Odontogenic ghost cell carcinoma: report of four new cases and review of the literature

Challenging pitfalls in frozen section pathology: a case of mandible ghost cell odontogenic carcinoma and the literature review

BACKGROUND

Ghost cell odontogenic carcinoma (GCOC) is a rare malignancy characterized by the presence of ghost cells, preferably in the maxilla. Only slightly more than 50 case reports of GCOC have been documented to date. Due to the rarity of this tumor and its nonspecific clinical criteria, there is a heightened risk of misdiagnosis in clinical examination, imaging findings, and pathology interpretation.

CASE PRESENTATION

A 50-year-old male patient presented to the hospital due to experiencing pain in his lower front teeth while eating for the past 2 months. Upon examination, a red, hard, painless mass was found in his left lower jaw, measuring approximately 4.0 cm × 3.5 cm. Based on the malignant histological morphology of the tumor and the abundant red-stained keratinized material, the preoperative frozen section pathology misdiagnosed it as squamous cell carcinoma (SCC). The surgical resection specimen pathology via paraffin section revealed that the tumor was characterized by round-like epithelial islands within the fibrous interstitium, accompanied by a large number of ghost cells and some dysplastic dentin with infiltrative growth. The malignant components displayed marked heterogeneity and mitotic activity. Additionally, a calcified cystic tumor component of odontogenic origin was observed. Hemorrhage, necrosis, and calcifications were present, with a foreign body reaction around ghost cells. Immunoreactivity for β-catenin showed strong nuclear positivity in tumor cells, while immunostaining was completely negative for p53. The Ki67 proliferation index was approximately 30-40%. The tumor cells exhibited diffuse CK5/6, p63, and p40 immunoreactivity, with varying immunopositivity for EMA. Furthermore, no BRAFV600E mutation was identified by ARMS-PCR. The final pathology confirmed that the tumor was a mandible GCOC.

CONCLUSION

We have reported and summarized for the first time the specific manifestations of GCOC in frozen section pathology and possible pitfalls in misdiagnosis. We also reviewed and summarized the etiology, pathological features, molecular characteristics, differential diagnosis, imaging features, and current main treatment options for GCOC. Due to its rarity, the diagnosis and treatment of this disease still face certain challenges. A correct understanding of the pathological morphology of GCOC, distinguishing the ghost cells and the secondary stromal reaction around them, is crucial for reducing misdiagnosis rates.

Treatment challenges of persistent ghost cell odontogenic carcinoma: a case report and literature review

The aim of this case report is to review and compare the clinical, radiologic, histopathologic, and immunohistochemical features, along with the treatment of a case of ghost cell odontogenic carcinoma. In addition, a report of the existing published literature with an emphasis on treatment will be described to provide information on this rare but aggressive tumor. The family of odontogenic ghost cell tumors comprises a spectrum of lesions characterized by odontogenic epithelium with ghost cell keratinization and calcifications. It appears that early detection is vital in proper treatment due to the high possibility of malignant transformation.

Comparative Analysis Between Dentinogenic Ghost Cell Tumor and Ghost Cell Odontogenic Carcinoma: A Systematic Review

Dentinogenic ghost cell tumor (DGCT) and ghost cell odontogenic carcinoma (GCOC) form a spectrum of rare benign and malignant odontogenic neoplasms, respectively. The aim of this study was to perform a comparative systematic review of the clinicopathological, genetic, therapeutic, and prognostic features of DGCT and GCOC. The electronic search was performed until December 2020 on seven electronic databases. Case reports, series, and research studies with enough histopathological criteria for diagnosis and all genomic studies were included. Both DGCT and GCOC showed a male prevalence (p = 0.043), with mandibular and maxillary predilections, respectively (p = 0.008). Peripheral DGCT (DGCTp) affected most elderly people (p < 0.001), and central DGCT (DGCTc) and GCOC occurred mainly in younger individuals. Unilateral enlargement of maxilla or mandible was the most common clinical sign associated with a radiolucent or mixed image. Ameloblastomatous epithelium was often present in both neoplasms. Basaloid and large cells with vesicular nuclei were also frequently seen in GCOC. β-catenin expression and mutations (CTNNB1 gene) were found in DGCT and GCOC. Conservative surgery was mostly used for DGCTp, while radical resection was chosen for DGCTc and GCOC. High recurrence rates were found in DGCTc and GCOC. Metastasis occurred in 16.7% of GCOC cases and the 5-year survival rate was 72.6%. DGCT and GCOC share numerous clinicopathological features and demand a careful histopathological evaluation, considering the overlap features with other odontogenic tumors and the possibility of malignant transformation of DGCT. A strict regular post-operative follow-up is mandatory due to high recurrence rates and metastatic capacity in GCOC.

A novel parotid carcinoma with a prominent ghost cell population: a masquerading tumor or "salivary ghost cell carcinoma"?

Ghost cell is one of several unique cellular morphologies associated with aberrant keratinization. We encountered a novel parotid tumor containing numerous ghost cells and herein describe its histological features and discuss diagnostic problems. The patient was a 90-year-old Japanese male, who complained of swelling of the left parotid area for four months. Positron emission tomography indicated no cervical lymph node metastasis or distant metastasis. The tumor was successfully resected with no signs of recurrence or metastasis for six months after surgery. Histologically, the tumor was mainly composed of squamous cells forming irregularly shaped nests with a mixture of pleomorphic giant or multinucleated cells and bland basaloid cell. Keratinized areas were occupied by a prominent ghost cell population. Immunohistochemically, CK5/6 and CK19 were widely positive as well as AE1/AE3, p40 and p63. Nuclear expression of β-catenin was also observed. The present case can be regarded as a particular form of squamous cell carcinoma and is believed to contain a large number of ghost cells resulting from an unclear mechanism. However, it seems difficult to consider such tumors as a clinicopathologically independent entity at present. Applying a term such as "salivary ghost cell carcinoma" would be premature.

Ghost cell odontogenic carcinoma of anterior mandible: A rare case report with review of literature

A 24-year-old male reported to the outpatient department with a complaint of swelling of the anterior lower jaw region for 9 months with history of traumatic injury and extraction of teeth from the same region, a month before the onset of swelling. Swelling was obvious extra- and intraorally which on examination presented as a soft to firm non-tender and non-fluctuant mass with an approximate size of 4 cm × 3 cm, extending from 34 to 43 region with obliteration of labial vestibule. Panoramic radiograph and cone-beam computed tomography showed a well-defined radiolucency in the mandibular anterior region crossing the midline with erosion of labial bony plates and root of 42 along with a tooth-like radiopaque mass within the lesion. Provisional diagnoses of odontogenic keratocyst, ameloblastomas, central giant cell granuloma and calcifying epithelial odontogenic tumor were listed. The histopathological and immunohistochemical examination of lesion followed by the biopsy confirmed the diagnosis of Ghost cell odontogenic carcinoma.

Ghost cell odontogenic carcinoma arising in the background of a calcifying odontogenic cyst

Ghost cell odontogenic carcinoma (GCOC) is a rare malignant neoplasm, representing 3% of all ghost cell lesions of the jaws. They can arise de novo or from a pre-existing calcifying odontogenic cyst (COC) or dentinogenic ghost cell tumour (DGCT). A systematic review of the literature reported only 12 cases of a GCOC arising from a pre-existing COC. This report highlights an additional case of a GCOC arising from a pre-existing COC after 3 years in an adolescent male. The patient initially presented with a painless swelling of the right mandibular corpus. Panoramic radiographic examination showed an expansive unilocular radiolucent lesion. After 3 years, the radiographic features appeared more aggressive with increased expansion and cortical perforation. A wide surgical resection was performed, whereby the lesion was diagnosed as a GCOC. Due to the rarity of these malignant neoplasms, limited information is available regarding their biological behaviour. One-year follow-up revealed no clinical signs of recurrence.

Ghost cell odontogenic carcinoma of the jaws: Report of two cases and a literature review

BACKGROUND

Ghost cell odontogenic carcinoma (GCOC) is a rare malignant odontogenic epithelial tumor with features of benign calcifying odontogenic cysts. Herein, we report two new cases of GCOC and systematically review the previous literature.

CASE SUMMARY

In case 1, a 46-year-old man complained of painless swelling of the right maxilla for 3 years, with a 1-mo history of hemorrhinia in the right nasal cavity. In case 2, a 72-year-old man was referred to our hospital with a chief complaint of painful swelling of the right mandible. Initially, the preliminary diagnoses were ameloblastomas. Thus, the two patients underwent resection of the tumor under general anesthesia. Finally, immunohistochemical examination confirmed the diagnosis of GCOC. The patient in case 1 was followed for 2 years, with no evidence of recurrence. However, the patient in case 2 was lost to follow-up.

CONCLUSION

GCOC is a rare malignant odontogenic epithelial tumor with high recurrence. Local extensive resection is necessary for the definitive treatment of GCOC.

Ghost cell odontogenic carcinoma with suspected cholesterol granuloma of the maxillary sinus in a patient treated with combined modality therapy: A case report and the review of literature

RATIONALE

Ghost cell odontogenic carcinoma (GCOC) is a rare malignant odontogenic tumor with aggressive growth characteristics.

PATIENT CONCERNS

A 41-year-old Chinese male visited our hospital in 2013, with a 4-month history of bloody purulent rhinorrhea with a peculiar smell in the right nasal cavity.

DIAGNOSES

The patient suffered from recurrent GCOC with suspected cholesterol granuloma of the maxillary sinus. The patient was incorrectly diagnosed with a calcifying epithelial odontogenic tumor at his first recurrence. Physical examination, radiological examination, and histopathology were used to identify GCOC.

INTERVENTIONS

Considering the recurrence of GCOC and poor effects of single surgery, postoperative adjuvant chemotherapy and concurrent chemoradiotherapy were performed after radical surgical excision.

OUTCOMES

So far, no significant evidence has suggested recurrence or metastasis after a long-term follow-up.

LESSONS

We advocate wide surgery with clean margins at the first accurate diagnosis. Combined modality therapy could be taken for the recurrent GCOC. We expect to provide a new treatment strategy to prevent the growth of this neoplasm.

Ghost Cell Odontogenic Carcinoma Arising Denovo with Distant Metastasis: A Case Report and Review of Literature

Ghost Cell Odontogenic Carcinoma (GCOC) is a rare malignant odontogenic tumour of epithelial origin accounting about 0.37% to 2.1% of all odontogenic tumours. They are characterized by the presence of ameloblastic islands along with ghost cells representing aberrant keratinization. The aim of this case report is to present a rare case that was diagnosed in a 37-year-old male patient and to describe the behavior of the tumour.

Odontogenic ghost cell carcinoma with pulmonary metastasis

Odontogenic ghost cell carcinoma (OGCC) is an exceptionally rare malignant odontogenic epithelial tumor. It is characterized by ameloblastic-like islands of epithelial cells with aberrant keratinization in the form of ghost cells with varying amounts of dysplastic dentin. Malignant histological characteristics include infiltration, cellular pleomorphism, numerous mitosis and necrosis. Its biological behavior varies from slow-growing locally invasive lesions to rapidly growing highly aggressive tumors. OGCC metastasizing to distant sites is extremely rare. Only three cases of metastasis have been reported in literature. We are reporting the case of a 54-year-old male patient who presented with tender swelling in the malar region. Histopathological examination revealed OGCC and he received postoperative radiotherapy. Two years later, he presented with a lung mass. Biopsy from the lung lesion showed the same morphology as that of maxillary tumor with scattered ghost cells. This case points to the aggressive behavior of OGCC and its metastatic potential. It also highlights the need for long-term follow-up of these patients.

Epidemiology, prognostic factors, and management of malignant odontogenic tumors: an analysis of 295 cases

OBJECTIVE

To determine the demographic characteristics, prognostic factors, and management for patients diagnosed with a malignant odontogenic tumor (MOT).

STUDY DESIGN

The Surveillance, Epidemiology, and End Results (SEER) registry was reviewed for patients diagnosed with MOT from 1973 to 2011. Kaplan-Meier and multivariate Cox regression analyses were performed on patient demographic characteristics and pathologic variables.

RESULTS

The SEER database identified 295 MOT patients. The mean age at diagnosis was 50.5 years (range 5-89 years). Of these patients, 61.7% were male and 38.3% were female. The racial composition was 66.4% White, 22% Black, 6.1% Asian, 3.1% Pacific Islander, 0.3% Native American, and 2.1% Other/Unknown. Kaplan-Meier analysis found an overall survival (OS) and disease-specific survival (DSS) at 5 years of 54% and 67%, respectively. Multivariate analysis of the entire cohort found that age and stage were predictors of OS and that age was a predictor for DSS. For stage I/II MOTs, age and surgical therapy were predictors of OS and DSS, respectively.

CONCLUSIONS

Here we report the largest study to date investigating demographic characteristics, prognostic factors, and management of MOT patients. Determinants of survival for OS and DSS include age, stage, and surgical therapy.

Ghost cell odontogenic carcinoma of the maxilla: a case report with a literature review

The aim of this report is to present a rare case of a Ghost cell odontogenic carcinoma (GCOC) of a 21-year-old man with review of the literature. The patient was treated surgically, and one of the surgical margins was involved, the patient received adjuvant radiotherapy for local control. Five months later, patient presented with infraorbital lesion which was proven histological to be GCOC. Radiological images, histological sections and clinical photographs are also presented. One year after the second surgery, the patient was tumor free. The only effective treatment modality was surgical removal.

Pediatric Metastatic Odontogenic Ghost Cell Carcinoma: A Multimodal Treatment Approach

Odontogenic ghost cell carcinoma (OGCC) is a rare and aggressive tumor wherein optimal treatment remains uncertain. We report the first pediatric metastatic OGCC case treated with multimodal therapy: surgery, adjuvant chemoradiation, and adjuvant immunotherapy. Adjuvant therapy was utilized due to locally advanced disease with pathologic features indicative of high recurrence risk. This multimodal approach was modeled after management of primary head and neck cancer, where adjuvant chemoradiation and immunotherapy are associated with improved outcomes. Our patient is alive and disease free at 14 months indicating a potentially positive role for multimodal therapy in the management of OGCC.

Ghost cell odontogenic carcinoma: A rare case report and review of literature

Objectives: Ghost cell odontogenic carcinoma is a rare condition characterized by ameloblastic-like islands of epithelial cells with aberrant keratinitation in the form of Ghost cell with varying amounts of dysplastic dentina. Material and Methods: We report a case of a 70 year-old woman with a rapid onset of painful swelling right maxillary tumor. Magnetic resonance showed a huge tumor dependent on the right half of the right hard palate with invasion of the pterygoid process and focally to the second branch of the trigeminal. Radiological stage was T4N0. The patient underwent a right subtotal maxillectomy with clear margins. Adjuvant radiotherapy was given. The patient was free of residual or recurrent disease 12 months after surgery. Results: The tumor was 3,9cm in diameter. It was spongy and whitish gray. Microscopically the tumor was arranged in nets and trabeculae, occasionally forming palisade. Tumoral cells had clear cytoplasm with vesicular nuclei. There was atipia and mitosi with vascular and perineural invasion. The excised tumor was diagnosed as a GCOC. Conclusions: Ghost cell carcinoma is a rare odontogenic carcinoma. Its course is unpredictable, ranging from locally invasive tumors of slow growth to highly aggressive and infiltrative ones. Wide surgical excision with clean margins is the treatment of choice although its combination with postoperative radiation therapy, with or without chemotherapy, remains controversial.

Key words:Ameloblastic carcinoma, calcifying odontogenic cyst, Ghost cell carcinoma, keratinizing epithelial odontogenic cyst, maxillary tumor, odontogenic carcinoma.

Ki-67 and p53 expression in ghost cell odontogenic carcinoma: a case report and literature review

Ghost cell odontogenic carcinomas are rare neoplasms that arise in the maxillary bones either from a calcifying odontogenic cyst or de novo. They are aggressive locally and can metastasize. We report herein a case of a ghost cell odontogenic carcinoma arising in the mandible of a Caucasian male 86 years of age. We have described the clinical and radiographic features, histological characteristics, immunohistochemistry findings, and surgical treatment. We especially focused on how Ki-67 expression guides the treatment choice. Finally, we reviewed 32 cases described in the literature and compared them with the cases described up until 2014 to help clinicians identify the diagnostic characteristics of and select appropriate treatment modalities for ghost cell odontogenic carcinomas.

Current Concepts and Occurrence of Epithelial Odontogenic Tumors: II. Calcifying Epithelial Odontogenic Tumor Versus Ghost Cell Odontogenic Tumors Derived from Calcifying Odontogenic Cyst

Calcifying epithelial odontogenic tumors (CEOTs) and ghost cell odontogenic tumors (GCOTs) are characteristic odontogenic origin epithelial tumors which produce calcifying materials from transformed epithelial tumor cells. CEOT is a benign odontogenic tumor composed of polygonal epithelial tumor cells that show retrogressive calcific changes, amyloid-like deposition, and clear cytoplasm. Differentially, GCOTs are a group of transient tumors characterized by ghost cell presence, which comprise calcifying cystic odontogenic tumor (CCOT), dentinogenic ghost cell tumor (DGCT), and ghost cell odontogenic carcinoma (GCOC), all derived from calcifying odontogenic cysts (COCs). There is considerable confusion about COCs and GCOTs terminology, but these lesions can be classified as COCs or GCOTs, based on their cystic or tumorous natures, respectively. GCOTs include ameloblastomatous tumors derived from dominant odontogenic cysts classified as CCOTs, ghost cell-rich tumors producing dentinoid materials as DGCTs, and the GCOT malignant counterpart, GCOCs. Many authors have reported CEOTs and GCOTs variably express keratins, β-catenin, BCL-2, BSP, RANKL, OPG, Notch1, Jagged1, TGF-β, SMADs, and other proteins. However, these heterogeneous lesions should be differentially diagnosed to allow for accurate tumor progression and prognosis prediction.

Pathogenesis and nomenclature of odontogenic carcinomas: revisited

Odontogenic carcinoma is rare group of malignant epithelial odontogenic neoplasms with characteristic clinical behavior and histological features, which requires an aggressive surgical approach. The pathogenesis of this rare group remains still controversial and there have been many varied opinions over the classification of this rare group of lesions. As there have not been many reviews on odontogenic carcinoma, the existing knowledge is mostly derived from the published case reports. This review is discussing the pathogenetic mechanisms and is updating the knowledge on nomenclature system of less explored odontogenic carcinomas. This review might throw light on the pathogenesis and nomenclature system of odontogenic carcinoma and this knowledge may be applied therapeutically.

Predictive factors of potential malignant transformation in recurrent calcifying cystic odontogenic tumor: review of the literature

Calcifying cystic odontogenic tumor (CCOT) demonstrates considerable diversity in histopathology and clinical behavior. Ghost cell odontogenic carcinoma (GCOC) is the rare malignant counterpart of CCOT and it frequently arises from malignant transformation of a recurrent CCOT. In this paper, we present a case of CCOT and discuss its distinct histopathologic features in recurrence. Then, we will have a review on clinical, histopathological, and immunohistochemical aspects of GCOC in the literature. Predictive factors of malignant transformation in a benign CCOT will also be discussed.

Calcifying cystic odontogenic tumor and adenomatoid odontogenic tumor: radiographic evaluation

OBJECTIVES

The aim of this study was to describe the radiographic features of calcifying cystic odontogenic tumors (CCOTs) and adenomatoid odontogenic tumors (AOTs) and to compare the radiographic findings for these 2 lesions.

STUDY DESIGN

We retrospectively reviewed radiographs of CCOTs and AOTs. Location, border, relationship of the lesion with the impacted tooth, calcification patterns, tooth displacement, and root resorption were evaluated.

RESULTS

Nine CCOTs and 8 AOTs were reviewed. Most CCOTs and AOTs had smooth borders. Three CCOTs and 7 AOTs enclosed impacted teeth. Of these cases, the radiolucencies of 3 CCOTs and 1 AOT were attached to the impacted teeth at the cementoenamel junctions. Three AOTs enclosed more portions of the roots, and the other 3 AOTs enclosed the entire teeth. Calcification in CCOTs appeared as a thin radiopaque line (2 cases) and discrete radiopaque foci (1 case), whereas AOTs had numerous dispersed or clustered radiopaque foci (4 cases).

CONCLUSIONS

Radiolucency with numerous radiopaque foci (particularly when the radiolucency surrounds a portion of the root or entire tooth) is suggestive of an AOT rather than a CCOT.

Malignant odontogenic tumors: a multicentric Latin American study of 25 cases

OBJECTIVE

The aim of this study was to show the epidemiological features of 25 malignant odontogenic tumors (MOT) in Latin America.

MATERIALS AND METHODS

We retrieved 25 cases of MOT out of 2142 odontogenic tumors, from four oral diagnostic centers in Latin America, and described the main clinical and pathological characteristics.

RESULTS

A total of 19 cases were carcinomas, including eight ameloblastic carcinomas, five primary intra-osseous squamous cell carcinomas, three clear cell odontogenic carcinomas and three ghost cell odontogenic carcinomas. All six sarcomas corresponded to ameloblastic fibrosarcoma. Thirteen cases occurred in men and 12 in women, age ranged from 7 to 77 years old, with a mean of 41.4 years. The average age of patients with carcinomas and sarcomas were 48.53 and 19 years old, respectively.

CONCLUSION

As malignant odontogenic tumors are very rare, this series helps to better clarify their relative frequency, predominant subtypes, and clinical characteristics in Latin America.

Primary intraosseous squamous cell carcinoma arising from an odontogenic keratocyst: a case report and literature review

Primary intraosseous squamous cell carcinoma (PIOSCC) derived from an odontogenic keratocyst (OKC) is a rare malignant neoplasm of the jaws, which is locally aggressive with quite poor prognosis. The incidence of carcinomas arising in odontogenic cysts was reported to be approximately 1-2/1000. The number of well-documented cases of PIOSCC ex OKC is extremely small; hence, no sufficient incidence data are available in the literature. Overall, the survival rate of an individual, which is a period of two years, is very poor, and this can be attributed to the delayed diagnosis. But knowledge of the histopathological and immunohistological features of PIOSCC allows accurate and early diagnosis of the lesion so that an early and appropriate treatment can be instituted for better prognosis. The following report describes an extremely rare case of PIOSCC of the mandible derived from an OKC in a 20-year-old female patient.

Ghost cell odontogenic carcinoma arising from calcifying cystic odontogenic tumor: a case report

Ghost cell odontogenic carcinoma (GCOC) is an exceptionally rare and malignant odontogenic tumor with aggressive growth characteristics. We describe a case of GCOC which was considerably derived from a previously resected calcifying cystic odontogenic tumor (CCOT). Cellular atypia, mitotic activity, Ki-67 labeling index and matrix metalloprotease-9 positive expression rate were all increased in the currently resected specimen compared to the initial one. This is a rare case of malignant transformation of CCOT to GCOC with respect to its histopathological and immunohistochemical findings.

Ghost cell odontogenic carcinoma arising in the background of a benign calcifying cystic odontogenic tumor of the mandible

Ghost cell odontogenic carcinoma (GCOC) is a rare malignant variant of odontogenic tumor with ghost cells; only 29 cases are documented. Our patient was a 68-year-old man with a painless, well-defined, radiolucent swelling of the mandibular gingiva in the right incisor-to-molar region. It was diagnosed as a benign calcifying cystic odontogenic tumor (CCOT) on fenestration biopsy. Eighteen years later, he returned with swelling in the same area. The lesion was excised, diagnosed as GCOC, and considered a secondary malignant manifestation of the benign CCOT. No adjuvant chemotherapy or radiotherapy was administered, and his postoperative course was uneventful for 48 months, with no recurrence or distant metastasis. Among the 30 reported cases of GCOC, the mean age at diagnosis was 40.3 years, 22 (73%) involved the maxilla. Twelve (40%) were secondary malignant manifestations of benign CCOTs or dentinogenic ghost cell tumors. Five patients died of recurrence or distant metastasis.

Ghost cell odontogenic carcinoma arising in calcifying odontogenic cyst

A case of exceptionally rare odontogenic malignant tumor, called ghost cell odontogenic carcinoma, is described. The tumor was considered to be derived from calcifying odontogenic cyst, which had been resected 5 years before. In the present resected specimen, cellular atypia, mitotic activity, Ki-67 labeling index, and p53 positivity were all increased in comparison with the initially resected specimen. This is a valuable case in which malignant transformation from calcifying odontogenic cyst to ghost cell odontogenic carcinoma was proven by the histopathologic and immunohistochemical findings. Pathologists should be aware of this rare entity.

Ghost cell odontogenic carcinoma of the mandible: a case report demonstrating expression of tartrate-resistant acid phosphatase (TRAP) and vitronectin receptor

INTRODUCTION

Ghost cell odontogenic carcinoma is a rare neoplastic variant of calcifying odontogenic cyst, with aggressive growth characteristics. A painful swelling in the jaws with local paraesthesia is the most common symptom. Although it often causes irregular destruction of the adjacent bone, immunohistochemical expression of tartrate-resistant acid phosphatase (TRAP) and vitronectin receptor has not previously been described in this carcinoma.

CASE REPORT

This article describes a ghost cell odontogenic carcinoma affecting the mandible of a 55-year-old man. The patient was treated by segmental mandibulectomy and there was no evidence of recurrence or metastasis for 1.8 years. Cytological features including the immunohistochemical expression of TRAP and vitronectin receptor were studied.

CONCLUSION

Specimens revealed varying sized islands of anucleate cell clusters with homogenous, pale eosinophilic cytoplasm, so called ghost cells, admixed with sheets of tumour. TRAP and vitronectin receptor were detected in the ghost cells, but they were not expressed in the tumour cells. Our findings suggest that some of the cytokines produced by ghost cells may play important roles in causing extensive bone resorption in the ghost cell odontogenic carcinoma.

Lesions of the jaws

The jaws differ in various aspects from all other bones in the skeleton. Embryologically, they are for the major part derived from migrating cells of the cranial neural crest, the so-called ectomesenchyme, and not merely from mesoderm, and they contain teeth. This latter point, especially, results in the presence of lesions that are not found in other bones, a broad variety of odontogenic cysts and tumours. They will be the major topic of this review. Other lesions, not strictly odontogenic but also mainly confined to the jaw bones, are giant cell lesions, fibro-osseous lesions, and the melanotic neuro-ectodermal tumour of infancy. They also will be included in this overview.

International collaborative study on ghost cell odontogenic tumours: calcifying cystic odontogenic tumour, dentinogenic ghost cell tumour and ghost cell odontogenic carcinoma

BACKGROUND

Calcifying odontogenic cyst was described first by Gorlin et al. in 1962; since then several hundreds of cases had been reported. In 1981, Praetorius et al. proposed a widely used classification. Afterwards, several authors proposed different classifications and discussed its neoplastic potential. The 2005 WHO Classification of Odontogenic Tumours re-named this entity as calcifying cystic odontogenic tumour (CCOT) and defined the clinico-pathological features of the ghost cell odontogenic tumours, the CCOT, the dentinogenic ghost cell tumour (DGCT) and the ghost cell odontogenic carcinoma (GCOC).

METHODS

The aim of this paper was to review the clinical-pathological features of 122 CCOT, DGCT and GCOC cases retrieved from the files of the oral pathology laboratories from 14 institutions in Mexico, South Africa, Denmark, the USA, Brazil, Guatemala and Peru. It attempts to clarify and to group the clinico-pathological features of the analysed cases and to propose an objective, comprehensive and useful classification under the 2005 WHO classification guidelines.

RESULTS

CCOT cases were divided into four sub-types: (i) simple cystic; (ii) odontoma associated; (iii) ameloblastomatous proliferating; and (iv) CCOT associated with benign odontogenic tumours other than odontomas. DGCT was separated into a central aggressive DGCT and a peripheral non-aggressive counterpart. For GCOC, three variants were identified. The first reported cases of a recurrent peripheral CCOT and a multiple synchronous, CCOT are included.

CONCLUSIONS

Our results suggest that ghost cell odontogenic tumours comprise a heterogeneous group of neoplasms which need further studies to define more precisely their biological behaviour.

Computerized tomography observation of a calcifying cystic odontogenic tumor with an odontoma: case report

The calcifying cystic odontogenic tumor is a rare benign odontogenic lesion. This report documents a case of this lesion associated with odontoma arising from the anterior maxilla in a 14-year-old boy. The diagnosis was confirmed based on computerized tomography findings, which clearly depicted the internal structures obscured in conventional images.

The Spectrum of Malignancy in Craniopharyngioma

Craniopharyngiomas are low-grade epithelial neoplasms occurring almost exclusively in the sellar/suprasellar region. Histologic malignancy is extremely rare; the literature consists mostly of isolated case reports. Herein, we report 3 patients with craniopharyngiomas exhibiting histologic malignancy, 2 of which received radiation therapy before its appearance. Hematoxylin and eosin-stained slides and selected immunohistochemical stains were reviewed in all cases. Microvessel density analysis was performed in case 2. The patients included 2 men and 1 woman, age 14, 31, and 58 years at presentation, respectively. All patients expired 3 months to 9 years after first resection and 3 to 9 months after identification of histologic malignancy. The latter developed after multiple recurrences and radiation therapy in 2 cases, but seemed to arise de novo in 1 case resembling odontogenic ghost cell carcinoma and lacking any definite low-grade craniopharyngioma precursor. The malignant component of the other 2 cases resembled squamous cell carcinoma and low-grade myoepithelial carcinoma, respectively. The MIB-1 labeling index was markedly increased in the malignant component in comparison with the low-grade precursor. Malignant transformation in craniopharyngiomas, although rare, does exist. It assumes varied histologic appearances, usually after multiple recurrences and radiation therapy, and has a near uniformly fatal outcome. De novo malignancy in odontogenic tumors of the sella is even more unusual, but also has an ominous prognosis.

Malignant odontogenic tumors: a 22-year experience

OBJECTIVES/HYPOTHESIS

Malignant odontogenic tumors are exceedingly rare and arise from odontogenic epithelial residues and odontogenic cysts in the jaw bones. Odontogenic malignancies have various origins. Some develop directly from the remnants of odontogenic epithelium left after completion of dental development; others may result from malignant transformation of a benign odontogenic cyst or ameloblastoma. These lesions are usually locally aggressive with radical surgery being the primary mode of treatment. Because of their rarity, much of the existing information about malignant odontogenic tumors with regard to their origin, clinicopathological features, biological behavior, and therapeutics is derived from case reports or small series. The study represents one of the largest series of malignant odontogenic tumors compiled in a single institution.

STUDY DESIGN

Retrospective 22-year review from an Academic Medical Center.

METHODS

Twenty cases of reported malignant odontogenic tumors were diagnosed in the authors' institution between 1981 and 2002. All pathological slides were reviewed to reconfirm diagnosis. Malignancy was confirmed based on the following criteria: histological findings of infiltrative growth, atypical cytological features, and focal necrosis or clear evidence of distant metastatic spread. Patient age, race, sex, treatment and outcome were recorded on chart review.

RESULTS

Of the twenty reported cases, only nine were actually found to be malignant tumors on re-evaluation. These consisted of four cases of malignant ameloblastomas, two cases of ameloblastic carcinoma, one case of malignant Pindborg tumor (calcifying epithelial odontogenic tumor), one case of odontogenic ghost cell carcinoma, and one case of squamous cell carcinoma arising in an odontogenic keratocyst. The racial demographics were six Caucasian patients, one African American patient, and two Asian patients; seven men and two women represented the gender distribution. Tumors of six cases were located in the mandible, and of three cases, in the maxilla. All cases were treated with radical surgical excision. Two patients died of their disease, three patients were alive and free of disease, and four patients were lost to follow-up.

CONCLUSION

Malignant odontogenic tumors are rare. They require a multidisciplinary team to determine proper treatment. Long-term surveillance is mandatory and is accomplished by routine physical examinations, along with serial radiographic imaging.

Clinical and radiological features of odontogenic ghost cell carcinoma: review of the literature and report of four new cases

OBJECTIVES

To analyse systematically the clinical and radiological features of odontogenic ghost cell carcinoma (OGCC).

METHODS

Clinical and radiological features of 22 OGCCs (4 new and 18 from the literature) were analysed.

RESULTS

There were 17 (77%) males and 5 (23%) females (male-to-female ratio of 3.4:1). Ages ranged from 13 years to 72 years (mean 36.7) with a peak in the fourth (40.9%) and fifth (27.3%) decades. The maxilla was involved in 68% and the mandible in 32%. Our study confirmed that OGCC is more prevalent in Asians (12/18) than in other racial groups. The mixed radiolucent and radiopaque lesion pattern was the most frequent (14/19) compared with radiolucent lesions (5/19). 89% (17/19) showed poorly defined borders and 11% (2/19) showed well defined borders. Root resorption was reported in 31% (6/19) of patients and tooth displacements in 21%.

CONCLUSIONS

OGCC demonstrates clinical and radiographic features of a malignant tumour with high recurrence.

Odontogenic ghost cell carcinoma

BACKGROUND

Odontogenic ghost cell carcinoma (OGCC), a malignant counterpart of the calcifying odontogenic cyst (COC), is exceedingly rare. Previous descriptions of this tumor were based on identification of malignant histologic characteristics such as infiltration, cellular pleomorphism, numerous mitoses, and necrosis concurrent with classical benign COC or its solid benign variant, the odontogenic ghost cell tumor.

METHODS

We present a case of a young Asian man who underwent multiple local excisions of a recurring maxillary COC. After one such excision, a rapid onset of painful swelling ensued, and the patient was referred to our institution for definitive surgery.

RESULTS

The patient underwent a right subtotal maxillectomy. Intraoperatively, a 5-cm tumor was found to be extending into the right maxillary sinus and nasal cavity. The excised tumor was diagnosed as an OGCC. The tumor was excised with clear margins, and no adjunctive radiotherapy was given. The patient was free of residual or recurrent disease 18 months after surgery.

CONCLUSION

On the basis of this case and prior cases found in the literature, OGCCs show a spectrum of growth from slow growing locally invasive tumors to highly aggressive, rapidly growing, infiltrative tumors. Wide local excision with histologically clean margins is the recommended mode of treatment. We recommend close long-term surveillance of recurrent or long-standing benign COCs and OGCC.

Beta-catenin mutations are frequent in calcifying odontogenic cysts, but rare in ameloblastomas

We have reported previously that alterations to beta-catenin occur frequently in adamantinomatous craniopharyngioma. Based on its histological resemblance to some odontogenic tumors, we suspected the presence of common genetic alterations among these tumors. To address this issue, 11 cases of calcifying odontogenic cyst (COC) and 20 cases of ameloblastoma were investigated for the presence of beta-catenin mutations and beta-catenin expression. Ten COCs were successfully analyzed by direct sequencing, and nine of them were found to harbor somatic beta-catenin mutations. Immunohistochemically, all of the COCs showed nuclear and cytoplasmic expression of beta-catenin with a heterogeneous pattern. No beta-catenin mutations were found in ameloblastomas, except for one case of the follicular type. All follicular ameloblastomas exhibited moderate nuclear and cytoplasmic accumulation of beta-catenin, in contrast to the predominantly membranous expression seen in the plexiform type. beta-Catenin mutation is considered to be a characteristic genetic feature of COC, and may play a critical role in its histogenesis. Although ameloblastoma closely resembles COC histologically, the two have genetically distinctive features.

Clinicopathologic spectrum of the so-called calcifying odontogenic cysts: a study of 21 intraosseous cases with reconsideration of the terminology and classification

The so-called calcifying odontogenic cyst (COC) represents a heterogeneous group of lesions that exhibit a variety of clinicopathologic and behavioral features. Because of this diversity, there has been confusion and disagreement on the terminology and classification of these lesions. We reviewed the clinicopathologic features of 21 intraosseous cases that were previously diagnosed as COC or under related diagnostic terms. Based on the biologic behavior, the lesions of the present series were divided into three subgroups: cyst, benign tumor, and malignant tumor. Sixteen cases (nine men and seven women) proved to be unicystic lesions with (five cases) or without associated odontoma. The lining epithelium of the cystic lesions fulfilled the histologic criteria for COC proposed by the World Health Organization, and their overall clinicopathologic features were consistent with that of developmental odontogenic cysts. The age of patients from the cyst group peaked at the second decade. The maxilla was affected more often (69%) than the mandible, with a predilection for the canine-premolar region (62.5%). Thirteen patients with follow-up information revealed no recurrence following enucleation. The four cases in the benign tumor group had variable clinicopathologic features. Two cases were solid tumors consisting of ameloblastoma-like sheets of odontogenic epithelium that contained ghost cells/calcification foci and juxtaepithelial dentinoid. Both patients experienced multiple recurrences following conservative surgeries. The other two lesions contained typical areas of COC and other types of odontogenic tumors (one ameloblastoma and one odontogenic myxofibroma). All four lesions occurred in the mandible and were relatively large. In the present series one case identified as malignant tumor arose from a previously benign COC. The tumor shared some features of COC (ghost cell foci and dystrophic calcification) but also had prominent mitotic activity, nuclear and cytoplasmic pleomorphism, areas of tumor necrosis, and infiltrative/destructive growth. Recognizing the extreme diversity in clinicopathologic features and biologic behavior among the so-called COCs, we suggest that the term COC should be used to specifically designate the unicystic lesions with or without an associated odontoma, i.e., lesions of the cyst group, and other related lesions identified as benign tumor and malignant tumor should be termed and classified separately. A tentative scheme with respect to the terminology and classification for this group of disparately behaving lesions was herein proposed to reflect the likely difference of their nature.

[Revision of the 1992 edition of the WHO histological typing of odontogenic tumors. A suggestion]

The WHO classification of odontogenic tumors (1992, OT) was revised. The following main changes were proposed: (1) OT are not only "related to" odontogenic tissues but are derived from these; (2) the stroma of the epithelial tumor group (1.1.1) is of a fibrous nature and does not contain any ectomesenchymal component; (3) subtypes of ameloblastomas have to be differentiated (intra-, extraosseous, desmoplastic, unicystic); (4) eponyms are no longer used in the revised classification; (5) the AOT is reclassified as an epithelial OT; (6) a neoplastic and non-neoplastic line of the ameloblastic fibroma and ameloblastic fibrodentinoma is proposed; (7) the calcifying ghost cell odontogenic tumor is included in the classification; (8) the simple and the WHO type of odontogenic fibroma are included in the classification; (9) the classification of malignant OT is adapted from Eversole (1999) with a few changes. In particular, ameloblastic carcinoma is differentiated from malignant ( metastasizing) ameloblastoma; (10) the term carcinoma in intraosseous (peripheral) ameloblastoma is introduced. Also, the malignant epithelial odontogenic ghost cell tumor is termed calcifying ghost cell odontogenic carcinoma; (11) the clear cell odontogenic tumor is termed clear cell odontogenic carcinoma; (12) the so-called pseudocysts are termed "cavities" (aneurysmal bone cavity, simple bone cavity, lingual and buccal mandibular bone cavity, focal marrow-containing jaw cavity).

Revision of the 1992-edition of the WHO histological typing of odontogenic tumours. A suggestion

Classification of odontogenic tumours is an academic exercise that has developed over the last 150 years. It was not until 1971 when a 5-year collaborated effort, organized by the World Health Organization (WHO), resulted in the first consensus on taxonomy of odontogenic tumours. The appearance of this first authoritative guide to the classification of odontogenic tumours marked the start of an era of quite intensive interest for studying this particular field of oral pathology. An updated 2nd edition of the WHO classification was published in 1992.

Aggressive epithelial odontogenic ghost cell tumor in the mandible: CT and MR imaging findings

We report a case of aggressive epithelial odontogenic ghost cell tumor arising from the mandible in a 32-year-old man. On CT and MR studies, the tumor was seen as a large, heterogeneous soft-tissue mass that caused marked destruction of the mandible and invaded the mouth floor and tongue base. The tumor displayed a variety of densities and signal intensities on CT and MR images, which correlated well with the degree of cellularity of epithelial islands, abundance of ghost cells and eosinophilic materials, calcification, and cystic areas on histologic sections. Owing to the unpredictable biological behavior of this type of tumor, careful, long-term follow-up is highly recommended.

Odontogenic ghost cell carcinoma: a case report with reference to the relation between apoptosis and ghost cells

The neoplastic variant of calcifying odontogenic cyst has various designations, and its malignant counterpart has been reported as aggressive epithelial odontogenic ghost cell tumor or odontogenic ghost cell carcinoma. We present a case of odontogenic ghost cell carcinoma with reference to the relation between the ghost cells and apoptosis. A 33-year-old man complained of a mandibular mass. The mass occupied the entire right side of the mandible with destruction of both buccal and lingual bone. The mass also infiltrated into submandibular and sublingual spaces. Histologically, the mass was composed of a solid proliferation of hyperchromatic and pleomorphic epithelial cells with abnormal mitoses. Islands of ghost cells were frequently admixed with nucleated cells, and there were foci of ameloblastic differentiation. Immunohistochemical stains for cytokeratins, involucrin, and apoptosis-related proteins such as Bcl-2, Bcl-X(L), and Bax were done. Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling (TUNEL) assay was also performed. The nucleated cells adjacent to the ghost cells expressed cytokeratins and involucrin, but the ghost cells had no reaction. Bcl-2 was negative. Both Bcl-X(L) and Bax were demonstrated in the nucleated cells adjacent to the ghost cells. The ghost cells exhibited Bax protein. Some nucleated cells adjacent to the ghost cells were positive with TUNEL assay. The above results indicate that ghost cells undergo abnormal terminal differentiation as an apoptotic process.