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The so called Calcifying Odontogenic Cyst

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The so called Calcifying Odontogenic Cyst

  1. 1. The so called calcifying odontogenic cyst
  2. 2. Background • Dualistic concept: Some authors prefer to consider COC as lesion existing in two forms either cyst or neoplasm. • Monistic concept: others like to regard the lesion as a tumor with a marked tendency toward cystic architecture. • Gorlin: described first as Calcifying odontogenic cyst in 1962 • Gold: Keratinizing calcifying odontogenic 1963 • Prætorius: proposed a widely used classification as one of the first to suggest that ghost cell lesions comprise a spectrum between true (developmental) cysts and solid neoplasms 1981 • Shear: Odontogenic ghost cell ameloblastoma 1994 • WHO calcifying cystic odontogenic tumour 2005
  3. 3. After 2005 WHO classification, praetrius and Ledesama changed the name. • For the cystic type: calcifying cystic odontogenic tumor • For the newplasm type: dentinogenic ghost cell tumor
  4. 4. In 2005 the WHO authors also chose to classify all ghost cell lesions as neoplasms, with little evidence besides the fact that ghost cell lesions occupy a spectrum from completely cystic to solid growths of cells They described three basic variants of the cystic lesions; • A cyst with a moderate amount of mural proliferation of epithelium with limited amounts of dentinoid. • A cyst in association with an odontoma • A cyst with extensive ‘‘ameloblastoma-like’’ proliferation in the wall or lumen of the cyst
  5. 5. They divided their tumors into (CCOT), (DGCT) and ghost cell odontogenic carcinoma (GCOC). They further subdivided the CCOT in four distinct types; • Type 1: simple cystic • Type 2: CCOT associated with an odontoma • Type 3: with ameloblastomatous-like proliferation • Type 4: associated with other benign odontogenic tumors other than odontoma.
  6. 6. CCOT • In chapter 6 of the WHO book, CCOT was defined as a benign cystic neoplasm of odontogenic origin, characterized by an ameloblastoma-like epithelium with ghost cells that may calcify
  7. 7. DGCT • DGCT was defined as a locally invasive neoplasm characterised by ameloblastoma-like islands of epithelial cells in a mature connective tissue stroma. • Aberrant ghost cell keratinization may be found in association with varying dysplastic dentin (so called dentinoid materials) amounts
  8. 8. GCOC • The previously reported cases named odontogenic ghost cell carcinoma and malignant epithelial odontogenic ghost cell tumours were re-named by the WHO as ghost cell odontogenic carcinoma (GCOC).
  9. 9. In Ledesma-Montes et al., (2008) study • CCOT cases were divided into four sub-types: • (i) simple cystic; • (ii) odontoma associated; • (iii) amelo- blastomatous proliferating; • (iv) CCOT associated with benign odontogenic tumours other than odontomas.
  10. 10. A simplified classification for the CCOT is shown in which includes central and peripherally located cases Classification of the ghost cell odontogenic tumours studied cases Calcifying cystic odontogenic tumour (CCOT). type 1. Simple cystic CCOT. type 2. Odontoma-associated CCOT type 3. Ameloblastomatous proliferating CCOT type 4. CCOT associated with benign odontogenic tumours Dentinogenic ghost cell tumour (DGCT) type 1. Central, solid, aggressive variant DGCT type 2. Peripheral, less aggressive variant Ghost cell odontogenic carcinoma (GCOC).
  11. 11. Clinically present either as central (85%) or peripheral lesion (15%). It shows bimodal age of occurrence commonly presenting in second and seventh decade of life. 1 predilection towards any gender and occurs in equal frequency in either of the jaw bones, anterior to the first molar in the incisor-canine region. 2 Asymptomatic bony expansion is the most common presentation of the central lesions, while sessile or pedunculated smooth surfaced mass are features of peripheral lesions. 3
  12. 12. Clinically • COC is predominantly an intraosseous lesion, although in 13% to 30% of reported cases, COC has manifested as a peripheral lesion. About 65% of cases are found in the incisor or canine areas. Mean age is 33 years, and most cases are diagnosed in the second and third decades of life. • However, COCs that are associated with odontomas tend to occur in younger patients (mean age, 17 years). Central COC is usually a unilocular, well-defined radiolucency, although the lesion may occasionally appear multilocular.
  13. 13. Clinically • Extraosseous COCs are usually localized sessile or pedunculated gingival masses with no distinctive clinical features, and can resemble common gingival fibromas, gingival cysts, or peripheral giant cell granulomas. • They appear as variably sized odontogenic epithelial islands in a fibrous stroma composed of peripheral palisading columnar cells and central stellate reticulum, reminiscent of ameloblastoma. However, ghost cell nests are present within epithelium.
  14. 14. Radiographically • Radiopaque structures within lesions, either irregular calcifications or toothlike densities, are present in about one third to one half of cases. The radiolucent lesion is associated with an unerupted tooth, usually a canine, in approximately one third of cases. • the central lesion appear as unilocular or sometime multilocular radiolucency with or without calcified structures. • Size and opacity of the calcified structure varies, sometime occupying the entire lesional area. • may be associated with an odontoma (24-35%) or an impacted tooth, most commonly the canine (10-32%).
  15. 15. histologically • microscopic features of are characteristic: Cyst epithelium is usually thin and tends to be detached easily, but is focally thickened by keratinized epithelial cells and ghost cells. Hyperplastic basal cells often grow into fibrous cyst walls, resulting in daughter cysts. Unlike other odontogenic cysts, COCs may contain highly-differentiated lining epithelium composed of columnar cells or stellate reticulum-like cells associated with ghost cells, and undifferentiated lining epithelium resembling reduced enamel epithelium
  16. 16. histologically • Anucleated epithelial cells with retention of cellular outline are present either in the epithelial lining or connective tissue is a characteristic finding and are called ‘ghost cells’. • Individual ghost cells may fuse together to form large sheets of amorphous eosinophilic structure on which calcification may occur. • Irregular masses of calcified structure suggestive of dysplastic dentin are present in association with basal layer denoting the inductive nature of the odontogenic epithelium.
  17. 17. Calcifying odontogenic cyst (COC) and calcifying cystic odontogenic tumor (CCOT) photomicrographs. COC, cystic epithelium is keratinized and produces irregular calcifications and aberrantly keratinized ghost cells
  18. 18. The CCOT is a cystic lesion in which the epithelial • Sometimes, variable quantities of dentinoid or dentin-like material are laid down adjacent to the epithelial lining and sometimes dental hard tissues resembling an odontoma are found. In some instances, melanin or clear cells could be identified
  19. 19. CCOT type 1 simple cystic CCOT. • This is a cystic lesion with features identical to the mentioned definition except for the presence of an associated odontoma.
  20. 20. Odontoma-associated CCOT, proliferating tumor mass containing dysplastic dentinoid materials (Den).
  21. 21. CCOT type 2 odontoma-associated CCOT • This is similar to the CCOT type 1, but dentin enamel, cementum and pulpal tissues are present in the form of a complex or compound odontoma.
  22. 22. CCOT type 3 ameloblastomatous proliferating CCOT • This is a cystic lesion with features similar to those described above. It is characterized by the presence of intraluminal or capsular plexiform growths similar to those seen in the plexiform variant of the cystic ameloblastoma. Sometimes follicles simulating solid ameloblastoma can be seen in the connective tissue capsule.
  23. 23. Ameloblastomatous proliferating CCOT, infiltratively proliferating tumor cells, accompanying multiple ghost cell calcifications.
  24. 24. type 4 CCOT-associated with benign odontogenic tumours other than odontoma • Certain cases are similar to CCOT type 1, but there are also areas resembling ameloblastic fibroma, ameloblastic fibroodontoma, adenomatoid odontogenic tumour or odontoameloblastoma.
  25. 25. The DGCT • is defined as a solid neoplastic growth formed by groups and islands of epithelial cells showing an ameloblastoma-like basal cell layer that sometimes shows nuclear polarization. • In the central part of the ameloblastomatous islands, tissue resembling the stellate reticulum of the enamel organ can also be found. Characteristically, it contains variable quantities of dentin-like material in the surrounding connective tissue and in close contact with the epithelial islands. Also, groups of ghost cells within the epithelial islands can be found. Two variants were identified: aggressive central and non-aggressive peripherally located tumours.
  26. 26. Dentinogenic ghost cell tumor photomicrographs. The polygonal epithelial strands are proliferative in the vicinity of eosinophilic dentinoid materials (D).
  27. 27. The GCOC • was diagnosed in terms of the 2005WHO guidelines. It is an uncommon malignant neoplasm that exhibits prominent mitotic activity, nuclear atypia and cellular pleomorphism, groups of ghost epithelial cells, necrosis, sometimes scarce mineralised or dentin- like material are found and has an infiltrative growth pattern. This neoplasm presents locally aggressive and destructive behaviour and at times, metastatic deposits can be found.
  28. 28. Malignant transformation • Malignant transformation rate • From 113 CCOTs, one case developed to a malignant • neoplasm (0.9%). • Less than 30 cases were reported
  29. 29. Conclusion • Previous reports indicate GCOTs have wide neoplastic potential. • CCOT is a cystic, painless, slowly growing tumor that commonly presents as a well-defined radiolucent or combined lesion that rarely recurs, whereas DGCT is aggressive and recurrences may be expected, and GCOC is in actuality a malignant neoplasm. • Furthermore, the term GCOT is useful for describing a solid neoplastic COC variant characterized by ameloblastomatous epithelial components accompanied by abundant ghost cell clusters and dentinoid materials
  30. 30. Refrances 1. Wright, J. M. et al. (2014) ‘Odontogenic Tumors, WHO 2005: Where Do We Go from Here?’, Head and Neck Pathology, 8(4), pp. 373–382. doi: 10.1007/s12105-014-0585-x.Lee, S. K. and Kim, Y. S. (2014) 2. ‘Current concepts and occurrence of epithelial odontogenic tumors: II. Calcifying epithelial odontogenic tumor versus ghost cell odontogenic tumors derived from calcifying odontogenic cyst’, Korean Journal of Pathology, 48(3), pp. 175–187. doi: 10.4132/KoreanJPathol.2014.48.3.175. 3. Thinakaran, M. et al. (2012) ‘Calcifying ghost cell odontogenic cyst: A review on terminologies and classifications.’, Journal of oral and maxillofacial pathology : JOMFP, 16(3), pp. 450–3. doi: 10.4103/0973-029X.102519.Hong, S. P., Ellis, G. L. and Hartman, K. S. (1991) 4. ‘Calcifying odontogenic cyst. A review of ninety-two cases with reevaluation of their nature as cysts or neoplasms, the nature of ghost cells, and subclassification’, Oral Surgery, Oral Medicine, Oral Pathology, 72(1), pp. 56–64. doi: 10.1016/0030-4220(91)90190-N.Csiba, A. (1983) 5. ‘Calcifying odontogenic cyst. (Gorlin cyst)’, Fogorvosi szemle, 76(10), pp. 314–316.Sonone, A., Sabane, V. S. and Desai, R. (2011) 6. ‘Calcifying ghost cell odontogenic cyst: report of a case and review of literature.’, Case reports in dentistry, 2011(Figure 1), p. 328743. doi: 10.1155/2011/328743.Arashiyama, T. et al. (2012) 7. ‘Ghost cell odontogenic carcinoma arising in the background of a benign calcifying cystic odontogenic tumor of the mandible’, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. Elsevier, 114(3), pp. e35–e40. doi: 10.1016/j.oooo.2012.01.018.Ledesma-Montes, C. et al. (2008) 8. ‘International collaborative study on ghost cell odontogenic tumours: Calcifying cystic odontogenic tumour, dentinogenic ghost cell tumour and ghost cell odontogenic carcinoma’, Journal of Oral Pathology and Medicine, 37(5), pp. 302–308. doi: 10.1111/j.1600-0714.2007.00623.x.Prætorius, F. et al. (1981) 9. ‘Calcifying Odontogenic Cyst TL - 39’, Acta Odontologica Scandinavica, 39 VN-r(4), pp. 227–240. doi: 10.3109/00016358109162284. 10. Regezi, J., 2012. Oral Pathology clinical pathological correlation. 6th ed. Missoury: Elsevier.