Adenomatoid odontogenic tumour: co-expression of keratin and vimentin

Adenomatoid odontogenic tumor: evidence for a mixed odontogenic tumor

OBJECTIVE

Adenomatoid odontogenic tumor (AOT) was classified by the World Health Organization as a mixed odontogenic tumor in 1992 and reclassified without a clear rationale as an epithelium-only tumor in 2005. The purpose of this study was to investigate if there was any evidence to suggest AOT might be a mixed odontogenic tumor.

STUDY DESIGN

Immunohistochemical studies with nestin, dentin sialophosphoprotein (DSPP), cytokeratin, and vimentin were performed using 21 cases of AOT, and the staining results were analyzed according to the various morphologic patterns seen in AOT. Sirius red stain was used to detect the presence of collagen types I and III in AOT products.

RESULTS

Our results showed that 20 of 21 (95.23%), 0 of 21 (0%), 21 of 21 (100%), and 20 of 21 (95.23%) cases expressed nestin, DSPP, cytokeratin, and vimentin, respectively. Some cells in rosette/duct-like structures (RDSs) expressed nestin, vimentin, or both, without cytokeratin. Coexpression of vimentin and cytokeratin or of nestin, cytokeratin, and vimentin was noted in some cells. Sirius red staining was positive in eosinophilic products in RDSs, double-layered spheres, and dentinoids.

CONCLUSION

Although most AOT cells appear epithelial, there is a small population of cells expressing mesenchymal proteins and secreting collagen types I and III. This evidence suggests that AOT is a mixed odontogenic tumor.

Adenomatoid Odontogenic Tumor of the Maxilla in a 13-year-old Patient: A Rare Case Report with a Review of Literature

Background

The AOT is an atypical tumor of odontogenic origin that comprises about 0.1% of jaw tumors and cysts as well as up to 3% of odontogenic tumors (OTs).

Aim and objective

This review describes the clinical, radiographical, histopathological, and immunohistochemical properties of adenomatoid odontogenic tumor (AOT) and reports an occurrence of an AOT in a boy, 13 years of age.

Case description

A male, 13 years of age, presented with a swelling with respect to the left maxilla, painless, and with obvious facial asymmetry. The orthopantomogram and computed tomography scan revealed a large unilocular radiolucency in the left maxilla with permanent lateral incisor embedded within the lesion and permanent canine pushed away from its normal position. After complete enucleation of the cyst under local anesthesia and extraction of associated impacted permanent teeth and retained deciduous teeth related to the lesion, the defect was filled with a bone graft and closed. Postoperative follow-up was uneventful.

Conclusion

An accurate diagnosis should be established through clinical, radiographical, and pathological correlations in order to be able to differentiate AOT from other conditions for early diagnosis.

Clinical significance

This report highlights the salient features of the AOT to be able to correctly diagnose and manage the lesion.

How to cite this article

Kamble A, Shimpi MR, Dash JK, et al. Adenomatoid Odontogenic Tumor of the Maxilla in a 13-year-old Patient: A Rare Case Report with a Review of Literature. Int J Clin Pediatr Dent 2021;14(4):596–600.

Expression of CK14 and vimentin in adenomatoid odontogenic tumor and dentigerous cyst

Background:

Origin of adenomatoid odontogenic tumor (AOT) has long been a controversy, and the issue of it being a neoplasm or hamartoma was a subject of debate for a long time. Earlier it was grouped under a mixed group of odontogenic tumors considering the varying degrees of inductive changes. Recently, the WHO classification states that the presence of hard tissue within AOT was not due to induction but was rather a metaplastically produced mineralization and hence the tumor was reclassified under a group of tumors arising from odontogenic epithelium. This study is an attempt to identify if both epithelial (cytokeratin 14 [CK14]) and mesenchymal (vimentin) markers are expressed in the follicular and extrafollicular variants of AOT and to compare the expression with dentigerous cyst (DC) as this cyst is known to arise from reduced enamel epithelium which expressed CK14. This is done to possibly relate the origin of AOT with reduced enamel epithelium.

Aims and Objectives:

To study, analyze and correlate the expression of CK14 and vimentin in AOT and DC.

Materials and Methods:

Retrospective study on paraffin embedded tissues. Sixteen cases of AOT and 15 cases of DC were retrieved from the departmental archives and subjected to CK14 and vimentin immunostaining.

Statistical Methods:

Measures of central tendency was used to analyze the results.

Results and Observations:

Ninety percent of cases of follicular AOT (FAOT) and 100% cases of extra-follicular AOTs (EAOTs) showed positivity for CK14 and all cases of DC showed positivity for CK14. Vimentin was positive in 44% and negative in 56% cases of both FAOT and EAOT taken together.

Conclusion:

The CK14 expression profile in AOT and DC supports its odontogenic epithelial specific nature. The possible role of reduced enamel epithelium and dental lamina in histogenesis of AOT and DC is strongly evident by their CK14 expression pattern.

Maxillary adenomatoid odontogenic tumor associated with a premolar

The adenomatoid odontogenic tumor (AOT) represents 3-7% of all odontogenic tumors, and over 750 cases have been reported in the literature. This lesion was formerly considered to be a variant of the ameloblastoma and was designated as adenoameloblastoma. These lesions may infrequently produce dentinoid material and rarely enamel matrix. Consequently, the WHO (2005) classification of odontogenic lesions considered this process to represent a mixed odontogenic neoplasm. We present a case of a 12-year-old female patient with an AOT of diameter 5 cm × 5 cm located in the anterolateral region of the maxilla in association with an impacted premolar tooth. The rarity of AOT, association of this lesion with regards to maxillary premolar, the exaggerated size at presentation, the eruption of the displaced canine postoperatively and uneventful healing of the bony defect without adjunctive therapy makes this case unique.

Study on the origin and nature of the adenomatoid odontogenic tumor by immunohistochemistry

The adenomatoid odontogenic tumor (AOT) is a clinically benign lesion. Discussions about the AOT hamartomatous or neoplastic nature, and the probable odontogenic epithelial cell it originates from still exist. This research aimed to study and discuss the subject by the immunohistochemical detection of cytokeratins, laminin, collagen IV, PCNA and p53 in 8 tumor samples and 8 dental follicle samples containing reduced enamel epithelium. The results have shown that CK14 labelling indicated differentiation grades for secreting ameloblasts or ameloblasts in the post-secreting stage in the adenomatoid structure of AOT. Laminin, found on the luminal surface of adenomatoid structures, was compatible with the reduced enamel epithelium during the "protective stage of amelogenesis". PCNA specifically labelled the spindled areas and peripheral cords of the AOT, indicating that these areas are responsible for tumor growth. After considerations about pathogenesis, the authors suggested that the nature of AOT is hamartomatous with histogenesis from the reduced enamel epithelium.

Nestin expression in odontoblasts and odontogenic ectomesenchymal tissue of odontogenic tumours

BACKGROUND

Nestin, one of the intermediate filaments constituting the cytoskeleton, is a marker of neural stem cells or progenitor cells. Its expression is also related to tooth development and repair of dentine.

AIMS

The aim of this study was to investigate nestin expression in various odontogenic tumours and evaluate its usefulness for histopathological diagnosis.

METHODS

We studied formalin fixed, paraffin embedded specimens from 129 cases of odontogenic tumours and 9 of mandibular intraosseous myxoma. After characterisation of odontogenic ectomesenchymal tissues in these tumours using antibodies to vimentin, desmin, neurofilament, and glial fibrillary acidic protein, we immunohistochemically examined nestin expression.

RESULTS

No differentiation towards muscle and nervous tissues was found in the odontogenic ectomesenchymal tissues. Although almost all the ameloblastomas and malignant ameloblastomas were negative for nestin, odontogenic ectomesenchyme in the odontogenic mixed tumours demonstrated nestin immunolocalisation, particularly in the region adjacent to the odontogenic epithelium. Odontoblasts and their processes, pulp cells near the positive odontoblasts, and flat cells adhering to the dentine showed immunoreaction with nestin in the odontomas and odontoma-like component in the ameloblastic fibro-odontomas. Neoplastic cells in almost half cases of jaw myxoma and one case of odontogenic fibroma expressed nestin.

CONCLUSIONS

The distribution of nestin in the odontogenic mixed tumours suggests that nestin expression in the odontogenic ectomesenchyme is upregulated by stimulation from odontogenic epithelium. In addition, nestin may also be involved in the differentiation from pulp cells to odontoblasts in odontogenic tumours. Therefore, nestin is a useful marker for the odontogenic ectomesenchyme and odontoblasts in odontogenic tumours. Nestin, one of the intermediate filaments constituting the cytoskeleton, is a marker of neural stem cells or progenitor cells. Its expression is also related to tooth development and repair of dentine.

Clinicopathological and immunohistochemical study of 39 cases of Adenomatoid Odontogenic Tumour: a multicentric study

Adenomatoid Odontogenic Tumour (AOT) is a relatively uncommon odontogenic lesion and few studies describing its cytokeratin profile have been reported in the English-language literature. Thirty-nine cases of AOT from three Oral Diagnosis services (Brazil, Mexico and Guatemala) were studied, considering their clinical, radiographic, and histological features and immunohistochemical expression of cytokeratins (AE1/AE3, 34betaE12, CK1, CK5, CK6, CK7, CK8, CK10, CK13, CK14, CK16, CK18, and CK19), vimentin and Ki-67. Sixty five percent of cases affected women, anterior maxilla was the preferred site and radiographically most cases showed unilocular radiolucency with well defined sclerotic borders. Calcifying epithelial odontogenic tumour (CEOT)-like areas were found in 36 out of 39 cases, and 10 cases showed positivity for Congo red in polarized light. All cases were positive for AE1/AE3, 34betaE12, CK5, CK14 and CK19. CEOT-like areas were negative for CK 19. Vimentin was also expressed in 27 cases and this profile may indicate the existence of a variable phenotype in certain areas of the tumour. There were no recurrences after surgical treatment, and this can be related to the low proliferative activity observed in all cases with Ki-67 marker.

A case of multiple AOT-like jawbone lesions in a young patient--a new odontogenic entity?

We assessed the immunohistochemical profile of an unusual case of multiple similarly looking tumors in the jawbone of a young patient. Histologically, the tumors exhibited features of adenomatoid odontogenic tumor (AOT) and adenomatoid dentinoma but showed no resemblance to any other defined odontogenic tumor entities. They expressed high amounts of cytokeratin (CK) 8 and 14 together with some Vimentin. A small rim of peripheral cells showed CK 5, 17, and 19 reactivity. Also, these lesions expressed some bcl-2 as well as p53 and Ki67. Histologically and immunohistochemically, the unusual multiple lesions differed in details from a simultaneously examined group of 24 classical AOT cases, suggesting that they may represent a hitherto less well-defined odontogenic tumor entity.

Cytokeratins in epithelia of odontogenic neoplasms

Neoplasms and tumours related to the odontogenic apparatus may be composed only of epithelial tissue or epithelial tissue associated with odontogenic ectomesenchyme. The immunohistochemical detection of different cytokeratins (CKs) polypeptides and vimentin has made it easier to explain the histogenesis of many epithelial diseases. The present study aimed to describe the immunohistochemical expression of cytokeratins 7, 8, 10, 13, 14, 18, 19 and vimentin in the epithelial components of the dental germ and of five types of odontogenic tumours. The results were compared and histogenesis discussed. All cells of the dental germ were positive for CK14, except for the preameloblasts and secreting ameloblasts, in which CK14 was gradually replaced by CK19. CK7 was especially expressed in the cells of the Hertwig root sheath and the stellate reticulum. The dental lamina was the only structure to express CK13. The reduced epithelium of the enamel organ contained CK14 and occasionally CK13. Cells similar to the stellate reticulum, present in the ameloblastoma and in the ameloblastic fibroma, were positive for CK13, which indicates a nature other than that of the stellate reticulum of the normal dental germ. The expression of CK14 and the ultrastructural aspects of the adenomatoid odontogenic tumour probably indicated its origin in the reduced dental epithelium. Calcifying odontogenic epithelial tumour is thought to be composed of primordial cells due to the expression of vimentin. Odontomas exhibited an immunohistochemical profile similar to that of the dental germ. In conclusion, the typical IF of odontogenic epithelium was CK14, while CK8, 10 and 18 were absent. Cytokeratins 13 and 19 labelled squamous differentiation or epithelial cells near the surface epithelium, and CK7 had variable expression.

Amelogenin-cytokeratin 14 interaction in ameloblasts during enamel formation

The enamel protein amelogenin binds to the GlcNAc-mimicking peptide (GMp) (Ravindranath, R. M. H., Tam, W., Nguyen, P., and Fincham, A. G. (2000) J. Biol. Chem. 275, 39654-39661). The GMp motif is found in the N-terminal region of CK14, a differentiation marker for ameloblasts. The binding affinity of CK14 and amelogenin was confirmed by dosimetric binding of CK14 to recombinant amelogenin (rM179), and to the tyrosine-rich amelogenin polypeptide. The specific binding site for CK14 was identified in the amelogenin trityrosyl motif peptide (ATMP) of tyrosine-rich amelogenin polypeptide and specific interaction between CK14 and [(3)H]ATMP was confirmed by Scatchard analysis. Blocking rM179 with GlcNAc, GMp, or CK14 with ATMP abrogates the CK14-amelogenin interaction. CK14 failed to bind to ATMP when the third proline was substituted with threonine, as in some cases of human X-linked amelogenesis imperfecta or when tyrosyl residues were substituted with phenylalanine. Morphometry of developing teeth distinguished three phases of enamel formation; growth initiation phase (days 0-1), prolific growth phase (days 1-7), and growth cessation phase (post-day 7). Confocal microscopy revealed co-assembly of CK14/amelogenin in the perinuclear region of ameloblasts on day 0, migration of the co-assembled CK14/amelogenin to the apical region of the ameloblasts from day 1, reaching a peak on days 3-5, and a collapse of the co-assembly. Autoradiography with [(3)H]ATMP and [(3)H]GMp corroborated the dissociation of the co-assembly at the ameloblast Tomes' process. It is proposed that CK14 play a chaperon role for nascent amelogenin polypeptide during amelogenesis.

Aberrant gene expression in epithelial cells of mixed odontogenic tumors

Comparative investigations of odontogenic cells in normally forming teeth and tumors may provide insights into the mechanisms of the differentiation process. The present study is devoted to late phenotypic markers of ameloblast and odontoblast cells, i.e., proteins involved in biomineralization. The in situ expression of amelogenins, keratins, collagens type III and IV, vimentin, fibronectin, osteonectin, and osteocalcin was performed on normal and tumor odontogenic human cells. The pattern of protein expression showed some similarities between ameloblasts and odontoblasts present in normally developing human teeth and cells present in neoplastic tissues of ameloblastic fibroma, ameloblastic fibro-odontomas, and complex odontomas. Amelogenins (for ameloblasts) and osteocalcin (for odontoblasts) were detected in cells with well-organized enamel and dentin, respectively. In contrast, "mixed" cells located in epithelial zones of mixed odontogenic tumors co-expressed amelogenins and osteocalcin, as shown by immunostaining. The presence of osteocalcin transcripts was also demonstrated by in situ hybridization in these cells. Keratins and vimentin were detected in the same epithelial zones. Tumor epithelial cells were associated with various amounts of polymorphic matrix (amelogenin- and osteocalcin-immunoreactive), depending on the types of mixed tumors. No osteocalcin labeling was found in epithelial tumors. This study confirms that the differentiation of normal and tumor odontogenic cells is accompanied by the expression of some common molecules. Furthermore, the gene products present in normal mesenchymal cells were also shown in odontogenic tumor epithelium. These data may be related to a tumor-specific overexpression of the corresponding genes transcribed at an undetectable level during normal development and/or to an epithelial-mesenchymal transition proposed to occur during normal root formation. A plausible explanation for the results is that the odontogenic tumor epithelial cells are recapitulating genetic programs expressed during normal odontogenesis, but the tumor cells demonstrate abnormal expression patterns for these genes.

Immunohistochemical observations on a possible ameloblastic fibro-odontoma

An ameloblastic fibro-odontoma which occurred in the mandible of a 3-year-old Japanese boy is reported together with immunohistochemical findings. Histologically, the tumor consisted of an ameloblastic fibroma-like area and some typical complex odontoma-like areas. The epithelial islands in the ameloblastic fibroma-like area showed different developmental stages of the epithelial-connective tissue interface. Immunohistochemical examination revealed that all epithelial components in the ameloblastic fibroma-like area showed expression of CK 8, CKs 13, 16, CK 14, CK 18 and CK 19, and coexpression of these cytokeratins and vimentin. These findings suggest that even the epithelial component without obvious epithelial-mesenchymal induction showed the final cell differentiation of the enamel organ with the potential for epithelial-mesenchymal induction.

'Combined ameloblastoma and odontogenic keratocyst' or 'keratinising ameloblastoma'

Four cases of either combined occurrence of ameloblastoma and odontogenic keratocyst or a rare keratinising variant of ameloblastoma are presented. The cardinal histomorphologic characteristics are simultaneous occurrence of ameloblastomatous epithelial islands with central keratinisation and multiple keratinising cysts. Immunohistochemically the tumour elements were keratin positive and occasionally S-100 protein and desmin positive. Major differential diagnosis of these neoplasms are discussed.

Immunohistochemical expression of amelogenins in odontogenic epithelial tumours and cysts

Amelogenins, enamel proteins in odontogenic tumours, were detected immunohistochemically using a monoclonal antibody. They were strongly expressed in amyloid-like material, ghost cells, and the cells surrounding ghost cells of calcifying epithelial odontogenic tumours and cysts, whereas calcified bodies within the tumours and cysts showed negative staining. The expression of amelogenins was also positive in tumour cells of ameloblastoma, adenomatoid odontogenic tumour, squamous odontogenic tumour and ameloblastic fibroma. Peripheral tumour cells of the follicular ameloblastoma were positive with relatively intense staining. Undifferentiated or flattened tumour cells of adenomatoid odontogenic tumour and non-keratinized tumour cells of the squamous odontogenic tumour showed marked staining. Reduced ameloblasts in the odontoma displayed the strongest staining for amelogenins. The study suggests that biosynthesis of amelogenins may occur in the homogeneous materials of calcifying epithelial odontogenic tumours and cysts.

The combined epithelial odontogenic tumour in Malaysians

The combined epithelial odontogenic tumour represents a hybrid lesion comprising primarily areas of adenomatoid odontogenic tumour intermixed with foci of calcifying epithelial odontogenic tumour. Five such cases retrieved from the files of the Division of Stomatology, Institute for Medical Research, Kuala Lumpur, and four others from the existing literature were analysed. A mean age of 18.8 years, a female preponderance (66.7%) with a male to female ratio of 1:2 and predilection for the mandible (55.6%) were observed. All cases were treated by conservative surgery and the lack of recurrence confirmed the innocuous nature of this lesion.

Adenomatoid odontogenic tumor: biologic profile based on 499 cases

Topographically, the AOT occurs in peripheral and central variants, the latter further in follicular (with embedded tooth) and extrafollicular (no embedded tooth) types. The AOT is slow growing with few or no symptoms. Tumor growth may cause displacement of teeth rather than root resorption. The follicular AOT mimics a follicular cyst, the extrafollicular a residual or "globulo-maxillary" cyst and the peripheral a gingival fibroma. All variants of AOT show identical histologic features. The central variants account for 97.2%, 73.0% of which are follicular. The follicular variant (M:F ratio 1 to 1.9) is three times as frequent as the extrafollicular. The follicular variant is diagnosed earlier in life (mean age 17 yr) than the extrafollicular (mean age 24 yr). 53.1% of all variants occur within the teens (13-19 yr). Follicular AOT is associated with one embedded tooth in 93.2%. Maxillary permanent canines account for 41.7% and all four canines for 60.1% of AOT-associated embedded teeth. Ranking four among the odontogenic tumors the AOT is not a particularly rare tumor. Conservative surgical excision is the treatment of choice. Documented recurrences have not been reported.

Regulation of vimentin expression in cultured human mammary epithelial cells

Using five different monoclonal antibodies to vimentin, we have examined the expression of vimentin in cryostat sections and serum-free cultures of normal human breast tissue. In cryostat sections, myoepithelial cells as well as stromal cells showed immunoreactivity to vimentin, irrespective of the antibody used. In contrast, luminal epithelial cells were negative for vimentin, but positive for keratin K18. In culture, myoepithelial cells showed immunoreactivity to vimentin from their first appearance in monolayer. Moreover, a fraction of luminal epithelial cells expressed vimentin in addition to keratin K18. We found a clear, reversible correlation between proliferation, determined by incorporation of [3H]-TdR, and induction of vimentin in the luminal epithelial cells. Thus, in growth-stimulated cultures on a medium containing cholera toxin (CT), epidermal growth factor (EGF), transferrin (Tf), hydrocortisone (H) and insulin (I), the fraction of vimentin-positive luminal epithelial cells increased, while it decreased within 14 days from approximately 36% to 3% on a medium containing CT and EGF, only. We therefore conclude: (1) vimentin is constantly expressed in myoepithelial cells in situ and in vitro, and (2) expression of vimentin in luminal epithelial cells in vitro is not a result of monolayer cultivation as such, but rather associated with the increased growth rate seen in culture.

Calcifying odontogenic cysts: co-expression of intermediate filament proteins, and immunohistochemical distribution of keratins, involucrin, and filaggrin

The epithelia lining the cyst of five cases of calcifying odontogenic cyst (COC) were evaluated immunohistochemically with the use of monoclonal antibodies (MoAb's) against keratin (PKK1, KL1, K4.62, K8.12) and vimentin, and polyclonal antisera agonist involucrin and filaggrin. Epithelial lining of COC was classified into 1) thin squamous-cell epithelium, 2) ameloblastoma-like, and 3) thin or 4) thick calcifying odontogenic epithelium. Foci consisting of ghost cells or calcified cells were categorized as calcifying epithelial odontogenic tumor (CEOT). Thin squamous-cell epithelium reacted with PKK1, KL1, K4.62, K8.12, and anti-vimentin MoAb's, thus demonstrating the co-expression of keratin and vimentin. Ameloblastoma-like cells showed positive staining with PKK1, KL1, and sometimes with anti-vimentin. Thick calcifying odontogenic epithelial lining showed stratification of cell layers, and the most strikingly reactive zone was the upper intermediate layer, which showed the presence of keratin, involucrin, and a small amount of filaggrin. Cells of this layer might be the most differentiated type of cells in COC. Undifferentiated odontogenic cells of COC masses were characterized by co-expression of keratin and vimentin, and by the absence of involucrin and filaggrin. All ghost cells were devoid of any immunostaining except for filaggrin, which was rarely positive, but eosinophilic or basophilic cells surrounding the ghost cells showed intense staining for all keratin proteins except vimentin.

Distribution of intermediate-filament proteins in the human enamel organ: unusually complex pattern of coexpression of cytokeratin polypeptides and vimentin

We applied immunohistochemical techniques and gel electrophoresis to examine the distribution of intermediate filaments in human fetal oral epithelium and the epithelia of the human enamel organ. Both methods demonstrated that human enamel epithelia contain cytokeratins 5, 14, and 17, which are typical of the basal cells of stratified epithelia, as well as smaller quantities of cytokeratins 7, 8, 19, and in trace amounts 18, which are characteristic components of simple epithelial cells. In the external enamel epithelium and stellate-reticulum cells, most of these components appeared to be simultaneously expressed. In contrast, the parental oral epithelium was negative for cytokeratin 7, thus indicating possible "neoexpression" during the course of tooth formation. Immunohistochemical procedures using various monoclonal antibodies against vimentin revealed the transient coexpression of vimentin and cytokeratins in the external enamel epithelium and in stellate-reticulum cells during enamel development. The significance of the coexpression of cytokeratins and vimentin is discussed in relation to previous findings obtained in other normal tissues and in the light of the functional processes characteristic of these epithelia.