PMC4860916_01
Gingival lesion at first evaluation. Note, the mandibular gingival recession bounded between right central incisor and first left premolar
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F1
The growth site was associted with gingival recession (Miller's Class III) [Figure 1].
Radiographic findings. Optical projection tomography: Radiolucency was appreciable between the left mandibular canine and first premolar teeth (arrow)
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F2
No signs of radiographic root resorption were detected [Figures 2 and 3].
(a) Computed tomography scan (occlusal view) showing buccal cortical bone loss. (b) Computed tomography showing buccal cortical bone loss
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F3
No signs of radiographic root resorption were detected [Figures 2 and 3].
(a) Proliferation of ovoid and fusiform epithelioid cells with nuclear and cellular pleomorphism arranged in nests and cords forming small vascular channels (H&E stain, x100). (b) The Ki-67 index was 20% (IHC stain, x100). The neoplastic cells were positive for (c): CD31 in both stromal and endothelial cells (IHC stain, x100) and (d): CD34 (IHC stain, x100)
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F4
The lesion exhibited small vascular channels with a moderate cellular inflammatory infiltrate, composed mainly of lymphocytes, plasma cells and eosinophils surrounding the vessels [Figure 4]. Thus, a diagnosis of MEH was made [Figure 4].
(a-d) Surgical excision and reconstruction of the mandible with an iliac crest bone graft
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F5
Mandibular reconstruction and stabilization were obtained by an iliac bone crest graft fixed with titanium reconstruction plates and screws [Figure 5].
Radiographic findings 4 years after bone reconstruction
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F6
The entire follow-up period was 46 months [Figure 6].
Involvement of bone and mucosa by the malignant cells (a) H&E stain, x40, (b) H&E stain, x400. Cells positive for (c) Ki-67 (IHC stain, x200) and (d) CD 31 (IHC stain, x100). (e) lymph node metastases (H&E stain, x40)
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F7
After ultrasonography and computed tomography, a bilateral selective neck dissection was performed and those nodes at levels 1-3 were excised; in addition, the submandibular glands were removed bilaterally with all associated nodes [Figure 7].