Secondary primary tumor mimicking osteoradionecrosis

Nasopharyngeal carcinoma (NPC) is a malignant tumor rarely found in the head and neck, representing about 1% of all malignancies. The main treatment for NPC is radiation therapy, which is often given in combination with chemotherapy. However, such treatment may lead to long‐term complications, including second primary tumors (SPTs) and osteoradionecrosis (ORN). Both complications have similar radiological characteristics, which can lead to erroneous diagnoses. This paper describes a case of a second primary tumor in a patient after 20 years of radiotherapy in the area where a previous extraction was performed, mimicking an osteoradionecrosis process.

Keywords:
Nasopharyngeal carcinoma; second primary neoplasms; squamous cell carcinoma of head and neck; osteoradionecrosis; case reports

Authorship

Giovanna Lopes Carvalho

A.C. Camargo Cancer Center, Departamento de Estomatologia, São Paulo, SP, BrasilA.C. Camargo Cancer CenterBrasilSão Paulo, SP, BrasilA.C. Camargo Cancer Center, Departamento de Estomatologia, São Paulo, SP, Brasil

http://orcid.org/0000-0001-9940-5590

Daniele Heguedusch

http://orcid.org/0000-0001-8902-8090

Antônio Cássio Assis Pellizzon

A. C. Camargo Cancer Center, Departamento de Radioterapia, São Paulo, BrasilA. C. Camargo Cancer CenterBrasilSão Paulo, BrasilA. C. Camargo Cancer Center, Departamento de Radioterapia, São Paulo, Brasil

http://orcid.org/0000-0001-7503-6751

Renan Bezerra Lira

A.C. Camargo Cancer Center, Departamento de Cirurgia de Cabeça e Pescoço e Otorrinolaringologia, São Paulo, SP, Brasil.A.C. Camargo Cancer CenterBrasilSão Paulo, SP, BrasilA.C. Camargo Cancer Center, Departamento de Cirurgia de Cabeça e Pescoço e Otorrinolaringologia, São Paulo, SP, Brasil.

http://orcid.org/0000-0002-1461-9053

Fábio Abreu Alves

http://orcid.org/0000-0003-3372-1536

Graziella Chagas Jaguar

http://orcid.org/0000-0002-8442-3830

Authors’ contributions: Giovanna Lopes Carvalho and Daniele Heguedusch were responsible for the data collection and draft manuscript preparation. Antônio Cássio Assis Pellizzon was responsible for the radiotherapy treatment and critical revision of the article. Renan Bezerra Lira was responsible for the surgical treatment and critical revision of the article. Fábio Abreu Alves was responsible for the data analysis and manuscript review. Graziella Chagas Jaguar was responsible for the study design, data analysis and manuscript review All authors approved the final version of the manuscript.

Conflict of interest: None.

CorrespondenceGraziella Chagas Jaguar A.C. Camargo Cancer Center, Departamento de Estomatologia R: Prof. Antônio Prudente, 211, CEP 01509-900, São Paulo, SP, Brasil Telefone +55 (11) 2189-5129graziellajaguar@gmail.com

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Figures

Figures (4)

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Figure 1
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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Figure 2
A and B – Histopathology showing a well-differentiated SCC (H&E, 40X).

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Figure 3
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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Figure 4
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.

Figure 1 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.

Figure 2 A and B – Histopathology showing a well-differentiated SCC (H&E, 40X).

Figure 3 A-C Photography of follow-up 5 months after surgery; D – panoramic radiography made after the segmental mandibulectomy showing the reconstruction of the mandible.

Figure 4 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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Secondary primary tumor mimicking osteoradionecrosis

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[1] Authors’ contributions: Giovanna Lopes Carvalho and Daniele Heguedusch were responsible for the data collection and draft manuscript preparation. Antônio Cássio Assis Pellizzon was responsible for the radiotherapy treatment and critical revision of the article. Renan Bezerra Lira was responsible for the surgical treatment and critical revision of the article. Fábio Abreu Alves was responsible for the data analysis and manuscript review. Graziella Chagas Jaguar was responsible for the study design, data analysis and manuscript review All authors approved the final version of the manuscript.