CASE 1
A 56-year-old female with no significant past medical history presented to an endodontic office for evaluation of a lingual swelling in the lower right quadrant . Teeth # 28-30 were previously root canal treated . The patient was subsequently referred to an oral and maxillofacial surgeon for further evaluation and biopsy . Examination revealed Class III tooth mobility and right mandibular lingual swelling , without purulence . A cone beam computed tomography scan ( CBCT ) ( Figure 1 ) showed an irregular , poorly demarcated , radiolucent lesion extending from tooth # 23 area to the mesial aspect of tooth # 29 , and confirmed previous endodontic therapy . Well-defined radiopacities are noted apical to teeth # 30 and 31 , and are most consistent with florid cemento-osseous dysplasia . An incisional biopsy was performed under local anesthesia and the specimen was sent for microscopic examination .
The biopsy revealed diffuse large B-cell lymphoma , germinal center phenotype . The patient was subsequently referred to hematology and oncology for management . Advanced imaging revealed no evidence of distant metastases . A bone marrow biopsy was normal with no evidence of lymphoma .
The patient subsequently underwent six cycles of R-CHOP therapy to treat the lymphoma ( rituximab , cyclophosphamide , doxorubicin , vincristine , prednisone ). The patient tolerated the chemotherapy well , and a positron emission tomography / computed tomography ( PET / CT ) showed no evidence of lymphoma at other sites . On follow-up with oral surgery , there was full resolution of the right mandibular mass . The patient will follow-up with hematology / oncology for physical examination and blood work every three months for two years , with computerized axial tomography ( CAT ) scans performed every six months .
FIGURE 1 |
[ Figure 1 : Axial image showing a blending radiolucency extending from the mesial of tooth # 29 to the # 23 area with thinning and resorption of the labial and lingual cortices .] |
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FIGURE 2 |
[ Figure 2 : Irregular radiolucency extending interproximally from the mesial of root canal treated teeth # 29 to the # 27 area . Blunting of the root apices is seen . Radiopacities are noted apical to root canal filled teeth # 30 and # 31 , which are most consistent with florid cemento-osseous dysplasia .] |
CASE 2
A 72-year-old male presented to an oral surgery office with a two-month history of a 3.5 x 3.0 cm , soft , expansile lesion of the entire right hard palate . The patient also had a contralateral cutaneous face rash . The patient ’ s past medical history was significant for chronic lymphocytic leukemia ( CLL ) over a decade ago . Previously , a small-volume CBCT was taken in an endodontic office ( Figure 3 ), and an unimpressive ( 3mm ) periapical lesion was noted associated with tooth # 3 . Tooth # 3 was treated with conventional endodontic therapy . Upon accessing the tooth , pulpal necrosis was confirmed . However , root canal therapy did not resolve the palatal swelling , rather it progressed and subsequently , an incisional biopsy of the palatal lesion was performed by an oral surgeon promptly upon referral .
Surprisingly , the lesion was characterized as chronic lymphocytic leukemia / small lymphocytic lymphoma . The patient subsequently underwent bone marrow biopsy and examination of the cerebrospinal fluid for evidence of malignancy . The cerebrospinal fluid was negative for
FIGURE 3
Figure 3 : Cone beam computed tomography image showing periapical radiolucencies apical to the palatal and mesiobuccal roots of tooth # 3 . Grafting material is present in the area of tooth # 4 .
malignant cells , while the bone marrow revealed that 30-70 % of the marrow was involved by chronic lymphocytic leukemia / small lymphocytic lymphoma .
The patient was treated with six cycles of venetoclax and obinutuzumab for one year . The patient responded well to treatment . On subsequent oral surgical clinical exam , the oral mucosa exhibited minimal swelling with substantial resolution of the skin rash .
JANUARY / FEBRUARY 2022 | PENNSYLVANIA DENTAL JOURNAL 15