Clear cell odontogenic tumor in the mandible: report of a case with an immunohistochemical study of epithelial cell markers

Maxillary clear cell odontogenic carcinoma with EWSR1-ATF1 fusion gene mimicking sclerosing odontogenic carcinoma: A case report and literature review

Both clear cell odontogenic carcinoma (CCOC) and sclerosing odontogenic carcinoma (SOC) are rare odontogenic malignancies. Here, we report a case of maxillary CCOC whose clinical and histologic features resembled those of SOC. Radiologically, the tumor presented as an ill-defined, expansile radiolucency with local bone destruction. Histologically, the tumor was comprised of thin cords or strands of odontogenic epithelium permeating through a sclerosed fibrous stroma with occasional clear cell foci. It damaged the cortical plates and invaded the adjacent soft tissue. Immunohistochemical expression of Pancytokeratin, Cytokeratin 19, p63, Cytokeratin 5/6, and Cytokeratin 14, as well as focal expression of Cytokeratin 7, demonstrated the epithelial nature of the tumor. Alcian Blue Periodic acid Schiff staining revealed a lack of intracellular mucin. Fluorescence in situ hybridization analysis revealed Ewing sarcoma RNA binding protein 1 and activating transcription factor 1 gene translocation, further confirming the diagnosis of CCOC. Lastly, we contextualized the genetic analysis of our case to that of CCOC in the literature.

Clear Cell Odontogenic Carcinoma a Systematic Review

Clear cell Odontogenic Carcinoma (CCOC) is an uncommon malignant odontogenic tumor (MOT). It is the fifth most common MOT. A systematic review is presented of reported cases, case series and retrospective studies of CCOC, to determine trends in presentation, diagnostic features, treatment, and patient outcome. Searches of detailed databases were carried out to identify papers reporting CCOC. The variables were demographics, patient symptoms, tumor location, histopathological findings, immunohistochemical studies, treatment, follow-up, and recurrence. 117 cases were identified; CCOC was most frequently seen in mature females 65% (n = 76). The total average age was 55.4 with a range from 17 to 89 years, for females 56.4 and males 53.6 years. The mean size was 3.41 cm. The most common location was in the mandibular body 36.2% (n = 42), followed by the anterior mandible 23.3% (n = 27). The most common clinical presentation was a swelling 80.4% (n = 74), and the main symptom was pain 41.3% (n = 31), followed by painless lesion 24% (n = 18). The most common Immunohistochemistry positive expression was CK19, EMA, and CEA, and for special staining periodic acid Shiff (PAS); 97% of cases were treated surgically. The average follow-up was 30.3 months, and recurrence was reported in 52.4% of the cases. Conclusion: CCOC shows a strong predilection for the body and anterior mandible, and females are more frequently affected. CCOCs can be painful and the principle clinical sign is swelling, CCOCs can metastasize, and the prognosis is fair.

Rare clear cell odontogenic carcinoma associated with impacted tooth in a young patient: case report and literature review

Clear cell odontogenic carcinoma (CCOC) is a rare malignant odontogenic tumor. It is characterized by showing, on histopathological examination, clusters of vacuolated and clear tumor cells with epithelial differentiation surrounded by fibrocollagenous stroma and fibroblasts. The present study presents a rare clinical case of mandibular CCOC associated with an impacted tooth in a 26-year-old woman surgically treated with mandibulectomy and reconstruction with iliac crest bone graft. The patient has been followed up for 22 months without signs of recurrence. A search for case report/case series was carried out in the PUBMED database, as well as in the references of relevant previously published literature reviews. Ninety-six publications were identified, totaling 136 distinct cases reported. Female sex was the most affected (63.1%) with 63.3% of cases occurring in patients in the fifth, sixth, or seventh decades of life. The mandible was more affected than the maxilla (74.2%). Association of CCOC with impacted teeth was found in 2.4% of cases, thus rendering it a rare occurrence. The present case report corroborates the results of the survey regarding sex and anatomical location of the tumor; however, it contradicts the findings regarding age predilection. The case described is the fourth known occurrence of tooth impaction associated with the tumor and the first in a female. In conclusion, CCOC should be considered, as well as other malignancies, as a possible diagnosis of maxillary or mandibular intraosseous lesions even in unusual circumstances such as in association with impacted teeth and in young patients.

Clear cell odontogenic carcinoma: a rare jaw tumor. A summary of 107 reported cases

The purpose of this study was to summarize the currently published cases of clear cell odontogenic carcinoma (CCOC). The PubMed and Springer databases were used to collect available reports, searching for 'clear cell odontogenic carcinoma', 'CCOC', or 'clear cell ameloblastoma'. The search resulted in 75 reports detailing 107 cases between 1985 and 2018. Clinically the tumor manifests as a swelling in the posterior mandible (n=46), anterior mandible (n=33), and maxilla (n=28). Radiological analysis of 85 cases typically showed a poorly defined expansive radiolucency (n=83). Of the 70 patients with symptoms reported, 44 specified a swelling, 11 tooth mobility, seven gingival/periodontal issues, five numbness, and three decreased jaw opening. One patient presented with a neck mass. The duration of symptoms prior to seeking care was specified for 52 patients: 2 months to 1 year for 34 patients, 1-2 years for seven, 2-4 years for two, 4-7 years for six, and 7-12 years for three. The incidence of recurrence appeared to be 38 of the 88 cases where recurrence was reported. CCOC can be distinguished from other oral cancers by its distinctive histology and immunohistochemical characteristics and less aggressive behavior. Currently, treatment should be early and aggressive resection with clear surgical margins and long-term follow-up. The overall goal is to collect a cohort of patients.

Clear cell odontogenic carcinoma: report of 7 new cases and systematic review of the current knowledge

OBJECTIVE

The goal of this study is to describe 7 cases of clear cell odontogenic carcinoma among a Brazilian population and compare these data with a systematic review of the English-language literature.

STUDY DESIGN

Descriptive statististics were used to compare the clinicopathologic data gathered retrospectively with those compiled from a review. Tumor sections were immunostained for Ki-67, p16, p53, and cytokeratins (CKs) 7, 8, 14, 18, and 19. Log-rank tests were performed for survival analysis.

RESULTS

Most cases occurred in the posterior mandible (5/7, 71.4%), and recurrence was diagnosed in all treated patients. Metastatic disease occurred in 2 patients (28.6%). Tumors were focally positive for CKs 7, 8, 14, and 18 and diffusely positive for CK19, p53, and p16. The mean number of Ki-67-positive cells was 35.2 cells/high-power field. Our systematic review provided evidence that tumor size (P = .046), histologic pattern (P = .034), regional metastasis (P = .001), distant metastasis (P = .001), and local recurrence (P = .05) were of significant prognostic value.

CONCLUSIONS

This study has contributed to improved characterization of clear cell odontogenic carcinoma, which is an aggressive odontogenic malignant neoplasm diagnosed mainly in the posterior mandible of middle-aged women and typically at an advanced stage. Radical surgical procedures remain the gold standard treatment.

Cytomorphology and immunohistochemistry of a recurrent clear cell odontogenic carcinoma with molecular analysis: A case report with review of literature

Clear cell odontogenic carcinoma (CCOC) is a rare, odontogenic tumor of the jaws with mandibular involvement usually present in sixth decade of life with female preponderance. It is classified as a malignant tumor of odontogenic origin in 2005 by the World Health Organization because of its aggressive and destructive growth capacity and potential to metastasize. It needs to be distinguished from other primary and metastatic clear cell tumors of the oral and maxillofacial region. Recently, CCOCs have been noted to harbor a Ewing sarcoma breakpoint region 1 gene RNA-binding protein 1 (EWSR1) and activating transcription factor (ATF) gene translocation. To date, cytologic features of only one case have been reported in the literature. We report an additional case of 55-year-old woman with enlarging mass in the left mandible. This report describes cytologic and immunohistochemical features of CCOC with positive EWSR1 gene rearrangements by fluorescence in situ hybridization (FISH). As diagnosis of CCOC is challenging on fine-needle aspiration, immunohistochemistry and FISH analysis are very useful diagnostic tool in clear cell lesions of mandible.

Clear cell odontogenic carcinoma of maxilla: A case report and mini review

Clear cell odontogenic carcinoma is a rare odontogenic tumor occurring predominantly in posterior mandible during 5^th-7^th decades with a female predilection. It is a potentially aggressive tumor, capable of frequent recurrences and loco-regional and distant metastases. Till date, only 73 cases have been reported in the literature. Current case is of a 55-year-old woman with tumor mass extending from canine to molar region on the left maxillary arch. Being locally aggressive tumor with the capacity to metastasize, it demands to be distinguished from other primary and metastatic clear cell tumors of the oral and maxillofacial region. A brief compilation of the reported cases is being attempted in the current article to better understand the behavior of the tumor.

Msx and dlx homeogene expression in epithelial odontogenic tumors

Epithelial odontogenic tumors are rare jaw pathologies that raise clinical diagnosis and prognosis dilemmas notably between ameloblastomas and clear cell odontogenic carcinomas (CCOCs). In line with previous studies, the molecular determinants of tooth development-amelogenin, Msx1, Msx2, Dlx2, Dlx3, Bmp2, and Bmp4-were analyzed by RT-PCR, ISH, and immunolabeling in 12 recurrent ameloblastomas and in one case of CCOC. Although Msx1 expression imitates normal cell differentiation in these tumors, other genes showed a distinct pattern depending on the type of tumor and the tissue involved. In benign ameloblastomas, ISH localized Dlx3 transcripts and inconstantly detected Msx2 transcripts in epithelial cells. In the CCOC, ISH established a lack of both Dlx3 and Msx2 transcripts but allowed identification of the antisense transcript of Msx1, which imitates the same scheme of distribution between mesenchyme and epithelium as in the cup stage of tooth development. Furthermore, while exploring the expression pattern of signal molecules by RT-PCR, Bmp2 was shown to be completely inactivated in the CCOC and irregularly noticeable in ameloblastomas. Bmp4 was always expressed in all the tumors. Based on the established roles of Msx and Dlx transcription factors in dental cell fates, these data suggest that their altered expression is a proposed trail to explain the genesis and/or the progression of odontogenic tumors.

Clear cell odontogenic carcinoma: case report with immunohistochemical findings adding support to the challenging diagnosis

Clear cell odontogenic carcinoma (CCOC) is a rare odontogenic tumor associated with aggressive clinical behavior, metastasis, and low survival. We report a case of CCOC affecting the mandible of a 39-year-old man. The tumor presented a biphasic pattern composed of clear cell nests intermingled with eosinophilic cells and separated by collagenous stroma. Immunoreactivity to cytokeratin (CK), specifically AE1/AE3 and CK 8, 14, 18, and 19 was found, as well as to epithelial membrane antigen (EMA). The tumor cells were negative for S100 protein, CK 13, vimentin, smooth muscle actin, laminin and type IV collagen. Low labeling indices for the proliferation markers Ki-67 and proliferating cell nuclear antigen and to p53 protein might predict a favorable prognosis for the lesion. A surgical resection was performed, followed by adjuvant radiotherapy. A 2-year follow-up has shown no signs of recurrence. The significance of histochemical and immunohistochemical resources in the correct diagnosis of CCOC is analyzed.

Clear cell odontogenic carcinoma of the maxilla: a case report and literature review

BACKGROUND

Clear cell odontogenic carcinoma (CCOC) is a rare tumor of odontogenic origin. It was first described as a clinicopathological entity in 1985, and since then, several case reports have been published.

METHODS

We present a patient with CCOC treated at the University of Florida and review the pertinent literature.

RESULTS

We treated a 52-year-old woman with CCOC of the maxilla. She received a maxillectomy and postoperative radiotherapy (RT). She developed pulmonary metastases 2 years after treatment. She remains alive and asymptomatic 7 years after completing treatment and has not required additional therapy. The literature search yielded 48 other case reports. The median age at presentation was 53 years (mean, 55 years), the female-to-male ratio was 2:1, and the most common site of presentation was the mandible. Three patients presented with submandibular lymphadenopathy. Most patients had a surgical resection (35 patients, 71%); the remainder underwent curettage. Six (12%) patients received postoperative RT. Eighty percent of patients who were initially treated with curettage developed a local recurrence. Local and/or regional recurrences occurred in 34% of patients who underwent surgical resection. Six patients developed distant metastatic disease; the most common site of the metastases was the lung. Seven patients died from or with the disease, and 3 are alive with the disease.

CONCLUSIONS

Clear cell odontogenic carcinoma is a rare tumor of the mandible and maxilla that has the propensity for local destruction and the potential for lymphatic and hematogenous metastases. We recommend radical excision as the primary treatment and that adjuvant RT be added for those who have close or positive margins as well as those with lymph node metastases.

Clear cell odontogenic carcinoma: a comprehensive analysis of treatment strategies

BACKGROUND

Odontogenic neoplasms of predominately clear cells are unusual. They represent a diagnostic dilemma, and as a result, treatment strategies are diverse. Our goal is to present two new cases, summarize reported cases of clear cell odontogenic carcinoma (CCOC), assess potential risk factors for recurrence, and propose definitive surgical and therapeutic strategies.

METHODS

A literature search and analysis was performed. Regression models were used to predict risk factors for recurrence.

RESULTS

Forty-three cases of CCOC were reviewed, including two reported here. The overall rate of recurrent disease was 55%. Local recurrence rates were higher for curettage (80%) than for resection alone (43%). Age (p = .20), sex (p = .28), and tumor site (p = .50) did not predict risk for recurrence.

CONCLUSIONS

CCOC is a potentially aggressive tumor with a tendency for recurrence. Treatment strategies should be directed toward wide surgical resection with confirmation of tumor-free margins. Lymph node dissection and adjuvant radiation therapy should be considered in selected cases.

Clear cell odontogenic carcinoma and clear cell ameloblastoma: a single clinicopathologic entity? A new case and comparative analysis of the literature

BACKGROUND

Clear cell odontogenic carcinoma (CCOC) is histologically characterized by solid sheets and nests of clear cells. Clear cell ameloblastoma (CCAM) is histologically characterized by an ameloblastomatous component intermixed with an extensive clear cell component. In all literature reviews, no separation has been made between the clinicopathologic features of CCOC and CCAM.

PURPOSE

We sought to review and analyze the clinicopathologic and radiologic features and the biologic behavior of CCOC and to compare them with those of CCAM to evaluate the possible separation between the 2 lesions.

MATERIALS AND METHODS

A MEDLINE search of the English-language literature was carried out for CCOC and CCAM. Cases were classified according to their histologic features.

RESULTS

A total of 27 cases of CCOC (26 from the literature and 1 new case) and 8 cases of CCAM were found. CCOC patients showed a male-to-female ratio of 1:2.4, with a mean age of 59 years. CCAM patients showed a male-to-female ratio of 1.7:1, with a mean age of 44 years. CCOC and CCAM were predominantly found in the mandible. Both CCOC and CCAM showed a high rate of recurrence (50% and 63%, respectively) and metastases (33% and 25%, respectively). Several patients with CCOC presented with metastases at time of diagnosis, whereas patients with CCAM usually developed metastases only after several recurrences.

CONCLUSION

Based on the relatively small number of cases in the literature on CCOC and CCAM, it is difficult to confidently separate the 2 lesions. Both lesions should be considered low-grade malignancies and could well represent a clinicopathologic continuum of a single disease entity rather than 2 separate lesions.

Clear cell odontogenic carcinoma: evaluation of reported cases

PURPOSE

We present the cases of 4 patients with clear cell odontogenic carcinoma and a contrasting case of a patient with a calcifying epithelial odontogenic tumor from Massachusetts General Hospital. Differential diagnosis, distinguishing characteristics, and data from 32 cases in the literature are also reported. Because this rare tumor behaves aggressively with both regional and distant spread, a better understanding of its biologic behavior is imperative.

PATIENTS AND METHODS

The 4 patients with clear cell odontogenic carcinoma were women and had an average age of 65 years (range, 40 to 77 years). Three tumors were in the posterior mandible and 1 was in the maxilla. Three patients complained of pain; bony expansion and tooth mobility were noted in isolated cases. A comparison is made with other reported cases, and factors associated with recurrence and survival are presented.

RESULTS

All patients were treated with resection, and 1 patient received postoperative radiotherapy. Two patients with positive surgical margins underwent further resection. All patients have been followed an average of 2 years (range, 0.5 to 4 years) and presently have no evident disease.

CONCLUSIONS

Recognition of this unusual tumor and differentiating it from other clear cell neoplasms is critical in developing an appropriate treatment plan. Management should include wide en bloc resection and long-term follow-up.

Clear cell odontogenic carcinoma

Clear cell tumours, in the head and neck region, are usually derived from salivary or odontogenic tissues, or may be metastatic. A few clear cells may be present in odontogenic cysts, while, odontogenic neoplasms composed predominantly of clear cells are quite rare. They include calcifying epithelial odontogenic tumours (CEOT), ameloblastoma and odontogenic carcinoma. Clear cell odontogenic tumour (CCOT) has been classified in the last WHO classification as a benign tumour, but it is now recognized as a more sinister lesion and current opinion is that CCOT should be designated as a carcinoma. These tumours are characterized by aggressive growth, recurrences, and metastatic disease. A recent review of the literature has yielded 30 cases of tumours with similar characteristics. These tumours have a peak incidence in the 5th-7th decades, with a female predilection. The anterior portions of the jaws, especially the mandible, are most frequently affected. The aggressive potential of these neoplasms is well documented by the extensive invasion of adjacent tissues, multiple recurrences and regional or distant metastases.

Clear cell odontogenic carcinoma. Report of two cases and review of the literature

This study reviews the literature and reports on the morphologic and immunophenotypic features of 2 clear cell odontogenic carcinomas occurring in the mandible of elderly women, showing extensive infiltration into adjacent tissues. The tumor cells were large, with clear cytoplasm, and arranged in irregular sheets. Some of the latter demonstrated a peripheral rim of cells with eosinophilic cytoplasm or included duct-like structures. There was no evidence of ameloblastic differentiation. Most cells contained glycogen granules and were immunoreactive for cytokeratins and epithelial membrane antigen. In the differential diagnosis other clear cell odontogenic, salivary gland, and metastatic tumors should be considered. Both cases were treated with surgical excision, and the patients are free of disease after 3 and 5 years, respectively. In the literature, however, variable behavior of these tumors has been reported, including recurrence and metastases. It is recommended that terms such as clear cell ameloblastoma and clear cell odontogenic tumor not be used to describe such tumors.

Radiographic manifestation of clear cell odontogenic tumor

Clear cell odontogenic tumors are uncommon, only 20 cases having been reported in the literature. We report a case that presented with unique radiographic manifestations over a period of 12 years; no similar case has been reported to date. Documentation of the malignant nature of the condition and of the range of clinical and radiographic manifestations with which this neoplasm can present provides useful insight into its pathogenesis and progression. Early and timely recognition of the lesion, histopathologic examination, and aggressive interventional procedures are in order to successfully treat this condition and prevent a potentially fatal outcome.

Expression of E-cadherin and alpha-catenin in epithelial odontogenic tumors: an immunohistochemical study

To clarify the possible role of cell adhesion in epithelial odontogenic tumors, expression of E-cadherin and alpha-catenin was examined by an immunohistochemical method. These molecules showed pericellular distribution in epithelial cells of the tooth germ and its derived tumors. In ameloblastomas, E-cadherin and alpha-catenin were expressed strongly in central polyhedral cells and slightly in peripheral columnar cells. These features resembled those of epithelial components in the tooth germ tissues, retaining cytodifferentiation of odontogenic epithelium. Expression of the molecules in the variants of ameloblastomas showed loss in the keratinizing areas and reduction in the granular cell clusters, suggesting terminal differentiation of the tumor cells. Calcifying epithelial odontogenic tumors and a clear cell odontogenic tumor preserved E-cadherin and alpha-catenin expression without a specific feature for histogenesis or cytodifferentiation. One case of two malignant ameloblastomas showed prominent reduction in expression of E-cadherin and alpha-catenin.