Question: What is your diagnosis for this case?
A 11 years old boy came to us with the complaint of pain and swelling for one month. o/e, diffused, hard swelling over the right side of mandible. intraorally, hard swelling with gingival enlargement seen buccally and lingually. all the teeth in this quadrent are mobile. give me your diagnosis. later i will post the histopathological and cbct reports.
Moosa Mohammad: Fibrous Dysplasia???
Abhay Shukla: I agree with Moosa sir!! May be fibrous dysplasia
Sandhya Gokavarapu: fnac can let us know weather it is solid or cystic, off course biopsy has to be done,. gaint cell lesions, juvenile ossiffying fibromas are differential diagnosis along with possible malignant counterparts, rabdomyosarcoma, lymphatic malignancies are common in younger individuals
Vishnu Gautham: intraoralllly loooks like drug(phenytoin) induced gingival hyperplasia, any h/of epilepsy? may be the mobility is due presence of pseudo pockets, extraorallly looks entirely diff looks like aecpa with 37 38???palpation & percussion with 38 37? more detailed hopi? thannnku
Sandhya Gokavarapu: ya thats why i did not feel it was ameloblastoma or regular benign tumors
Sridhar Reddy Arumalla: neither gingival fibromatosis nor fibrous dysplasia.
Moosa Mohammad: peripheral giant cell granuloma
Anthony Shieh: leukemia?
Sekhar Reddy: Adding to dr sandhya’s possibilities: histiocytosis or mucopolysacharidosis
Salahuddin Ahmed: ameloblastoma
Amit Jha: epulis
Sridhar Reddy Arumalla: his teeth were mobile and visible during his firrst visit, the growth of the tumor was very rapid that all his teeth were covered with tissue after 10 days.
Varun Sidhar: might be ameloblastoma becz of repid growth and pts age
Salahuddin Ahmed: Sir, does it looks like a pyogenic granuloma ?
Salahuddin Ahmed: Sir, does it looks like a pyogenic granuloma ?
Muthyam Mounika: ???
Sridhar Reddy Arumalla: patients over 20 yrs of age have the highest incidence of ameloblastoma,the average age being 40 yrs.
Ngs Rajan: odontogenic myxoma/
Sridhar Reddy Arumalla: pyogenic granuloma is the asymptomatic reddish papule, nodule or polyp. this is a peripheral oral exophytic lesion.
Srikanth Karumuri: Giant cell granuloma
Naga Anand: sir, it can be ameloblastic fibroodontoma as it looks expansile and seen in young children
Naga Anand: can be eiosoinophilic granuloma -d.d
Vimal Bhalodiya: Waiting for final diagnosis
Naseer Jahan: mucoepidermiod carcinoma
Ai’shah Khan: Bone pathology?? Osteoma?
Nitin Toshniwal: central giant cell granuloma?
Shain Prabha: Gingival hyperplasea ?
Alagesan Chinnasamy: bucco lingual expansion is suggestive of ameloblastoma, however takinghis age it may also be fibrous dysplasia also
Alagesan Chinnasamy: giant cell granuuloma also possible
Kamal Hasan: All.acute lymphoid luekamia
Noushad Ali: Sir…any radiograpgic findings??
Virendra Kumar: I don’t KNOW…….
Madhu Nallapuneni: W’d hv posted even OPG.
Bharath Vardhana: Is the patient on any Phenytoin therapy? (Dilantin Hyperplasia/Or Elephantiasis Gingivae)?
Sridhar Reddy Arumalla: radiographic findings ; rarified and multilocular pattern of bone loss seen in the affected side of mandible.
Bharath Vardhana: But it doesn’t look generalized.
Bharath Vardhana: Sir, the clinical findings and ur rad findings such as multilocular, rapidly growing, destructive to bone, drive home the point that it can be “Giant cell granuloma”..other supporting features include:usually occurs in 10-20 years of age,multiloculated in appearance,sometimes locules appear diffues on rad visualization. Hope I’m right..
Bharath Vardhana: If it is GCG, then Surgical resection (along with involved teeth) is the only way to go.
Sridhar Reddy Arumalla: histopathology report ; shows monotonous sheets of lymphocytes along with “starry sky” pattern.
Naga Anand: burkitts lymphoma
Devulapalli Swathi Vyas: Sir,we have done biopsy for that case at that time tumour was smal later the patient did not turn up . .the report came as round cel tumour . .
Noushad Ali: Burkitts lymphoma
Bharath Vardhana: i guesed so Burk lymph?
Sridhar Reddy Arumalla: @noushad and bharat, u both are right.
Sridhar Reddy Arumalla: pls give treatment options.
Naga Anand: chemo therapy
Bharath Vardhana: Chemotherapy sir.
Bharath Vardhana: along with drugs that act on B lymphocytes… Dn kno trade names.
Vishnu Gautham: it shud be an endemic type of burkitts as it affecting the mandible, 90% of the endemic cases are associated with eb virus,most aggresive of alll,the prognosis is poor as it effects the myc gene affecting myc transloacation leading to abnormal growth….methotrexate and cyclophosphamide willl help along with dexameth ,radiation therapy directly to cns followed by stem celll transplantation n long run
Noushad Ali: Chemotherapy
Chaitanya Divi: burkit’s lymphoma?
Mohd Aijaz Ahmed: ewing sarcoma
Sunil Babu: Ameloblastoma
Sridhar Reddy Arumalla: FINAL DIAGNOSIS : BURKIT’S LYMPHOMA. NOW PLS DISCUSS ABOUT CAUSE AND TREATMENT.
Sandhya Gokavarapu: Cause: god only knows. Treatment : Refer to medical oncologist:)
Anthony Shieh: young boy, surgery is preferred. Recovery too will be fast.
Mahmoud Zizo: Osteomylites
Sridhar Reddy Arumalla: pls refer books about treatment.
Vishnu Gautham: sir i hv disscused n da above post 🙂 hv a loook just a nascent explaination not a complete one though 🙂
Sandhya Gokavarapu: Its associated with EBV virus. . Treatment is chemotherapy
Sridhar Reddy Arumalla: @mahmod, pls read above comments,final diagnosis already mentioned.
Sandhya Gokavarapu: Never surgery
Sridhar Reddy Arumalla: pls discuss about tratment protocols, prognosis dr. sandhya.
Anthony Shieh: intensive chemotherapy can achieve long term survival in more than half the people with Burkitt lymphoma.
Sandhya Gokavarapu: Prognosis depends on staging. Nevertheless it is good with newer chemo regimes. 80% survival for 3 years is reported. Hich is chemotherapy associated medical complications due to rapid lysis of cancer cells.
Anthony Shieh: Treatments for Burkitt LymphomaIntensive intravenous chemotherapy — which usually involves a hospital stay — is the preferred treatment for Burkitt lymphoma. Because Burkitt lymphoma can spread to the fluid surrounding the brain and spinal cord, chemotherapy drugs also may be injected directly into the cerebrospinal fluid, a treatment known as intrathecal chemotherapy. Examples of drugs that may be used in various combinations for Burkitt lymphoma include:cyclophosphamide (Cytoxan)cytarabine (Cytosar-U, Tarabine PFS)doxorubicin (Adriamycin)etoposide (Etopophos, Toposar, VePesid)methotrexate (Rheumatrex)vincristine (Oncovin) Other treatments for Burkitt lymphoma may include intensive chemotherapy in combination with:Rituximab (Rituxan), a monoclonal antibody that sticks to proteins on cancer cells and stimulates the immune system to attack cancer cellsAutologous stem cell transplantation, in which the patient’s stem cells are removed, stored, and returned to the bodyRadiation therapySteroid therapyIn some cases, surgery may be needed to remove parts of the intestine that are blocked, bleeding, or have ruptured.Prognosis for Burkitt LymphomaBurkitt lymphoma is fatal if left untreated. In children, prompt intensive chemotherapy usually cures Burkitt lymphoma, leading to long-term survival rates of 60% to 90%. In adult patients, results are more variable. Overall, prompt treatment is associated with long-term survival rates of 70% to 80%.
Noushad Ali: Anthony Shieh..well explained doc..thanks
Naseer Jahan: burkits lymohoma
Virendra Kumar: i got the answer…. i will surely get univerdiy rank
Virendra Kumar: University rank
Sekhar Reddy: Over the last few years tremendous advances in the management of lymphomas in general, by chemotherapy. Must have been the case with Burkits lymphoma too ( only assuming). Dr sridhar, You need a good medical oncologist.
Manthru Naik Ramavath: round cell variant of ewings sarcoma
Sridhar Reddy Arumalla: he is taking treatment from medical oncologist, his condition is improving now. right now he is hospitalised and undergoing chemotherapy. i will upload the latest pics within two days.
Zameer Ahamed: Treatment may be dose-adjusted EPOCH with Rituxan (rituximab)[13] or the modified Magrath regimen (R-CODOX-M/IVAC).[14]The effects of the chemotherapy, as with all cancers, depend on the time of diagnosis. With faster growing cancers, such as Burkitt’s, the cancer actually responds faster than with slower growing cancers. This rapid response to chemotherapy can be hazardous to the patient, as a phenomenon called “tumor lysis syndrome” could occur. Close monitoring of the patient and adequate hydration is essential during the process.Chemotherapycyclophosphamidedoxorubicinvincristinemethotrexatecytarabineifosfamideetoposiderituximab[15]Other treatments are immunotherapy, bone marrow transplants, stem cell transplant, surgery to remove the tumor, and radiotherapy.
Zameer Ahamed: Currently Burkitt’s lymphoma can be divided into three main clinical variants: the endemic, the sporadic and the immunodeficiency-associated variants.The endemic variant occurs in equatorial Africa. It is the most common malignancy of children in this area. Children affected with the disease often also had chronic malaria, which is believed to have reduced resistance to Epstein-Barr virus (EBV), allowing it to take hold. The disease characteristically involves the jaw or other facial bone, distal ileum, cecum, ovaries, kidney or the breast.The sporadic type of Burkitt lymphoma (also known as “non-African”) is another form of non-Hodgkin lymphoma found outside of Africa. The tumor cells have a similar appearance to the cancer cells of classical African or endemic Burkitt lymphoma. Sporadic lymphomas are rarely associated with the Epstein-Barr virus. [3] Non-Hodgkin lymphoma, which includes Burkitt’s, accounts for 30-50% of childhood lymphoma. The jaw is less commonly involved, compared to the endemic variant. The ileo-cecal region is the common site of involvement.Immunodeficiency-associated Burkitt lymphoma is usually associated with HIV infection[4] or occurs in the setting of post-transplant patients who are taking immunosuppressive drugs. Burkitt lymphoma can be one of the diseases associated with the initial manifestation of AIDS.By morphology (i.e. microscopic appearance) orimmunophenotype, it is almost impossible to differentiate these three clinical variants. Immunodeficiency-associated Burkitt lymphoma may demonstrate more plasmacytic appearance or more pleomorphism, but these features are not specific.
Zameer Ahamed: All types of Burkitt’s lymphoma are characterized by disregulation of the c-myc gene by one of three chromosomal translocations.[8] This gene is found at 8q24.The most common variant is t(8;14)(q24;q32), which accounts for approximately 85%[8] of cases. This involves c-myc and IGH@. A variant of this, a three-way translocation, t(8;14;18), has also been identified.[9]A rare variant is at t(2;8)(p12;q24).[10] This involves IGK@ and c-myc.Another rare variant is t(8;22)(q24;q11).[10] This involves IGL@ and c-myc.Combined, the two less-common translocations, t(2;8)(p12;q24) and t(8;22)(q24;q11), account for the remaining 15% of cases not due to the t(8;14)(q24;q32) translocation.[8]
Zameer Ahamed: Unique genetic alterations promote cell survival in Burkitt lymphoma, distinct from other types of lymphoma.[11] These TCF3 and ID3 gene mutations in Burkitt correspond to a cell survival pathway that may be found to be amenable to targeted therapy.[12]
Zameer Ahamed: The tumor consists of sheets of a monotonous (i.e. similar in size and morphology) population of medium size lymphoid cells with high proliferative activity and apoptotic activity. The “starry sky” appearance seen[6] under low power is due to scattered tingible body-laden macrophages (macrophages containing dead body of apoptotic tumor cells). The old descriptive term of “small non-cleaved cell” is misleading. The tumor cells are mostly medium in size (i.e. tumor nuclei size similar to that of histiocytes or endothelial cells). “Small non-cleaved cells” are compared to “large non-cleaved cells” of normal germinal center lymphocytes. Tumor cells possess small amount of basophilic cytoplasm. The cellular outline usually appears squared off.
Zameer Ahamed: Tussi great ho Boss! its a great achievement to examine, investgate and diagnosis of such cases.best part is refreshing all by sharing it.
Bharath Vardhana: Sir,Rituxan is an effective drug against for B.L. A Medical Oncologist wd be best to dcd. The best part as Dr Zameer Ahmd mentioned is a refresher we had bec of ur post. Thank You.:)
Nripjeet Singh Anand: How is the patient coping up ? Is he responding well to chemotherapy ?
Nripjeet Singh Anand: Ramayan khatam ho gayi,you are asking who Ram is ?Read all the posts before asking questions.