PMC9352367_01
A - initial panoramic radiography made for diagnosis of the pain in 26, 27 and 37 in 2017 showing alveolar bone loss in the region of 26 and 27, and element 37 with abnormal shape and presence of radiolucent image around; B - a panoramic made for follow the healing of the alveolus, 10 months after tooth extraction of 37, showing an alveolar bone repair; C - panoramic radiography made in 2020 after the complained of bleeding, showing an irregular and diffuse radiolucent area in the posterior region of the mandible; D - CT of the head, in axial section showing ill-defined hypodense area in alveolar process of the left mandible in the region of 37 tooth, with rupture of the cortical bone and bone sequestration areas.
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Due to the risk of ORN development, the patient maintained semiannual appointments to monitor the complete healing of the alveolus. (Figure 1A-B). Panoramic radiography was performed and revealed diffuse and undefined radiolucency in the posterior region of the mandible (Figure 1C). Computed tomography (CT) scan of the area showed a hypodense structure in the alveolar process of the left mandible in the region of the mandibular left permanent second molar (Figure 1D).
A and B - Histopathology showing a well-differentiated SCC (H&E, 40X).
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The histopathologic report showed a well-differentiated SCC of 1.8 x 1.8 cm, with an infiltration depth of 0.8 cm and infiltration in the lingual nerve (Figure 2A and 2B).
A-C Photography of follow-up 5 months after surgery; D - panoramic radiography made after the segmental mandibulectomy showing the reconstruction of the mandible.
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The patient was submitted to new radiotherapy (IMRT technique) with 5 fractions, totalizing 2500cGy in the tumor area, and maintained monthly follow-up, free of new lesions. (Figure 3A-D).
CT of the head, in axial section showing a poorly delimited lesion located in the left masticatory space/flap margins, with gaseous foci intermingling, with apparent extension to the skin of the malar region, pterygoid plate, nasopharynx, soft palate, carotid space, deep portion of the left parotid (red brackets), a diffuse change in the bone texture of the distal left mandibular stump/coronoid process, with bone erosions with cortical rupture (yellow arrow), and lymph node enlargement in the cervical and paratracheal region, favoring the diagnosis of locoregional recurrence and tumor site infection.
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The CT scan showed an expansive lesion in the left masticatory space and lower cervical lymph nodes that were also suspected of secondary neoplastic involvement (Figure 4).