Are All Odontogenic Keratocysts Keratocystic Odontogenic Tumors? Correlation between Imaging Features and Epithelial Cell Proliferation

New perspectives in the differential diagnosis of jaw lesions: Machine learning and inflammatory biomarkers

This study aimed to assess the diagnostic performance of a machine learning approach that utilized radiomic features extracted from Cone Beam Computer Tomography (CBCT) images and inflammatory biomarkers for distinguishing between Dentigerous Cysts (DCs), Odontogenic Keratocysts (OKCs), and Unicystic Ameloblastomas (UAs). This retrospective study involves 103 patients who underwent jaw lesion surgery in the Maxillofacial Surgery Unit of Federico II University Of Naples between January 2018 and January 2023. Nonparametric Wilcoxon-Mann-Whitney and Kruskal Wallis tests were used for continuous variables. Linear and non-logistic regression models (LRM and NLRM) were employed, along with machine learning techniques such as decision tree (DT), k-nearest neighbor (KNN), and support vector machine (SVM), to predict the outcomes. When individual inflammatory biomarkers were considered alone, their ability to differentiate between OKCs, UAs, and DCs was below 50 % accuracy. However, a linear regression model combining four inflammatory biomarkers achieved an accuracy of 95 % and an AUC of 0.96. The accuracy of single radiomics predictors was lower than that of inflammatory biomarkers, with an AUC of 0.83. The Fine Tree model, utilizing NLR, SII, and one radiomic feature, achieved an accuracy of 94.3 % (AUC = 0.95) on the training and testing sets, and a validation set accuracy of 100 %. The Fine Tree model demonstrated the capability to discriminate between OKCs, UAs, and DCs. However, the LRM utilizing four inflammatory biomarkers proved to be the most effective algorithm for distinguishing between OKCs, UAs, and DCs.

The clinicopathological features and treatments of odontogenic keratocysts

An odontogenic keratocyst (OKC) is a benign but aggressive intraosseous tumor derived from the remains of the original tooth germ or dental lamina. It has a marked ability to recur and become cancerous. However, patients with early-stage OKC often have no symptoms and manifestations. The common clinical manifestation is swelling. Hence, it is critical to precisely diagnose the disease, to use differential diagnosis in combination with auxiliary examination methods, and to select the most appropriate treatment option to reduce the loss of bone tissue and the related damage to patients. In recent years, with the advancement in understanding the molecular basis of this disease and the development of early detection and targeted therapy, the diagnosis and the prognosis of OKC have been improved. The aim of this study was to provide an overview on the clinical features, diagnosis, and treatment of OKC. The molecular and genetic basis of this disease and the characteristics of malignant transformation of OKC were also discussed. Finally, we presented patient cases from our clinical practice to provide some advice on the diagnosis and treatment of OKC.

Inhibition of L-type voltage-gated calcium channel-mediated Ca2+ influx suppresses the collective migration and invasion of ameloblastoma

Objectives

Ameloblastoma (AM) has been known as a benign but locally invasive tumour with high recurrence rates. Invasive behaviour of the AM results in destruction of the adjacent jawbone and the non‐detectable remnants during surgery, interrupting the complete elimination of cancer cells.

Methods

To explore novel targets for the tumour cell invasion, a transcriptomic analysis between AM and odontogenic keratocyst were performed through next‐generation sequencing in detail.

Results

Enrichment of CACNA1C gene (encoding Cav1.2) in AM, a subunit of the L‐type voltage‐gated calcium channel (VGCC) was observed for the first time. The expression and channel activity of Cav1.2 was confirmed by immunostaining and calcium imaging in the patient samples or primary cells. Verapamil, L‐type VGCC blocker revealed suppression of the Ca²⁺‐induced cell aggregation and collective invasion of AM cells in vitro. Furthermore, the effect of verapamil in suppressing AM invasion into the adjacent bone was confirmed through orthotopic xenograft model specifically.

Conclusion

Taken together, Cav1.2 maybe considered to be a therapeutic candidate to decrease the collective migration and invasion of AM.

The immunohistochemical profile of basal cell nevus syndrome-associated and sporadic odontogenic keratocysts: a systematic review and meta-analysis

OBJECTIVES

To provide a systematic review of the literature on studies comparing the immunoprofile of nevoid basal cell carcinoma syndrome (BCNS)-associated and sporadic odontogenic keratocysts (OKCs), in order to identify markers that could accurately distinguish the two OKC subtypes.

MATERIALS AND METHODS

We searched MEDLINE/Pubmed, Web of Science, EMBASE via OVID, and grey literature for publications until December 28th, 2019, that compared the immunohistochemical expression of the two OKC subtypes. The studies were qualitatively assessed using the Critical Appraisal Tool for Case Series (Joana Briggs Institute). Sensitivity and specificity, positive and negative likelihood ratio, diagnostic odds ratio and area under the curve, and pooled estimates were calculated, using a random-effects model.

RESULTS

Seventy-one studies were qualitatively analyzed; 61 markers were evaluated in one study and 32 in ≥ 2 studies. Twenty-five studies reported differential expression of 29 markers in the form of higher number of positive cells or greater staining intensity usually in BCNS-associated OKCs. Meta-analysis for bcl-2, Cyclin D1, CD56, CK18, p53, and PCNA showed that none of those markers is distinguishable between BCNS-associated and sporadic OKCs, in a 95% confidence interval. The risk of bias was high in 34 studies, moderate in 22, and low in 15.

CONCLUSIONS

The present systematic review and meta-analysis uncovered that, although several immunohistochemical markers might characterize the OKC phenotype, they cannot discriminate between the BCNS-associated and sporadic OKCs.

CLINICAL RELEVANCE

This study highlighted the requirement for additional screening for markers by immunohistochemistry, preferentially coupled to alternative diagnostic applications such as genomics technologies.

The presentation of odontogenic keratocysts in the jaws with an emphasis on the tooth-bearing area: a systematic review and meta-analysis

PURPOSE

This study was conducted in order to gain insight in the actual ratio of odontogenic keratocysts occurring in the tooth-bearing area as compared to the posterior region of the jaws in order to come up with reliable data to base upon a rational treatment policy.

METHODS

We searched MEDLINE, Web of Science, Scopus, and Cochrane databases for studies reporting on the location of mandibular and maxillary odontogenic keratocysts. All records were independently assessed and a meta-analysis was performed. Risk difference with a confidence interval of 95% of having the lesion in the posterior region versus the tooth-bearing area was the effect measure. P value for the summary effect of < 0.05 was considered statistically significant.

RESULTS

The 2615 records retrieved were reduced to 34 studies to be qualitatively/quantitatively assessed. The pooled values showed that the difference in the clinical risk of having keratocysts in the posterior region of the mandible and in the tooth-bearing area of the maxilla is 21 and 43%, respectively (P < 0.02 and P < 0.00001).

CONCLUSIONS

A substantial amount of keratocysts occur in the tooth-bearing area of the jaws, requiring attention.

E-cadherin regulators are differentially expressed in the epithelium and stroma of keratocystic odontogenic tumors

BACKGROUND

The epithelial-mesenchymal transition (EMT) is the process where cells lose their epithelial features and acquire properties of typical mesenchymal cells. The dissociation of tumor cells due to changes in cell-cell adhesion is one of the key principles of tumor invasion and EMT. Thus, the knowledge of the molecular features of EMT in keratocyst odontogenic tumor (KOT) can provide useful markers to aid in the diagnosis and prognosis and perhaps contribute to an alternative therapeutic approach as it shows an aggressive clinical behavior and high recurrence rates. This study aimed to evaluate the EMT in KOT by the immunoexpression of E-cadherin, N-cadherin, Snail, and Slug and comparing to radicular cysts and dental follicles.

METHODS

Thirty-two KOTs, 15 radicular cysts, and 08 dental follicles were used for immunohistochemistry, evaluating the extent, intensity, labeling pattern, cellular compartment in the epithelium and stroma, and the presence of inflammation.

RESULTS

E-cadherin was preserved in most cases of keratocystic odontogenic tumor. N-cadherin was increased in the tumor epithelium, a result that was positively correlated with the heterogeneous and nuclear immunoexpression of Slug in the epithelium; Slug also correlated with high Snail immunoexpression. N-cadherin was positively correlated with Slug in the stroma of keratocystic odontogenic tumors.

CONCLUSIONS

The high immunoexpression of Snail and nuclear Slug in keratocystic odontogenic tumors suggests these proteins as transcription factors without necessarily participating in 'cadherin switching'. However, the knowledge of their induction of the epithelial-mesenchymal transition in odontogenic tumors is still limited.

Five years follow-up of a keratocyst odontogenic tumor treated by marsupialization and enucleation: A case report and literature review

Odontogenic cysts are considered as nonneoplasic benign lesions. Among the cysts, keratocyst odontogenic tumor (KCOT) is an intra-osseous tumor characterized by parakeratinized stratified squamous epithelium and a potential for aggressive, infiltrative behavior, and for the possibility to develop carcinomas in the lesion wall. Thus, the aim of this study was to describe a clinical case of KCOT in a young patient and discuss the treatment alternatives to solve this case. A 15-year-old male was referred for treatment of a giant lesion in his left side of the mandible. After the biopsy, a diagnostic of KCOT was made, and the following procedures were planned for KCOT treatment. Marsupialization was performed for lesion decompression and consequent lesion size reduction. Afterward, enucleation for complete KCOT removal was performed followed by third mandibular molar extraction. After 5 years, no signs of recurrence were observed. The treatment proposed was efficient in removing the KCOT with minimal surgical morbidity and optimal healing process, and the first and second mandibular molars were preserved with pulp vitality. In conclusion, this treatment protocol was an effective and conservative approach for the management of the KCOT, enabling the reduction of the initial lesion, the preservation of anatomical structures and teeth, allowing quicker return to function. No signs of recurrence after 5 years were observed.

Correlation between collagen fibers and radiographic patterns of keratocystic odontogenic tumour

BACKGROUND

WHO has recently renamed odontogenic keratocyst as keratocystic odontogenic tumour (KCOT) depending on its tumour like behaviour.

AIM

To quantitate and qualitate different types of collagen fibers in KCOT using picrosirius red stain under polarising microscopy and to correlate with different radiographic patterns of KCOT to elucidate its biological behaviour in order to determine whether all KCOTs behave like a tumour.

MATERIALS AND METHODS

Sixty histopathologically confirmed cases of KCOT were selected and stained histochemically using picrosirius red and examined under polarising microscope to evaluate colour of collagen fibers in the wall. Radiographic analysis of all the cases were also carried out and correlated with type of collagen of fibers.

RESULTS

Greenish yellow collagen fibers were present statistically significantly more in multilocular KCOT and KCOT with multiple radiolucencies (both syndromic and non-syndromic) as compare to unilocular whereas orange red were significantly more in unilocular variety. Syndromic variety showed significantly higher number of greenish yellow collagen fibers than non-syndromic variety.

CONCLUSION

Quality, organization and packing of collagen fibers of unilocular type is different than other radiographic patterns which accounts for difference in biological behaviour of these lesion, so we conclude that aggressive treatment should be reserved for selected cases.