Pathology – Research and Practice 210 (2014) 224–227
Contents lists available at ScienceDirect
Pathology – Research and Practice journal homepage: www.elsevier.com/locate/prp
Original Article
Utility of cell block in the cytological preoperative diagnosis of keratocystic odontogenic tumor Elena Riet Correa Rivero a,∗ , Liliane Janete Grando a , Grasieli de Oliveira Ramos b , Maria Fernanda da Silva Belatto c , Filipe Ivan Daniel a a
Department of Pathology, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil Post-Graduate Program in Dentistry, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil c Post-Graduate Program in Dentistry, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil b
a r t i c l e
i n f o
Article history: Received 24 September 2013 Received in revised form 14 November 2013 Accepted 16 December 2013 Keywords: Cytology Biopsy Odontogenic tumors
a b s t r a c t In most cases involving jaw lesions, a biopsy and a histopathological analysis are necessary to establish the final diagnosis. However, biopsy may be a complex procedure at some maxillomandibular sites, and some systemic conditions could contraindicate the procedure. Thus, a search for new, less invasive techniques, which could eventually replace biopsy and simplify the diagnostic process, would benefit both professionals and patients. The aim of this study was to evaluate the cell block technique, prepared from the aspiration of luminal contents, in the preoperative diagnosis of keratocystic odontogenic tumors (KCOT). From 135 cases of lesions aspirated and processed by the cell block technique, we selected those containing keratin. In all cases selected, histological diagnosis was based on surgical biopsy. From 20 cases containing keratin in the cytological analyses, 19 were KCOTs and one was an orthokeratinized odontogenic cyst (OOC). In all KCOT cases, we observed the presence of parakeratin, even in those with intense inflammation. In the cytological analysis of the OOC, parakeratin was not observed. In conclusion, there is strong evidence that KCOT can be confidently diagnosed preoperatively by cytological analyses of lesions punctured and processed by the cell block technique. © 2013 Elsevier GmbH. All rights reserved.
Introduction Since first described, the odontogenic keratocyst has been among the most controversial pathological entities of the maxillofacial region [14]. The World Health Organization (WHO) recently reclassified it as a benign neoplasm, recommending the term “keratocystic odontogenic tumor” (KCOT) [3]. This change reflects the neoplastic nature of the lesion, due to its aggressive potential (infiltrating the medullary spaces of jaw bones), high recurrence rates, and, in some cases, association with nevoid basal cell carcinoma syndrome [4,5]. KCOT is defined as a benign uni- or multicystic intraosseous tumor of odontogenic epithelial origin [13]. Its typical histological features include a thin and regular stratified squamous epithelium with a corrugated parakeratin surface layer. The basal cells exhibit a characteristic palisaded pattern with uniform nuclei. The
∗ Corresponding author at: Department of Pathology, Center of Health Sciences, Federal University of Santa Catarina, University Campus, Trindade, Florianópolis 88.040-370, SC, Brazil. Tel.: +554837215068; fax: +554837219542. E-mail addresses: [email protected], [email protected] (E.R.C. Rivero). 0344-0338/$ – see front matter © 2013 Elsevier GmbH. All rights reserved. http://dx.doi.org/10.1016/j.prp.2013.12.006
epithelium can show budding of the basal layer into underlying connective tissue, with formation of detached microcysts, called daughter cysts. The wall of the cystic capsule is relatively thin and usually without inflammatory infiltrate [13,10]. In the presence of intense inflammation, the epithelial lining loses its cellular characteristic and architectural features, making histopathological diagnosis difficult [13]. Aspiration puncture is a suitable technique to aid in the establishment of a clinical diagnosis of jaw lesions. A cystic lesion aspiration can provide additional information on its content, whether it is liquid, serous, or absent, supporting an initial clinical diagnosis. Cell blocks prepared from residual tissue fluids using fine-needle aspirations can be useful adjuncts for establishing a cytopathologic diagnosis [11]. The advantage of using cell blocks is that the cell dispersion characteristic of analyzed fluids is decreased, through centrifugation and embedding in paraffin blocks, which allows a better analysis of the content present in the collected liquid [6]. Although it is a simple, fast, and low-cost technique, the cell block has been rarely mentioned in the dental literature. In previous research, we demonstrated the cytological differentiation between KCOTs and inflammatory cysts of the jaw [12,15]. In the present
E.R.C. Rivero et al. / Pathology – Research and Practice 210 (2014) 224–227
225
Fig. 1. Cytological analysis (cell block) of KCOT (H&E 400×): (A) presence of several desquamated keratinocytes, with different degrees of maturity, as well as short parakeratin strips; (B) parakeratin strips; (C) several inflammatory cells with presence of keratin, and parakeratin (arrow) in the focal area; (D) short parakeratin strips and keratinocyte (arrow).
study, our objective was to evaluate the cell block’s result as a cytological tool for KCOT diagnosis, regardless of the presence of inflammation. Materials and methods This study was approved by the Ethics Committee of the Federal University of Santa Catarina (no. 145/2008). Patients with intraosseous jaw lesions, and clinical recommendation of aspiration, were submitted to asepsis, local anesthesia, and puncture by an 18-gauge needle attached to a 10 mL syringe. The syringe containing the material collected was immediately packaged in an ice-cooled container. In the laboratory, the material was removed from the syringe, transferred to a test tube, and centrifuged at 2000 rpm for 20 min. The pellet obtained was transferred to absorbent paper and fixed in a 10% formaldehyde solution for 24 h. Sequentially, the material was processed as follows: dehydration, clearing, impregnation and embedment in paraffin. Sections of 3 m were obtained and stained with hematoxylin-eosin (H&E). The cell block slides were analyzed by light microscopy (Axiostar Plus; Carl Zeiss, Oberkochen, Germany). From all lesions punctured, we selected those containing keratin in the cytological analysis. The selected cases were evaluated to characterize the type of keratin (parakeratin or orthokeratin), and to determine the presence of epithelial and inflammatory cells. In all cases, the histological diagnosis was performed by surgical biopsy. Results From 135 cases of lesions punctured and processed by the cell block technique, 20 cases were found to contain keratin in the cytological analyses. Of these, 19 were KCOTs, and only one was an orthokeratinized odontogenic cyst (OOC). In all cases of KCOT, we observed the presence of parakeratin (Fig. 1), even in lesions with intense inflammation (Fig. 1C). In some
samples, keratin was composed of short and sparse lamellae (Fig. 1A and D) and in others of long lamellae (Fig. 1B). Several desquamated normal keratinocytes, with different degrees of maturity, and numerous anucleated squamous cells were observed in most samples (Fig. 1A). These results demonstrated the high sensitivity of the technique. The biopsy specimens of KCOT revealed a cystic capsule lined by parakeratinized stratified squamous epithelium, with palisaded basal cells and a corrugated surface pattern (Fig. 2A and B). In the presence of intense inflammation, some cases showed partial loss of epithelial appearance (Fig. 2C and D). In the OOC, the epithelial lining was thin and uniform, with an average thickness of 4–8 cells, showing an onion skin-like orthokeratin layer and a prominent granular cell layer (Fig. 3A). In the cytological analysis of this case, the keratin was composed of short and sparse lamellae, and parakeratin and epithelial cells were not observed (Fig. 3B). In the other 115 cases punctured, in which cytological analyses showed a lack of keratin, none were classified as KCOT or OOC in the histological diagnosis. Discussion Biopsy and histopathological analyses are necessary to establish a definitive diagnosis in most bone lesions [1]. As a surgical procedure may be complex at some maxillomandibular sites, with many local and systemic implications contraindicating it, aspiration may be used in some cases [15]. The material collected should be first visually examined, with a special focus on color and consistency. Later, this material must be microscopically assessed. This cytological analysis can be done by smearing the aspirated fluid directly onto a glass slide or by the cell block technique. The latter involves a histological technique for processing, and thus multiple sections of the same material can be used for routine stains. The advantage of using the cell block, as compared with conventional smears, is decreased cellular dispersion, contributing to maximum
226
E.R.C. Rivero et al. / Pathology – Research and Practice 210 (2014) 224–227
Fig. 2. Biopsy specimens of KCOT: (A) connective tissue capsule lined by thin and uniform epithelial tissue (H&E 100×); (B) high magnification showing the stratified epithelial lining with a palisade basal layer and corrugated parakeratin on the surface (H&E 400×); (C) histological appearance of inflamed KCOT, with the presence of cholesterol clefts inside the capsule and the stratified epithelial lining (H&E 100×); (D) high magnification showing the loose epithelial appearance of KCOT (H&E 400×).
cellular concentration, and facilitating microscopic analysis. Another advantage is that the material may be stored for future use to carry out special stains and for immunocytochemistry, if necessary [7,9,16]. Previously, Kramer and Toller reported the presence of keratin in cyst contents as strong evidence of KCOT [8]. Other authors have demonstrated the utility of the cytological analysis of KCOT by fineneedle aspiration biopsy, in preoperative surgical planning [2,17]. In two previous studies, we presented the applicability of the cell
block technique in differential diagnosis between KCOT and other jaw lesions with cystic characteristics, aiding in the therapeutic planning for treatment of these lesions [12,15]. In the same way, Vargas et al. demonstrated the value of fine-needle aspiration cytology by using the cell block technique combined with cytokeratin immunohistochemical analysis, as a reliable and safe tool for the preoperative diagnosis of KCOT [16]. In our study, the cell block method was shown to be very effective in the diagnosis of KCOTs through parakeratin identification.
Fig. 3. Orthokeratinised odontogenic cysts: (A) histological appearance showing stratified epithelial lining with an onion skin-like orthokeratin layer and prominent granular cell layer (H&E 400×); (B) cytological analysis of the same case showing short and sparse lamellae of keratin, without the presence of parakeratin (H&E 400×).
E.R.C. Rivero et al. / Pathology – Research and Practice 210 (2014) 224–227
Parakeratin was present in all cases, even in the presence of intense inflammatory infiltrate. It is important to note that inflammation could affect the KCOT wall, causing epithelial metaplasia and loss of the peculiar tumor characteristics [5], and making the correct diagnosis difficult. In secondarily infected lesions, diagnosis could be very difficult, depending on the lesion area biopsied. Another point is that, in all punctured KCOT cases, it was possible to observe the presence of parakeratin in cell block specimens. A variety of bone lesions can show radiographic manifestations similar to those of KCOT. The differential diagnosis includes odontogenic and nonodontogenic cysts, as well as other odontogenic tumors (ameloblastomas and adenomatoid odontogenic tumors) and nonodontogenic tumors (central giant cell lesions) [1,18,19]. Depending on the diagnosis, treatment options vary, and thus, it is important to ensure the correct preoperative diagnosis prior to undertaking definitive surgical therapy. In our sample of 135 punctured cases, cytological analyses showed keratin in 20, and of these, 19 were KCOT. In only one case was keratin (rather than parakeratin) associated with an OOC, in contrast to all KCOT cases in this study. Unlike KCOT, OOC is rare, with low aggressive potential and a minimal rate of recurrence [20]. According to our results, cytological assessment by the cell block technique, prepared from the aspiration of luminal contents, is useful in the preoperative diagnosis of KCOT, eliminating the requirement for an incisional biopsy, which may result in discomfort to the patient or in contamination and subsequent infection of the lesion. References [1] M. Ali, R.A. Baughman, Maxillary odontogenic keratocyst: a common and serious clinical misdiagnosis, J. Am. Dent. Assoc. 134 (2003) 877–883. [2] M. August, W. Faquin, M. Troulis, L. Kaban, Differentiation of odontogenic keratocysts from nonkeratinizing cysts by use of fine-needle aspiration biopsy and cytokeratin-10 staining, J. Oral Maxillofac. Surg. 58 (2000) 935–941. [3] L. Barnes, J.W. Eveson, P.A. Reichart, D. Sidransky, WHO Classification of Tumours, in: Pathology and Genetics of Head and Neck Tumours, IARC Press, Lyon, 2005, pp. 430.
227
[4] R.B. Bell, E.J. Dierks, Treatment options for the recurrent odontogenic keratocyst, Oral Maxillofac. Surg. Clin. N. Am. 15 (2003) 429–446. [5] R.C. Jordan, Histology and ultrastructural features of the odontogenic keratocyst, Oral Maxillofac. Surg. Clin. N. Am. 15 (2003) 325–333. [6] P.N. Karnachow, R.E. Bonin, Cell block technique for fine needle aspiration biopsy, J. Clin. Pathol. 35 (1982) 688. [7] K.K. Khurana, I. Ramzy, L.D. Truong, p53 immunolocalization in cell block preparations of squamous lesions of the neck: an adjunct to fine-needle aspiration diagnosis of malignancy, Arch. Pathol. Lab. Med. 123 (1999) 421–425. [8] I. Kramer, P. Toller, The use of exfoliative cytology and protein estimations in preoperative diagnosis of odontogenic keratocysts, Int. J. Oral Surg. 2 (1973) 143–151. [9] F. Mayall, B. Chang, A. Darlington, A review of 50 consecutive cytology cell block preparations in a large general hospital, J. Clin. Pathol. 50 (1997) 985– 990. [10] R.A. Mendes, J.F. Carvalho, I. van der Waal, Characterization and management of the keratocystic odontogenic tumor in relation to its histopathological and biological features, Oral Oncol. 46 (2010) 219–225. [11] N.A. Nathan, E. Narayan, M.M. Smith, M.J. Horn, Cell block cytology. Improved preparation and its efficacy in diagnostic cytology, Am. J. Clin. Pathol. 114 (2000) 599–606. [12] A.C. Oenning, E.R. Rivero, M.C. Calvo, M.I. Meurer, L.J. Grando, Evaluation of the cell block technique as an auxiliary method of diagnosing jawbone lesions, Braz. Oral Res. 26 (2012) 355–359. [13] H.P. Philipsen, Keratocystic odontogenic tumour, in: L. Barnes, J.W. Eveson, P.A. Reichart, D. Sidransky (Eds.), World Health Organization Classification of Tumours. Pathology and Genetics of Head and Neck Tumours, IARC Press, Lyon, 2005, pp. 306–307. [14] H.P. Philipsen, Om keratocyster (kolesteratomer) i kaeberne, Tandlaegebladet 96 (1956) 3–71. [15] E.R. Rivero, L.J. Grando, F. Menegat, J.D. Claus, F.M. Xavier, Cell block technique as a complementary method in the clinical diagnosis of cyst-like lesions of the jaw, J. Appl. Oral Sci. 19 (2011) 269–273. [16] P. Vargas, D. da Cruz Perez, G. Mata, O. de Almeida, A. Jones, R. Gerhard, Fine needle aspiration cytology as an additional tool in the diagnosis of odontogenic keratocyst, Cytopathology 18 (2007) 361–366. [17] O. Dereci, A. Oztürk, O. Günhan, The efficacy of fine needle aspiration cytology in the preoperative evaluation of parakeratotic odontogenic keratocysts, Acta Cytol. 55 (2011) 131–134. [18] J.A. Garlock, G.A. Pringle, M.L. Hicks, The odontogenic keratocyst: a potential endodontic misdiagnosis, Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 85 (1998) 452–456. [19] R. Raitz, L. Correa, M. Curi, L. Dib, M. Fenyo-Pereira, Conventional and indirect digital radiographic interpretation of oral unilocular radiolucent lesions, Dentomaxillofac. Radiol. 35 (2006) 165–169. [20] Q. Dong, S. Pan, L.S. Sun, T.J. Li, Orthokeratinized odontogenic cyst: a clinicopathologic study of 61 cases, Arch. Pathol. Lab. Med. 134 (2010) 271–275.
Contents lists available at ScienceDirect
Pathology – Research and Practice journal homepage: www.elsevier.com/locate/prp
Original Article
Utility of cell block in the cytological preoperative diagnosis of keratocystic odontogenic tumor Elena Riet Correa Rivero a,∗ , Liliane Janete Grando a , Grasieli de Oliveira Ramos b , Maria Fernanda da Silva Belatto c , Filipe Ivan Daniel a a
Department of Pathology, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil Post-Graduate Program in Dentistry, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil c Post-Graduate Program in Dentistry, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil b
a r t i c l e
i n f o
Article history: Received 24 September 2013 Received in revised form 14 November 2013 Accepted 16 December 2013 Keywords: Cytology Biopsy Odontogenic tumors
a b s t r a c t In most cases involving jaw lesions, a biopsy and a histopathological analysis are necessary to establish the final diagnosis. However, biopsy may be a complex procedure at some maxillomandibular sites, and some systemic conditions could contraindicate the procedure. Thus, a search for new, less invasive techniques, which could eventually replace biopsy and simplify the diagnostic process, would benefit both professionals and patients. The aim of this study was to evaluate the cell block technique, prepared from the aspiration of luminal contents, in the preoperative diagnosis of keratocystic odontogenic tumors (KCOT). From 135 cases of lesions aspirated and processed by the cell block technique, we selected those containing keratin. In all cases selected, histological diagnosis was based on surgical biopsy. From 20 cases containing keratin in the cytological analyses, 19 were KCOTs and one was an orthokeratinized odontogenic cyst (OOC). In all KCOT cases, we observed the presence of parakeratin, even in those with intense inflammation. In the cytological analysis of the OOC, parakeratin was not observed. In conclusion, there is strong evidence that KCOT can be confidently diagnosed preoperatively by cytological analyses of lesions punctured and processed by the cell block technique. © 2013 Elsevier GmbH. All rights reserved.
Introduction Since first described, the odontogenic keratocyst has been among the most controversial pathological entities of the maxillofacial region [14]. The World Health Organization (WHO) recently reclassified it as a benign neoplasm, recommending the term “keratocystic odontogenic tumor” (KCOT) [3]. This change reflects the neoplastic nature of the lesion, due to its aggressive potential (infiltrating the medullary spaces of jaw bones), high recurrence rates, and, in some cases, association with nevoid basal cell carcinoma syndrome [4,5]. KCOT is defined as a benign uni- or multicystic intraosseous tumor of odontogenic epithelial origin [13]. Its typical histological features include a thin and regular stratified squamous epithelium with a corrugated parakeratin surface layer. The basal cells exhibit a characteristic palisaded pattern with uniform nuclei. The
∗ Corresponding author at: Department of Pathology, Center of Health Sciences, Federal University of Santa Catarina, University Campus, Trindade, Florianópolis 88.040-370, SC, Brazil. Tel.: +554837215068; fax: +554837219542. E-mail addresses: [email protected], [email protected] (E.R.C. Rivero). 0344-0338/$ – see front matter © 2013 Elsevier GmbH. All rights reserved. http://dx.doi.org/10.1016/j.prp.2013.12.006
epithelium can show budding of the basal layer into underlying connective tissue, with formation of detached microcysts, called daughter cysts. The wall of the cystic capsule is relatively thin and usually without inflammatory infiltrate [13,10]. In the presence of intense inflammation, the epithelial lining loses its cellular characteristic and architectural features, making histopathological diagnosis difficult [13]. Aspiration puncture is a suitable technique to aid in the establishment of a clinical diagnosis of jaw lesions. A cystic lesion aspiration can provide additional information on its content, whether it is liquid, serous, or absent, supporting an initial clinical diagnosis. Cell blocks prepared from residual tissue fluids using fine-needle aspirations can be useful adjuncts for establishing a cytopathologic diagnosis [11]. The advantage of using cell blocks is that the cell dispersion characteristic of analyzed fluids is decreased, through centrifugation and embedding in paraffin blocks, which allows a better analysis of the content present in the collected liquid [6]. Although it is a simple, fast, and low-cost technique, the cell block has been rarely mentioned in the dental literature. In previous research, we demonstrated the cytological differentiation between KCOTs and inflammatory cysts of the jaw [12,15]. In the present
E.R.C. Rivero et al. / Pathology – Research and Practice 210 (2014) 224–227
225
Fig. 1. Cytological analysis (cell block) of KCOT (H&E 400×): (A) presence of several desquamated keratinocytes, with different degrees of maturity, as well as short parakeratin strips; (B) parakeratin strips; (C) several inflammatory cells with presence of keratin, and parakeratin (arrow) in the focal area; (D) short parakeratin strips and keratinocyte (arrow).
study, our objective was to evaluate the cell block’s result as a cytological tool for KCOT diagnosis, regardless of the presence of inflammation. Materials and methods This study was approved by the Ethics Committee of the Federal University of Santa Catarina (no. 145/2008). Patients with intraosseous jaw lesions, and clinical recommendation of aspiration, were submitted to asepsis, local anesthesia, and puncture by an 18-gauge needle attached to a 10 mL syringe. The syringe containing the material collected was immediately packaged in an ice-cooled container. In the laboratory, the material was removed from the syringe, transferred to a test tube, and centrifuged at 2000 rpm for 20 min. The pellet obtained was transferred to absorbent paper and fixed in a 10% formaldehyde solution for 24 h. Sequentially, the material was processed as follows: dehydration, clearing, impregnation and embedment in paraffin. Sections of 3 m were obtained and stained with hematoxylin-eosin (H&E). The cell block slides were analyzed by light microscopy (Axiostar Plus; Carl Zeiss, Oberkochen, Germany). From all lesions punctured, we selected those containing keratin in the cytological analysis. The selected cases were evaluated to characterize the type of keratin (parakeratin or orthokeratin), and to determine the presence of epithelial and inflammatory cells. In all cases, the histological diagnosis was performed by surgical biopsy. Results From 135 cases of lesions punctured and processed by the cell block technique, 20 cases were found to contain keratin in the cytological analyses. Of these, 19 were KCOTs, and only one was an orthokeratinized odontogenic cyst (OOC). In all cases of KCOT, we observed the presence of parakeratin (Fig. 1), even in lesions with intense inflammation (Fig. 1C). In some
samples, keratin was composed of short and sparse lamellae (Fig. 1A and D) and in others of long lamellae (Fig. 1B). Several desquamated normal keratinocytes, with different degrees of maturity, and numerous anucleated squamous cells were observed in most samples (Fig. 1A). These results demonstrated the high sensitivity of the technique. The biopsy specimens of KCOT revealed a cystic capsule lined by parakeratinized stratified squamous epithelium, with palisaded basal cells and a corrugated surface pattern (Fig. 2A and B). In the presence of intense inflammation, some cases showed partial loss of epithelial appearance (Fig. 2C and D). In the OOC, the epithelial lining was thin and uniform, with an average thickness of 4–8 cells, showing an onion skin-like orthokeratin layer and a prominent granular cell layer (Fig. 3A). In the cytological analysis of this case, the keratin was composed of short and sparse lamellae, and parakeratin and epithelial cells were not observed (Fig. 3B). In the other 115 cases punctured, in which cytological analyses showed a lack of keratin, none were classified as KCOT or OOC in the histological diagnosis. Discussion Biopsy and histopathological analyses are necessary to establish a definitive diagnosis in most bone lesions [1]. As a surgical procedure may be complex at some maxillomandibular sites, with many local and systemic implications contraindicating it, aspiration may be used in some cases [15]. The material collected should be first visually examined, with a special focus on color and consistency. Later, this material must be microscopically assessed. This cytological analysis can be done by smearing the aspirated fluid directly onto a glass slide or by the cell block technique. The latter involves a histological technique for processing, and thus multiple sections of the same material can be used for routine stains. The advantage of using the cell block, as compared with conventional smears, is decreased cellular dispersion, contributing to maximum
226
E.R.C. Rivero et al. / Pathology – Research and Practice 210 (2014) 224–227
Fig. 2. Biopsy specimens of KCOT: (A) connective tissue capsule lined by thin and uniform epithelial tissue (H&E 100×); (B) high magnification showing the stratified epithelial lining with a palisade basal layer and corrugated parakeratin on the surface (H&E 400×); (C) histological appearance of inflamed KCOT, with the presence of cholesterol clefts inside the capsule and the stratified epithelial lining (H&E 100×); (D) high magnification showing the loose epithelial appearance of KCOT (H&E 400×).
cellular concentration, and facilitating microscopic analysis. Another advantage is that the material may be stored for future use to carry out special stains and for immunocytochemistry, if necessary [7,9,16]. Previously, Kramer and Toller reported the presence of keratin in cyst contents as strong evidence of KCOT [8]. Other authors have demonstrated the utility of the cytological analysis of KCOT by fineneedle aspiration biopsy, in preoperative surgical planning [2,17]. In two previous studies, we presented the applicability of the cell
block technique in differential diagnosis between KCOT and other jaw lesions with cystic characteristics, aiding in the therapeutic planning for treatment of these lesions [12,15]. In the same way, Vargas et al. demonstrated the value of fine-needle aspiration cytology by using the cell block technique combined with cytokeratin immunohistochemical analysis, as a reliable and safe tool for the preoperative diagnosis of KCOT [16]. In our study, the cell block method was shown to be very effective in the diagnosis of KCOTs through parakeratin identification.
Fig. 3. Orthokeratinised odontogenic cysts: (A) histological appearance showing stratified epithelial lining with an onion skin-like orthokeratin layer and prominent granular cell layer (H&E 400×); (B) cytological analysis of the same case showing short and sparse lamellae of keratin, without the presence of parakeratin (H&E 400×).
E.R.C. Rivero et al. / Pathology – Research and Practice 210 (2014) 224–227
Parakeratin was present in all cases, even in the presence of intense inflammatory infiltrate. It is important to note that inflammation could affect the KCOT wall, causing epithelial metaplasia and loss of the peculiar tumor characteristics [5], and making the correct diagnosis difficult. In secondarily infected lesions, diagnosis could be very difficult, depending on the lesion area biopsied. Another point is that, in all punctured KCOT cases, it was possible to observe the presence of parakeratin in cell block specimens. A variety of bone lesions can show radiographic manifestations similar to those of KCOT. The differential diagnosis includes odontogenic and nonodontogenic cysts, as well as other odontogenic tumors (ameloblastomas and adenomatoid odontogenic tumors) and nonodontogenic tumors (central giant cell lesions) [1,18,19]. Depending on the diagnosis, treatment options vary, and thus, it is important to ensure the correct preoperative diagnosis prior to undertaking definitive surgical therapy. In our sample of 135 punctured cases, cytological analyses showed keratin in 20, and of these, 19 were KCOT. In only one case was keratin (rather than parakeratin) associated with an OOC, in contrast to all KCOT cases in this study. Unlike KCOT, OOC is rare, with low aggressive potential and a minimal rate of recurrence [20]. According to our results, cytological assessment by the cell block technique, prepared from the aspiration of luminal contents, is useful in the preoperative diagnosis of KCOT, eliminating the requirement for an incisional biopsy, which may result in discomfort to the patient or in contamination and subsequent infection of the lesion. References [1] M. Ali, R.A. Baughman, Maxillary odontogenic keratocyst: a common and serious clinical misdiagnosis, J. Am. Dent. Assoc. 134 (2003) 877–883. [2] M. August, W. Faquin, M. Troulis, L. Kaban, Differentiation of odontogenic keratocysts from nonkeratinizing cysts by use of fine-needle aspiration biopsy and cytokeratin-10 staining, J. Oral Maxillofac. Surg. 58 (2000) 935–941. [3] L. Barnes, J.W. Eveson, P.A. Reichart, D. Sidransky, WHO Classification of Tumours, in: Pathology and Genetics of Head and Neck Tumours, IARC Press, Lyon, 2005, pp. 430.
227
[4] R.B. Bell, E.J. Dierks, Treatment options for the recurrent odontogenic keratocyst, Oral Maxillofac. Surg. Clin. N. Am. 15 (2003) 429–446. [5] R.C. Jordan, Histology and ultrastructural features of the odontogenic keratocyst, Oral Maxillofac. Surg. Clin. N. Am. 15 (2003) 325–333. [6] P.N. Karnachow, R.E. Bonin, Cell block technique for fine needle aspiration biopsy, J. Clin. Pathol. 35 (1982) 688. [7] K.K. Khurana, I. Ramzy, L.D. Truong, p53 immunolocalization in cell block preparations of squamous lesions of the neck: an adjunct to fine-needle aspiration diagnosis of malignancy, Arch. Pathol. Lab. Med. 123 (1999) 421–425. [8] I. Kramer, P. Toller, The use of exfoliative cytology and protein estimations in preoperative diagnosis of odontogenic keratocysts, Int. J. Oral Surg. 2 (1973) 143–151. [9] F. Mayall, B. Chang, A. Darlington, A review of 50 consecutive cytology cell block preparations in a large general hospital, J. Clin. Pathol. 50 (1997) 985– 990. [10] R.A. Mendes, J.F. Carvalho, I. van der Waal, Characterization and management of the keratocystic odontogenic tumor in relation to its histopathological and biological features, Oral Oncol. 46 (2010) 219–225. [11] N.A. Nathan, E. Narayan, M.M. Smith, M.J. Horn, Cell block cytology. Improved preparation and its efficacy in diagnostic cytology, Am. J. Clin. Pathol. 114 (2000) 599–606. [12] A.C. Oenning, E.R. Rivero, M.C. Calvo, M.I. Meurer, L.J. Grando, Evaluation of the cell block technique as an auxiliary method of diagnosing jawbone lesions, Braz. Oral Res. 26 (2012) 355–359. [13] H.P. Philipsen, Keratocystic odontogenic tumour, in: L. Barnes, J.W. Eveson, P.A. Reichart, D. Sidransky (Eds.), World Health Organization Classification of Tumours. Pathology and Genetics of Head and Neck Tumours, IARC Press, Lyon, 2005, pp. 306–307. [14] H.P. Philipsen, Om keratocyster (kolesteratomer) i kaeberne, Tandlaegebladet 96 (1956) 3–71. [15] E.R. Rivero, L.J. Grando, F. Menegat, J.D. Claus, F.M. Xavier, Cell block technique as a complementary method in the clinical diagnosis of cyst-like lesions of the jaw, J. Appl. Oral Sci. 19 (2011) 269–273. [16] P. Vargas, D. da Cruz Perez, G. Mata, O. de Almeida, A. Jones, R. Gerhard, Fine needle aspiration cytology as an additional tool in the diagnosis of odontogenic keratocyst, Cytopathology 18 (2007) 361–366. [17] O. Dereci, A. Oztürk, O. Günhan, The efficacy of fine needle aspiration cytology in the preoperative evaluation of parakeratotic odontogenic keratocysts, Acta Cytol. 55 (2011) 131–134. [18] J.A. Garlock, G.A. Pringle, M.L. Hicks, The odontogenic keratocyst: a potential endodontic misdiagnosis, Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 85 (1998) 452–456. [19] R. Raitz, L. Correa, M. Curi, L. Dib, M. Fenyo-Pereira, Conventional and indirect digital radiographic interpretation of oral unilocular radiolucent lesions, Dentomaxillofac. Radiol. 35 (2006) 165–169. [20] Q. Dong, S. Pan, L.S. Sun, T.J. Li, Orthokeratinized odontogenic cyst: a clinicopathologic study of 61 cases, Arch. Pathol. Lab. Med. 134 (2010) 271–275.
