor from
and coronal planes demonstrate a well-demarcated bone destructive
the nasal cavity and right maxillary antrum all the way from the
lesion with speckled calcification occupying the entire nasal cavity
base of the skull cephalad lo the floor of the nasal cavity caudad
and the right maxillary antrum, approaching the floor of the orbit
(Figs 14.76-14.78). Since this is a low-grade lesion, no additional
and the cribriform plate al the base of the skull (Figs 14.74 and
treatment is necessary.
14.75). Tissue diagnosis of low-grade chondrosarcoma in this
Fig. 14.73 Axial view of the MRI scan shows a Fig. 14.74 Sagittal view of the MRI scan shows Fig. 14.75 Coronal view of the MRI scan shows
honeycomb-like tumor in the nasal cavity and the tumor extending upto the cribriform plate. tumor of the nasal cavity and maxilla extending
right maxilla. up to the skull base.
Fig. 14.76 Axial view of the postoperative MRI Fig. 14.77 Sagittal view of the postoperative Fig. 14.78 Coronal view of the postoperative
scan. MRI scan. MRI scan.
565
BONE TUMORS (TUMORS AND CYSTS OF THE |AWS) 14
HIGH-GRADE CHONDROSARCOMA OF THE ORBIT demonstrates a massive tumor involving the medial portion of the
left orbit with extension into the nasal cavity (Fig. 14.82). This
patient required a craniofacial resection with orbital exenteration
The patient shown in Fig. 14.79 had previously undergone a
and resection of a portion of the frontal bone and the roof of the
conservative surgical approach for excision of a chondrosarcoma
orbil to excise the tumor in a monobloc fashion. The surgical
of the frontal ethmoid region through a supraorbital incision but
specimen is shown in Fig. 14.83. Technical details of the surgical
the tumor had promptly recurred. Biopsy of the excised tumor
procedure of craniofacial resection are discussed at length in
proved this to be a high-grade chondrosarcoma. The plain x-ray of
chapter 4.
the skull shown in Fig. 14.80 demonstrates bone destruction of
the superior medial quadrant of the left orbit with extension of
tumor to destroy a portion of the frontal bone and the adjacent
skull base. A conventional coronal tomogram of the skull further Fig. 14.81
demonstrates the bone destructive lesion involving the medial Conventional coronal
portion of the left orbit with destruction of the cribriform plate tomogram of the skull
and extension of tumor into the anterior cranial fossa (Fig. 14.81). showing bone
destruction at the
An axial CT scan through the level of the mid-orbit vividly cribriform plate.
566
14 BONE T U M O R S ( T U M O R S A N D CYSTS O F THE | A W S ]
The patient whose upper alveolus is shown in Fig. 14.84 had a Myxomas and fibroniyxomas are benign lesions of the facial
nodular firm lesion arising from the midline of the upper alveolus skeleton which usually present as expansile lesions with minimal
in the premaxillary region. The lesion had been present for several soft tissue component. The dentition at the site of the tumor is
years but had shown recent growth. She was unable to wear her usually loose or the teeth have spontaneously extruded. The
upper denture as a result of the presence of this lesion. Open patient whose upper alveolus is shown in Fig. 14.87 presented
biopsy of this lesion showed that this was a low-grade chondro- with a fullness of the left cheek, and spontaneous extrusion of the
sarcoma. A preoperative CT scan of the patient (Fig. 14.85) upper teeth on the left-hand side. CT scans of the paranasal sinuses
demonstrates a bone destructive lesion of the premaxilla with a in the axial and coronal planes demonstrate a homogeneous
honeycomb-like appearance which is classic for a chondrosarcoma. tumor mass causing expansion of the alveolus with minimal bone
This patient's tumor was excised through a per oral approach destruction (Figs 14.88-14.91). The lesion extends into the
with resection of the premaxilla and upper alveolus with satisfactory maxillary antrum with its expansion to produce obstruction of the
bony and soft tissue margins in all three dimensions. The surgical left nasal cavity and displacement of the contents of the orbit
defect was left open to heal by secondary intention since it did not cephalad without any soft tissue invasion by tumor. In spite of
communicate with the nasal cavity or maxillary antrum on either this being a histologically benign tumor, due to its dimensions
side. The postoperative appearance of the patient approximately total maxillectomy would be required for treatment.
six months following surgery is shown in Fig. 14.86. Note the
absence of the alveolar process in the anterior half of the upper
alveolus. This patient required a specially fabricated upper denture
to provide protrusion of the upper lip to fill the defect created by
the surgical resection.
Fig. 14.85
Preoperative CT scan
showing a bone
destructive lesion of
the premaxilla.
Fig. 14.86
Postoperative view of
the upper alveolus six
months following
1 surgery.
Fig. 14.88 Axial view of the CT scan showing an expansile lesion with
bone destruction.
567
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S )
The maxilla is the second most frequent site of origin for osteogenic
sarcoma in the craniofacial skeleton. The patient whose oral cavity
is shown in Fig. 14.92 is a 19-ycar-old man with the history of
having noted pain, discomfort and swelling of the posterior part
of the left upper gum for three months. He also complained of a
loosening of his molar teeth al that site. CT scans of the paranasal
sinuses in the axial and coronal planes show a bone forming and
hone-destructive expansile lesion of the left maxilla (Figs 14.93
and 14.94). The lesion appears to be contained within the confines
of the maxillary antrum with minimal soft tissue component
anterolateral!}'. Surgical treatment for osteogenic sarcoma of the
maxilla requires a true total maxillectomy. The resection includes
the entire maxilla including the left half of the hard palate, the
floor of the orbit, the zygomatic process and the pterygoid plates,
as well as the nasal process of the maxilla and the lateral wall of
the nasal cavity. When a maxillectomy is undertaken for a sarcoma
in contrast to an epithelial carcinoma, very generous true en bloc-
Fig. 14.89 Axial view of CT scan showing displacement of the medial
wall of the maxilla into the nasal cavity.
total resection of the maxilla should be undertaken, with generous
soft tissue margins around the maxilla in all directions. Every
Fig. 14.92 Intraoral view showing tumor of the left maxilla causing
expansion of the left upper alveolus.
568
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS)
attempt must he made (o achieve monobloc excision of the lunior Fig. 14.94 Coronal
to ensure adequacy of resection. Extreme care should be exercised view of the CT scan
shows a well-
during the course of Ihe operation not to fracture the specimen circumscribed tumor of
and avoid removing the lunior piecemeal. Removal of the tumor the left maxilla without
in a piecemeal fashion significantly increases the risk of leaving soft tissue involvement.
residual tumor behind. Since this is a neoplastic lesion of osseous
origin, ils monobloc removal is not that difficult. The technique
of total maxillectomy is described in Chapter 3.
The lateral view of Ihe specimen shows transected zygoma and
intact posterolateral wall of the maxilla (Fig. 14.95). The medial
view of the specimen shows Ihe transected hard palate and lateral
wall of the nasal cavity (Fig. 14.96). The left half of the hard
palate forms the inferior margin of the specimen (Fig. 14.97). The
anterosuperior view of the specimen clearly shows the tumor
contained in the maxillary antrum (Fig. 14,98). This patient will
need a dental obturator to obliterate the maxillectomy defect and
facilitate his ability to speak and swallow by mouth.
Fig. 14.95 Lateral view of the specimen shows the transected zygoma Fig. 14.96 Medial view of the specimen shows the intact lateral wall of
and intact posterolateral wall of the left maxilla. the nasal cavity.
Fig. 14.97 The palatal surface of the specimen shows the intact hard Fig. 14.98 The anterosuperior view of the specimen shows the upper
palate with an expansile lesion of the alveolus. border of the tumor in the maxillary antrum.
569
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS)
TUMORS OF THE MANDIBLE patient's symptoms, and radiographic appearance of the lesion.
The patient shown in Fig. 14.99 is a 14-ycar-old boy who
presented with the history of a fullness on the left side of his face
The mandible is the most frequent site of odontogenic and non-
noted by his parents several years ago. He had experienced
odontogenic tumors of bone in the head and neck region. The
intermittent discomfort on the left side of the mandible with
most frequent non-odontogenic benign tumors are fibro-osseous
progressive tenderness and pain within the past year. A plain x-ray
lesions. Osteogenic sarcoma and chondrosarcoma are the most
of the mandible (Fig. 14.100) demonstrates a periosteal reaction
common malignant tumors. Ameloblastoma is the most common
over the ascending ramus of the mandible on the left-hand side
odontogenic tumor seen in the mandible; the mandible is more
signifying an active neoplastic process. A panoramic x-ray of the
often involved by ameloblastoma compared to the maxilla. A variety
mandible (Fig. 14.101) demonstrates an irregular osteolytic lesion
of odontogenic cystic lesions are also more commonly seen in the
involving the ascending ramus and the posterior part of the body
mandible.
of the mandible. Due to progressive symptoms of pain and
discomfort, surgical excision of the lesion was recommended.
Exposure of the lesion is obtained through an upper neck incision
OSSIFYING FIBROMA OF THE MANDIBLE
through a skin crease remaining deep to all the soft tissues and
directly over the periosteum of the mandible since this is a benign
The histologic diagnosis between mono-ostotic fibrous dysplasia lesion and truly a subperiosteal process (Fig. 14.102). The
and ossifying fibroma of the mandible is difficult. A decision mandible is exposed from the temporomandibular joint to the
regarding treatment should therefore be based on physical findings, menial foramen on the left-hand side. Soft tissue attachments
Fig. 14.99 This patient presented with a history of pain and a fullness
on the left side of his face.
Fig. 14.101 Panoramic x-ray of the mandible showing an ill-defined
osteolytic lesion.
Fig. 14.100 Plain x-ray of the mandible shows periosteal reaction. Fig. 14.102 The upper neck incision with exposure of the mandible.
570
BONE TUMORS (TUMORS AND CYSTS OF THE |AWS)
including the masseter muscle and the temporalis and pterygoid LOW-GRADE OSTEOGENIC SARCOMA OF THE
muscles are detached with the use of an electrocautery. The MANDIBLE
mandible is divided just posterior to the mental foramen on the
left-hand side and the temporomandibular joint is disarticulated.
The surgical specimen is shown in Fig. 14.103. A sagittal section Osteogenic sarcomas may be endosteal, parosteal, or periosteal.
through the mandible demonstrates the fibrous nature of the They may also be histologically low-grade lesions or high-grade
lesion replacing bone in the entire involved hemimandible (Fig. tumors. The patient shown in Fig. 14.105 presented with the
14.104). A surgical defect of this magnitude requires mandible history of a slowly enlarging bony mass near the angle of the
reconstruction with a fibula free flap with the added consideration mandible on the left-hand side for eight months. On physical
that this patient is a growing child and will probably require examination, there was a bony hard mass involving the region of
further revision surgery as he grows. It is also important that the angle of the mandible with expansion of the lateral cortex and
the upper and lower teeth be kept in intermaxillary fixation to overlying soft tissues. He had anesthesia of the skin of the chin on
maintain alignment and occlusion to prevent progressive facial the left-hand side. Intraoral examination showed the presence of
deformity. a granular polypoid lesion adjacent to the retromolar gingiva in
the gingivobuccal sulcus (Fig. 14.106). Biopsy of this lesion
Fig. 1 4 . 1 0 3 The surgical specimen of left h e m i m a n d i b u l e c t o m y . Fig. 1 4 . 1 0 5 This p a t i e n t h a d a slowly e n l a r g i n g b o n y mass near the
angle of the m a n d i b l e .
Fig. 14.104 W h o l e o r g a n section s h o w i n g a dysplastic f i b r o u s lesion. Fig. 1 4 . 1 0 6 I n t r a o r a l v i e w shows a p o l y p o i d lesion near the retromolar
gingiva.
571
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS)
through the oral cavity c o n f i r m e d t h e diagnosis of a low-grade HIGH-GRADE OSTEOGENIC SARCOMA OF THE
osteogenic sarcoma. A panoramic x-ray of the m a n d i b l e shows MANDIBLE
bone destruction in the edenliilous m a n d i b l e on Hie left-hand
side ( F i g . 14.107). Surgical treatment for a low-grade osteogenic
The patient s h o w n in Fig. 14.109 had previously undergone
sarcoma requires total excision of the clinically palpable a n d
chemotherapy and radiation therapy for a biopsy-proven osteogenic
radiographically demonstrable t u m o r w h i c h can be achieved
sarcoma of the mandible. The t u m o r had s h o w n slight response
through segmental m a n d i b u l e c t o m y . This patient underwent a
but was persistent at w h i c h p o i n t he presented for consideration
segmental resection of the entire ascending ramus of the m a n d i b l e
of surgical resection. Physical e x a m i n a t i o n showed Ihc tumor to
from the c o n d y l o i d process cephalad up to the m i d b o d y of the
be arising from the body of Ihc m a n d i b l e adjacent to the
mandible anterior to the mental foramen on the left-hand side.
symphysis on Ihc left-hand side, presenting as a submental and
The surgical specimen is s h o w n in F i g . 14.108. M a n d i b l e recon-
submandibular f i r m b o n y mass arising from the mandible w i t h
struction f o l l o w i n g such a resection is desirable. However, in this
fixation of the overlying soft tissues and skin. Intraoral examination
elderly gentleman, microvascular free flap reconstruction was not
showed significant expansion of the buccal and lingual cortex of
undertaken due to medical contraindications. Therefore a p r i m a r y
(he m a n d i b l e e x t e n d i n g f r o m t h e region o f t h e right f i r s t molar
closure of the mucosal defect was performed w i t h o u t any bone
l o o t h to t h e last molar t o o t h on the left-hand side (Fig. 14.110).
reconstruction.
Fig. 14.107 Panoramic x-ray showing a bone destructive lesion. Fig. 14.109 This patient had undergone previous chemotherapy and
radiation therapy for osteogenic sarcoma of the mandible.
572
-? A
I -' I BONE T U M O R S ( T U M O R S A N D CYSTS OF THE ) A W S )
The panoramic x-ray of the mandible shows a classic sun-ray mandible, to encompass the entire tumor. The specimen shown in
appearance of a bone destructive and bone forming lesion of the Fig. 14.113 demonstrates a monobloc resection of the tumor
mandible (Fig. 14.111). A CT scan of the mandible with bone with the mandible resected from angle-to-angle. The surgical
window demonstrates a new bone-forming neoplastic lesion defect shown in Fig. 14.114 demonstrates the stumps of the
involving the body of the mandible with sun-ray appearance mandible on both sides with a soft tissue and skin delect in the
within the tumor, a classic picture for osteogenic sarcoma (Fig. anterior floor of the mouth and the chin. Massive resections such
14.112). as this require a major reconstructive effort with a composite
Surgical resection for this tumor required resection of the mandible microvascular free flap of bone, soft tissues and skin. The technical
from angle-to-angle with a through-and-through resection of the details and the choices of reconstructive surgery in this setting are
skin and soft tissues of the chin near the symphysis of the discussed in Chapter 15.
573
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS)
AMELOBLASTOMA OF THE MANDIBLE taken inlraorally with curettage and placement of a non-
vascularizcd bone graft (Fig. 14.116). Although it appeared that
the bone graft had healed, a recurrent lytic lesion was noted two
Ameloblastoma is an epithelial odontogenic tumor which is histo- years following the last surgical procedure in the body of the
logically benign but is biologically aggressive. The lesion is most mandible (Fig. 14.117). By the time of presentation for treatment
often seen in the mandible but it may also arise in the maxilla. this time, the patient had developed further bone destruction,
The surgical treatment of ameloblastoma requires its 'total now extending across the midline to the body of the mandible on
excision' if cure is to be achieved. Very small localized lesions can
be excised through the oral cavity with marginal mandibuleclomy
or, occasionally, by per oral excision and curettage. However, lesions
of significant size are seldom cured by intraoral excision and curettage
since they invariably develop local recurrence and require a more
aggressive surgical resection down the road. Therefore, the optimal
treatment for ameloblastoma is its total excision at initial pre-
sentation. The patient whose recurrent ameloblastoma is shown
here vividly demonstrates the inadequacy of intraoral resection
and the need for eventual mandibulectomy of a larger segment of
the mandible due to local recurrences.
This patient gave the history of spontaneous extrusion of her
lower premolar and first molar teeth due to a bone destructive
lesion eight years prior to this presentation. The panoramic x-ray
at that time showed a bone destructive lesion in the body of the
mandible on the right-hand side (Fig. 14.115). An intraoral
excision and curettage was attempted but the lesion recurred three
years later. At that point a second surgical procedure was under- Fig. 14.117 Further local recurrence.
Fig. 14.115 Panoramic x-ray showing a lytic lesion of the mandible on Fig. 14.118 Progressive bone destruction of the mandible.
the right-hand side.
Fig. 14.116 Per oral re-excision for recurrence and placement of a non-
vascularized bone graft. Fig. 14.119 Intraoral view shows an expansile lesion at the symphysis of
the mandible.
574
1
14 BONE T U M O R S ( T U M O R S A N D CYSTS O F THE ( A W S )
the left-hand side (Fig. 14.118). Intraoral examination demonstrated hemimandibulectomy, reconstruction with a fibula free flap, and
an ulcerated granular exophytic expansile lesion near the eventual osseointegrated implants for dental rehabilitation are
symphysis of the mandible with expansion of both the labial and shown in Fig. 14.122. Note the ameloblastoma presenting in the
lingual cortex (Fig. 14.119). Surgical resection of this tumor region of the body and retromolar trigone of the right-hand side
required excision of the anterior arch of the mandible from the of the mandible. A segmental mandibulectomy up to the lateral
region of the first molar tooth on the left-hand side to the first incisor teeth was necessary for resection of this tumor. Recon-
molar tooth on the right-hand side. The surgical specimen is struction of the resected mandible was performed with a fibula
shown in Fig. 14.120. The lesion did not extend beyond the bone free flap. The fibula required multiple osteotomies and fixation
and therefore there is minimal soft tissue loss in the oral cavity or with several miniplatcs and screws. Approximately one year
the chin. The surgical defect is shown in Fig. 14.121. Recon- following reconstruction the screws and plates in the region of the
struction of the anterior arch of the mandible in this patient will reconstructed body of the mandible were removed and osseo-
require a microvascular fibula free flap with appropriate osteotomies integrated implants were placed for dental rehabilitation. Post-
to recreate the shape, size, and configuration of the resected operative appearance of the patient shown in Fig. 14.123 shows
mandible. The technical details of mandible reconstruction are excellent esthetic restoration of the right hemimandible with
discussed in Chapter 15. dental rehabilitation accomplished through the osseointegrated
Serial panoramic x-rays of another patient who underwent implants.
Fig. 14.120 The surgical specimen from resection of the anterior arch of
the mandible.
Fig. 14.121 The surgical defect following arch resection. Fig. 14.123 Postoperative appearance of the patient.
575
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS) 1 Z|
ODONTOGENIC CYSTS AND TUMORS marsupialization. In such an event, the patient will require a
dental obturator.
The surgical treatment for cystic lesions of odontogenic origin is
usually conservative. If the etiology is of inflammatory nature, ODONTOGENIC CYST OF THE MANDIBLE
then the inflammatory process should be appropriately addressed.
In other situations, the cystic lesion is usually approached intraorally The patient shown in Fig. 14.128 is a 67-year-old female who
and is widely opened for curettage and complete removal of its presented with a six-year history of a slowly expanding mass in the
epithelial lining. The surgical defect occasionally requires a bone region of the angle of the mandible on the left-hand side. She had
graft but is usually packed open and allowed to heal by secondary no symptoms from this mass. A panoramic x-ray of the mandible
intention. Most odontogenic tumors are benign, and have charac-
teristic clinical features and radiographic appearance. A conservative
surgical approach with excision of these tumors is recommended.
576
14 BONE T U M O R S ( T U M O R S A N D CYSTS O F THE ) A W S )
DENTICEROUS CYST
Fig. 14.129 Panoramic x-ray of the mandible shows a multiloculated
cystic lesion of the left-hand side of the mandible. A dentigerous cyst is a developmental cystic lesion around an
unerupted tooth, lined by an epithelium. The radiographic
appearance is similar to an odontogenic cyst but the characteristic
presence of an uneruplcd tooth in the cystic lesion is confirmatory
of its diagnosis. The panoramic x-ray of a patient with a dentigerous
cyst involving the ascending ramus and the body of the mandible
on the right-hand side is shown in Fig. 14.132. The surgical
treatment for a dentigerous cyst is essentially similar to that for an
odontogenic cyst. The lesion is approached intraorally. The unerupted
tooth is extracted al the time of curettage and marsupialization of
the cyst. Postoperative management is similar with daily packing
of the surgical defect until adequate obliteration of the dead space
lakes place by healing with secondary intention.
Fig. 14.131 Follow-up panoramic x-ray one year following surgery Fig. 14.132 Panoramic x-ray shows a multiloculated cystic lesion with an
shows good healing with new bone formation. unerupted tooth.
shows an expansile multiloculated smooth thin-walled cystic GIANT CELL REPARATIVE GRANULOMA
lesion involving the ascending ramus of the mandible (Fig.
14.129). Hie sensations of the skin of the chin and the tongue are
within normal limits. This lesion is approached intraorally through Giant cell reparative granuloma is a bone-destructive rapidly
an incision in the mucosa of the retromolar gingiva to expose the expanding lesion, usually seen in (he young. It is a self-limiting
anteromedial cortex of the ascending ramus of the mandible. The lesion and it may show spontaneous regression. The classic-
cyst wall is entered into with an osteotome and its epithelial appearance of a giant cell reparative granuloma is shown in Fig.
lining is carefully elevated with a periosteal elevator and excised. 14.133. The clinical, radiologic and histologic differential diagnosis
Meticulous attention should be paid to completely excise all the rests between giant cell granuloma and giant cell tumor of bone.
epithelial lining of the cyst wall or local recurrence is likely to The latter occurs in adults and does not show spontaneous regression
develop. The surgical defect thus created is left open to heal by and often manifests recurrence after treatment, these lesions have
577
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S ) TT
to be differentiated from the 'brown' tumor of hyperparathyroidism. Fig. 14.135 Axial view
Therefore, when a lesion of this nature is demonstrated in the of the CT scan (bone
window) demonstrates
mandible, then appropriate tissue diagnosis should be supple- an osteolytic lesion in
mented by studies for serum calcium, parathormone and a skeletal the posterior part of
survey to rule out involvement of other bones. Surgical treatment the body of the
for giant cell granuloma is usually undertaken by an intraoral mandible on the right-
hand side.
approach with curettage and marsupialization. The surgical defect
is left open and is allowed to heal by secondary intention.
Fig. 14.134 This patient presented with a slightly painful, granular Fig. 14.137 A well-demarcated bony defect remains after surgical
fleshy lesion of the right lower gum. excision of the tumor.
578
14 B O N E T U M O R S ( T U M O R S A N D CYSTS O F THE JAWS)
CEMENTIFYING FIBROMA Lesions of the craniocervical junction and first two cervical
vertebrae present very special surgical challenges for approach and
exposure. Small lesions can be approached through the open
Cementifying fibroma is a benign neoplasm of fibrous origin with mouth. A patient with a craniocervical chordoma presented with
calcium deposition which usually presents in the adult in the a bulging posterior pharyngeal wall. An MRI scan in sagittal plane
molar region of the mandible (Fig. 14.140). Surgical treatment shows the lesion arising from the region of the first and second
for symptomatic lesions consists of local excision of the lesion, cervical vertebrae (Fig. 14.141). This lesion is approached through
usually performed through a per oral approach. Most incidentally the oral cavity under general endotracheal anesthesia. A Dingman
found asymptomatic lesions are left alone. mouth retractor is used to open the oral cavity and expose the
579
BONE T U M O R S ( T U M O R S A N D CYSTS O F THE | A W S )
580
14 BONE T U M O R S ( T U M O R S A N D CYSTS O F THE | A W S )
carefully dissected and retracted laterally along with the carotid expose Ihc tumor. The prevertebral muscles, thus exposed, are
sheath. Injury lo Ihc sympathetic chain will lead to the incised vertically and dissected off Ihc anterior surface of the
development of Horner's syndrome. The larynx and esophagus are vertebral bodies providing the necessary exposure. In this patient
retracted medially and the carotid sheath is retracted laterally to the tumor has destroyed the anterior aspect of the vertebral bodies
on the left-hand side with the tumor projecting into the
prevertebral plane. Appropriate retraction of the larynx,
esophagus and the carotid sheath provide the necessary exposure
to deliver the tumor into Ihc wound (Fig. 14.147). Following
complete excision of tumors of this magnitude, stabilization of
the cervical spine is essential. This may be accomplished either by
fusion of the cervical spine by a poslerior approach or
reconstruction of the vertebral bodies anteriorly and internal
fixation through the anterior approach. As discussed before,
resection of the chordoma or similar tumors of Ihc cervical spine
should be accomplished by a multidisciplinary surgical team of
head and neck surgeons and neurosurgeons. The role of the head
and neck surgeon in this joint approach would be to provide
satisfactory exposure and the role of the neurosurgeon would be
to accomplish a satisfactory resection of the tumor and
reconstruction of the vertebral column with either anterior or
poslerior fusion. Assistance from a third surgical team of orthopedic
surgeons may be required in certain circumstances. Transient post-
Fig. 14.145 Outline of the clinically palpable extent of the tumor and operative swallowing difficulties are to be expected and Iherefore
the skin incision.
a nasogastric feeding tube is required for Ihrcc to four days following
surgery. A tracheostomy is usually not necessary.
581
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S ) 14
The surgical approach for exposure and resection of this vertebral Fig. 14.153. The left sternocleidomastoid muscle is now detached
body needs two surgical teams: a head and neck surgeon for ex- from its insertion on the manubrium as well as the clavicle and is
posure of the vertebral column and a neurosurgeon for resection allowed to retract cephalad. Likewise, the strap muscles on the left-
and replacement of the vertebral body. hand side are divided close to the sternum and are allowed to retract
The surgical incisions necessary for exposure are shown in Fig. cephalad. The exposure thus oblained is depicted in Fig. 14.154.
14.150. A T-shaped incision with its transverse component The actual surgical field exposed by dividing the sternomastoid
extending from the posterior triangle of one side of the neck to the muscle and the strap muscles is shown in Fig. 14.155. The internal
posterior triangle of the other side of the neck is necessary. The jugular vein can be seen deep to the sternomastoid muscle. The
vertical incision is in the midline extending from the transverse middle thyroid vein and the inferior thyroid artery are thereafter
incision over the sternum. The patient is shown on the operating doubly clamped, divided and ligated. The thyroid gland, larynx,
table under general endotracheal anesthesia in the supine position trachea and esophagus can now be retracted towards the right-hand
(Fig. 14.151). Upper and lower skin flaps are elevated to expose the side and the carotid sheath towards the left-hand side (Fig.
strap muscles in the midline and the sternocleidomastoid muscles 14.156). The medial third of the clavicle is now cleared
as depicted in Fig. 14.152. The lower skin flaps should be elevated circumferentially of all its muscular and ligamentous attachments.
enough to expose the entire manubrium. Use of an electrocautery The periosteum of the medial third of the clavicle is incised and
expedites clearance of the anterior surface of the sternum by elevated circumferentially. Using a Gigli or power saw, the clavicle
detaching the origin of the pectoralis major muscle from the is divided at the junction of its medial and middle thirds. The
manubrium. The surgical field exposed up to this point is shown in sternoclavicular joint on the left-hand side is opened by incising its
Fig. 14.149 Myelogram (anteroposterior Fig. 14.150 The surgical incisions necessary for
projection) shows blockage at the level of C I . exposure of the cervico-thoracic vertebral
column.
Fig. 14.152 Elevation of upper and lower skin Fig. 14.153 The surgical field after elevation of Fig. 14.154 The sternomastoid muscle is
flaps. the skin flaps. detached and the strap muscles on the left side
are divided. The clavicle is now ready to be
divided.
582
14 BONE TUMORS (TUMORS AND CYSTS OF THE |AWS)
capsule and the medial third of the clavicle is disarticulated and exposure up to this point is shown in Fig. 14.158. The larynx,
preserved for subsequent use as a bone graft. Removal of the medial trachea and esophagus are mobilized by blunt dissection in the
third of the clavicle requires division of the dense capsule of the prevertebral plane and are retracted to the right-hand side.
joint, the ultra-articular disc and the costoclavicular ligament on Similarly, the common carotid artery and internal jugular vein are
the lower border of the clavicle. This is best done with an mobilized from the prevertebral fascia and are retracted laterally,
electrocautery. Now using a high-speed drill with an olive-shaped exposing the vertebral column at the root of the neck as shown in
burr, the manubrium is scored along its periphery, coring through Fig. 14.159. A self-retaining Cloward retractor is employed to keep
its anterior cortex and the cancellous part of the manubrium up to the anterior surface of the vertebral column exposed for further
its posterior cortex. Finally, using a I.ebsche knife, the manubrium work of resection of the vertebral body (Fig. 14.160). The accurate
is excised to gain exposure of the superior mediastinum as shown in placement of the Cloward retractor is depicted in Fig. 14.161. The
Fig. 14.157. The excised cancellous bone from the manubrium is operative procedure beyond this point may be taken over by the
also preserved for subsequent use as a bone graft. The surgical neurosurgical team.
Fig. 1 4 . 1 5 5 The strap muscles a n d t h e Fig. 1 4 . 1 5 6 The t h y r o i d g l a n d , larynx, trachea Fig. 1 4 . 1 5 7 Exposure of the superior
sternomastoid muscle on t h e left side a r e a n d esophagus a r e r e t r a c t e d t o w a r d s t h e r i g h t - mediastinum.
divided. h a n d side a n d the carotid sheath t o w a r d s t h e
l e f t - h a n d side.
Fig. 1 4 . 1 5 8 The surgical exposure of t h e Fig. 1 4 . 1 5 9 Exposure of t h e v e r t e b r a l c o l u m n Fig. 1 4 . 1 6 0 Placement of the Cloward
mediastinum after resection o f t h e m a n u b r i u m . a t t h e r o o t o f t h e neck. retractor.
583
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS) 14
The neurosurgical aspects of the operative procedure are described Reconstruction and internal stabilization of the spine requires
here briefly. Excision of the involved vertebral body is generally insertion of stainless steel wires or pins in the healthy vertebral
done in a piecemeal fashion using appropriate rongeurs and body above and below. Following this, the remaining surgical
curettes as depicted in Fig. 14.162. If the surface of the vertebral defect created by resection of the vertebral bodies is filled with
body in question does not show any abnormality, then appropriate bone cement (methyl methacrylate) as depicted in Fig. 14.164.
localization films should be obtained to ensure that the vertebral Alternatively the previously harvested bone grafts (segment of
body exposed is indeed the one involved by I he disease process, clavicle and cancellous bone from manubrium) may be used
and not the one cephalad or caudad. This is vitally important additionally to complete the reconstruction. Extreme caution must
since accurate localization of the involved vertebral body can be exercised to prevent excessive projection of the reconstructed
sometimes be difficult in the surgical field. The involved vertebral vertebral column posteriorly or else it may create impingement on
body is completely curetted out to remove all grossly abnormal the spinal cord. The reconstructed vertebral column is shown in
bone. If the dura is involved by tumor, or if there is intraspinal Fig. 14.165. The upper part of the surgical field shows the upper
tumor, then it is removed at this time and the spinal dura border of the bone cement aligned against the undersurface of the
appropriately repaired, following complete curettage of the involved vertebral body of the seventh cervical vertebra. Further retraction
vertebral body and 'excision' of all gross tumor, the surgical defect caudad in the mediastinum shows adequate alignment of the
is irrigated with antibiotic solution. Complete hemostasis must be reconstructed vertebral column with the third thoracic vertebra.
secured before reconstruction of the vertebral column begins. The The wound is irrigated at this point with Bacitracin solution.
surgical defect after excision of the vertebral body is shown in Fig. Suction drains are placed in the field and the incision is closed in
14.163. In this patient, the vertebral bodies of T, and T2 were layers (Fig. 14.166).
resected because of involvement by the tumor. Postoperative care requires bed rest until satisfactory healing of
584
TT BONE T U M O R S ( T U M O R S A N D CYSTS OF THE | A W S )
585
BONE T U M O R S ( T U M O R S A N D CYSTS OF THE JAWS) 14
Fig. 14.168 The manubriosternal junction. A lateral extension of the sternotomy is
palpable extent of the taken up to the second intercostal space on the right-hand side
tumor is shown along
with its relation to the (Fig. 14.172). Retraction of the divided manubrium provides
innominate artery, the satisfactory exposure of the superior mediastinum. I5y alternate
common carotid artery, blunt and sharp dissection the tumor is carefully mobilized from
and the subclavian the great vessels in the superior mediastinum. At this juncture it
artery.
becomes apparent that a contiguous tumor thrombus is present in
the innominate vein on the right-hand side (Fig. 14.173). Therefore,
a segment of the innominate vein on the right-hand side is
resected in a monobloc fashion. The surgical specimen shown in
Fig. 14.174 demonstrates monobloc resection of the intact tumor
along with tumor extension into the innominate vein. The
bisected specimen clearly shows the tumor growing through the
Fig. 14.170 Axial view of the CT scan at the level of the superior
mediastinum.
Fig. 14.171 The exposure obtained after Fig. 14.172 The manubrium sterni is divided Fig. 14.173 A contiguous tumor thrombus is
elevation of the skin flaps of the T-shaped just medial to the left sternoclavicular joint and seen in the innominate vein on the right-hand
incision. a lateral extension of the sternotomy is taken side.
up to the second intercostal space on the right-
hand side.
586
•R BONE T U M O R S ( T U M O R S A N D CYSTS OF THE ) A W S )
RESULTS OF TREATMENT
587
BONE TUMORS (TUMORS AND CYSTS OF THE JAWS)
Fig. 1 4 . 1 7 9 Five-year overall survival f o r osteogenic sarcomas of t h e Fig. 1 4 . 1 8 0 Five-year survival f o r chondrosarcomas of the head and
head and neck by site. neck by histological g r a d e a n d m a r g i n s .
588