The spectrum of gnathic osteosarcoma: caveats for the clinician and the pathologist

Clinical significance of adjuvant therapy after radical surgery for primary osteosarcoma of the jaws

BACKGROUND

Osteosarcoma of the jaw is one of the rare malignancies and the role of postoperative adjuvant therapy is unclear. This study explored the efficacy of adjuvant therapy after radical surgery for primary osteosarcoma of the jaw.

METHODS

The data were retrospectively analyzed from May 2012 to June 2021. The recurrence rate, disease-free survival (DFS) and 5‑year overall survival (OS) rate were calculated by Kaplan-Meier method. Intergroup rates were examined by chi-square test.

RESULTS

125 post-radical surgery patients were included. The median follow-up time was 66 months. Forty five cases suffered recurrence. The recurrence rate was 36.0%, and the 5‑year OS rate was 68.8%. In the adjuvant treatment group, twenty eight of 99 patients experienced disease progression. In the surgical treatment alone group, seventeen of 26 patients experienced disease progression. The recurrence rates in the two groups were 28.3 and 65.4%, respectively (χ2 = 12.303, p < 0.001). The 5‑year OS rate was 75.8 and 42.3%, respectively (χ2 = 10.734, p = 0.001). The median DFS of the relapse patients was 15.1 months (95% CI:13.00-17.20 months), and the 5‑year OS rate was 40.0%. Among them, 28 patients received adjuvant therapy while 17 received surgical treatment alone. The median DFS was 15.7 and 11.5 months, respectively, p = 0.024. The median OS was 69.6 months (95% CI 55.69 ~ 83.51 months) and 62.4 months (95% CI 49.06 ~ 75.74 months), respectively(p = 0.034).

CONCLUSION

Adjuvant therapy is one of the effective measures to reduce the relapse rate and improve OS after radical surgery for primary osteosarcoma of the jaw.

Low-grade osteosarcoma is predominant in gnathic osteosarcomas: A report of seven cases of osteosarcoma of the jaw

OBJECTIVE

Primary osteosarcoma of the jaw bones is very rare, and histological features of gnathic osteosarcoma remain obscure. The purpose of this study was to describe the clinicopathological features of gnathic osteosarcoma.

MATERIALS AND METHODS

Seven cases of gnathic osteosarcoma from Japan diagnosed during the period between 2000 and 2016 were examined retrospectively. The histology of the surgical pathology materials was reviewed by two pathologists. Clinical information was obtained from the hospital's information system.

RESULTS

Of the seven cases, two patients had secondary osteosarcomas. As for the five cases of primary osteosarcoma, their ages ranged from 26 to 58 years (mean: 36.2, median: 28). Histologically, three cases were fibrotic tumors composed of spindle-shaped cells with mild to moderate nuclear atypia and the collagenous stroma accompanied by woven bones or mature lamellar-like bones. Two cases had cartilage formation. MDM2 and CDK4 expression was observed in two out of three cases on immunostaining. The histopathology of these three cases was regarded as the counterpart of low-grade osteosarcomas, namely, parosteal osteosarcoma and low-grade central osteosarcoma, arising in long bones.

CONCLUSIONS

The surprisingly high incidence (60%, 3/5 cases) of low-grade osteosarcoma explains the reason why gnathic osteosarcomas present a more favorable prognosis than osteosarcomas arising in long bones. Furthermore, it provides insight into the tumorigenesis mechanism of low-grade osteosarcomas arising in the jaw and other sites.

A rare case of a metastatic giant cell-rich osteosarcoma of the mandible: Update and differential diagnostic considerations

A metastatic giant cell-rich osteosarcoma (GCRO) to the jaws is an exceedingly rare neoplasm. To date, fewer than 10 cases have been reported in the English language literature. In this article, we describe an additional case of a metastatic GCRO that presented the diagnostic challenge of a painless mass in the posterior mandible of a 19-year-old girl who exhibited rapid and aggressive local growth. The lesion was confirmed radiologically as an ill-defined expansive osteolytic mass showing cortical perforation. Microscopically, the presence of osteoclast-like giant cells permeated with atypical oval and rounded mesenchymal cells in a fibrovascular stroma, cellular atypia, and scarce osteoid formation were observed. Immunohistochemistry revealed the Ki-67 proliferative index in 50% of positive cells, positivity for vimentin and CD68, as well as scarce positivity for CDK4. The patient's medical history involved a GCRO in the proximal ulna. This report highlights the aggressive behavior of GCRO and its high capacity for metastasis to different parts of the body. Clinicians, pathologists, and surgeons should be aware of the giant cell-rich variant of osteosarcoma of the jaws, an imminent "wolf in a sheep's skin", because its indolent but unrelenting growth and dissemination, with radiographic and histologic characteristics that may represent a diagnostic pitfall regarding aggressive central giant cell lesions of the jaws.

The Management of Head and Neck Sarcoma

OBJECTIVE

To describe the incidence, types, features, treatment and outcomes of head and neck sarcoma managed at a treatment center in eastern China.

METHODS

Cases of head and neck soft tissue sarcoma and osteogenic sarcoma treated at the Stomatology Hospital of Nanjing University between 2008 and 2018 were retrospectively analyzed. Patient characteristics, site of lesion, main presenting symptoms, treatment, histology, local recurrence, development of metastatic disease, duration of follow-up and survival rates are described and compared.

RESULTS

Sixty-three patients were diagnosed with head or neck sarcoma of which 42.9% had soft tissue sarcoma and 57.1% had osteogenic sarcoma. Of soft tissue sarcoma patients, the most frequently observed histologies were fibrosarcoma and malignant fibrous histiocytoma. Of 36 cases of osteogenic sarcoma, osteosarcoma, and fibrosarcoma of bone were most frequent. Mean latency period between initial symptoms and clinical presentation was 4.5 months. Radical resection was performed on 56 patients. For 33 patients, resection and radiotherapy were used and 10 patients received a triple combination of resection, chemotherapy and radiotherapy. Within the observation period, 17 patients died.

CONCLUSIONS

Head and neck sarcomas, although rare, can represent a variety of pathological diagnoses. Surgery remains the main intervention although the data suggest chemotherapy, radical resection and irradiation as treatment. Outcomes are poor with high rates of local recurrence. Positive prognostic factors were tumor-free resection margins and choice of therapy. Due to the rarity of head and neck sarcoma, information remains limited and choice of treatment should be within the focus of clinical multi-center studies.

Malignant Transformation of Ossifying Fibroma into Parosteal Osteosarcoma with High-grade Component: Presentation of an Unusual Case and Review of the Literature

Background:

Parosteal Osteosarcoma of the Jaw (POSJ) is a rare entity that is associated with a high survival rate. Several case reports and case series of POSJ have been published in the literature, but few authors have described development of this tumor by possible transformation from a fibro-osseous neoplasm.

Objective:

We present a rare occurrence of parosteal osteosarcoma with involvement of the posterior maxilla, orbit floor, and infra-temporal fossa in a 20-year-old man. Furthermore, we performed a literature review regarding clinical, radiological, and histological features; treatment strategies; and etiology/pathophysiology.

Methods:

A PubMed search yielded a total of 74 articles and the articles were sorted according to their corresponding key area of focus.

Results:

This was a case of POSJ with high-grade component in the maxillofacial region of a 20-year old male. Co-expression of MDM2 and CDK4 was confirmed. At 2.5-year follow-up, the patient had died. The literature review revealed 18 articles including 20 cases of POSJ. Four cases represent the possible development of this tumor by transformation from a fibro-osseous neoplasm: Two cases of fibrous dysplasia, one case of cemento-ossifying fibroma, and the case of Ossifying Fibroma (OF) in the present study.

Conclusion:

In conclusion, we found an unusual case of POSJ of the midface in a patient with a previous diagnosis of OF in the same region. To our knowledge, there have been no previous reports of development of POSJ in OF. Furthermore, this is the first described case of high-grade surface osteosarcoma in the craniofacial region.

Atypical Presentation of a Maxillary Chondroblastic Osteosarcoma and Complex Management

We report a rare case of a 23-year-old male who presented with a four-week history of unilateral recurrent epistaxis and nasal obstruction. This was subsequently diagnosed as high-grade chondroblastic osteosarcoma of the maxillary antrum. Neo-adjuvant chemotherapy was commenced following a multidisciplinary team discussion. The disease progressed through first-line treatment. A radical surgical resection was not possible, and a palliative debulking procedure was performed. The literature comprehensively points towards an early surgical resection with suitable margins at the earliest possible stage. This case highlights that osteosarcoma of the maxilla can be challenging to diagnose and manage. Thus, a high index of suspicion and an early referral to a head and neck specialist is imperative to improve the long-term prognosis in such patients.

Osteoid producing primary lesion at morphologic and biologic interface

Fibroosseous gnathic lesions comprise a wide spectrum of diseases. Many of the entities have overlapping features. A pediatric case is encountered with a complex clinicopathologic profile. Although radiographically the lesion appears benign but on histopathological examination it possesses features of osteoid producing aggressive neoplasm. This paper highlights the unusual histologic features existing within the spectrum of fibroosseous lesions and discusses relevant clinicopathologic correlations.

Bone- and cartilage-forming tumors and ewing sarcoma: an update with a gnathic emphasis

Over the past decade, there have been remarkable advances in bone tumor pathology. Insights into the genetic basis and pathobiology of many tumor types have impacted diagnosis, classification, and treatment. However, because gnathic lesions may comprise only a small proportion of cases overall for many tumors, clinicopathologic features and management considerations specific to this subset may be overlooked. Here we provide a summary of recent developments in the following tumor types: osteosarcoma (OS), chondrosarcoma (CS), osteoid osteoma (OO), osteoblastoma (OB), and Ewing sarcoma (ES). In particular, we will give special consideration to cases arising in the jaws.

Pathological and clinical features of primary osseous tumours of the jaw

Primary bone tumors of the jaw are rare. The neoplastic cells in these tumors are the osteoblasts and osteoclasts. The gnathic bone tumors have also been referred to as borderline. The clinicopathologic approach towards these bony lesions have been reviewed.

Incidence and grading of cranio-facial osteosarcomas

Osteosarcoma of the cranio-facial structures and skull is rare. In children, only 5.6% of cases are localized in these areas. It is claimed that the mean age at presentation is at least 10-15 years higher than for osteosarcomas in other parts of the body. However these reports are based on data from single institutions or compiled from several registries. It is further claimed that tumours in the mandible and maxilla are less malignant, as based on observations of a better prognosis and lower incidence of metastatic spread as compared with osteosarcomas arising elsewhere. We report all histologically proven cranio-facial osteosarcomas in The Netherlands occurring over a 20-year period, based on the national registration covering all Dutch pathology laboratories (PALGA). The age-corrected incidence of primary osteosarcoma ranged from 0.33 to 0.41 per million across the age ranges. The mandible was the most frequent site of involvement. Only 61% had a high malignant histological grading. Our data indicate that the age-corrected incidence of primary osteosarcomas is similar across all age ranges. In respect to histology, a lower grade of malignancy is more frequent. Maxillary lesions significantly more often have a lower histological grade of malignancy.

Osteosarcoma of the maxilla: a rare case with unusual clinical presentation

Osteosarcoma (OS) is a malignant mesenchymal tumor, which rarely occurs in the maxilla. Although variable histologic and radiographic features of OS have been reported previously, in the majority of the cases painful swelling of the jaw is mentioned as the first clinical presentation. Furthermore, early diagnosis and wide surgical resection of the tumor are the most important determinant factors of prognosis. Therefore, the unusual clinical presentations of OS should be considered meticulously to expedite the diagnosis process. We describe a case of OS of the maxilla with extremely unusual presenta-tion in a 42-year-old female, that was initially designated as “epulis fissuratum”. Here, we highlight the importance of com-bining the clinical, radiographic and histopathologic examination to obtain a definitive diagnosis and also the significance ofearly effective surgical intervention in evaluation of pathologic lesions.

Osteosarcoma: A Comparison of Jaw versus Nonjaw Localizations and Review of the Literature

Purpose. It is assumed that osteosarcomas of the jaws mainly occur at older ages, whereas the most prominent sites, that is, the long bones, are more affected at ages <20. Jaw-localized tumors are less malignant and have lower metastatic spread rates. Patients and Methods. This study analyses the nationwide data of the Dutch Cancer Registry on osteosarcoma during the period from 1991 to 2010. Age-corrected incidence rates were calculated. Results. In 949, 38 patients had tumors in the maxilla and in 58 in the mandible. Median age for maxilla, mandible, and other localizations was 45.5, 49, and 23 years, respectively. Age-corrected incidence for osteosarcomas increased after a steep decline for the age cohorts from 20 to 60 years to nearly the same level as the younger patients. The incidence for maxillary lesions showed a steady increase from 0.46 to 1.60 per million over all age ranges; the highest incidence for mandibular lesions was found in the age cohort from 60 to 79 years. In respect to histology, no shifts for age were found, except for Paget's disease-related osteosarcoma. In older patients, chemotherapy was omitted more often. Overall survival was similar for all age groups, except for extragnatic tumor patients in the age range of 60-79 years. Conclusions. Osteosarcomas have comparable incidences below the age of 20 as compared with ages >60 years. Poorer outcome in older people is likely due to refraining from chemotherapy.

Osteosarcoma of the jaws: a review of literature and a case report on synchronous multicentric osteosarcomas

Background

In the head and neck region, osteosarcoma is the most common primary malignant bone tumor, representing 23% of total head and neck malignancies. Osteosarcomas of the jaws are nevertheless rare lesions, representing only 2 to 10% of all osteosarcomas. This report reviews a single-center histopathology experience with craniofacial osteosarcomas, and reports the management of unusually large synchronous mandibular and maxillary osteosarcomas in a patient.

Patients and methods

A search of the hospital pathology database for specimens with a histological diagnosis of osteosarcomas submitted between July 1992 and May 2011 was made. A chart review of a patient with large synchronous maxillary and mandibular osteosarcomas was performed, and is reported.

Case presentation

A 21-year-old African man with large maxillary and mandibular tumors under palliative care presented with increasing difficulties with eating, speech, and breathing. Surgical debulking was performed, with histology confirming synchronous osteosarcomas of the mandible and maxilla. The patient is well after one year, with no evidence of recurrence, having undergone no further treatment.

Conclusion

Osteosarcomas of the jaw remain enigmatic, and a number of difficulties related to their diagnosis and treatment are yet to be resolved. True synchronous multicentric osteosarcomas of the jaws are extremely rare but, like other osteosarcomas of the jaws, have a favorable outcome, and palliative resection of such lesions, though challenging, can therefore lead to an enormously improved quality of life and self-image, and may even offer the opportunity for cure.