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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 28  |  Issue : 3  |  Page : 320-323

Osteosarcoma: A rare case report and review of literature


1 Department of Oral Medicine and Radiology, Yashoda Superspeciality Hospitals, Ghaziabad, Uttar Pradesh, India
2 Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India
3 Department of Oral Medicine and Radiology, Sarjug Dental College and Hospital, Darbhanga, Bihar, India

Date of Submission09-Jun-2015
Date of Acceptance26-Nov-2016
Date of Web Publication13-Dec-2016

Correspondence Address:
Dr. Mallika Kishore
Department of Oral Medicine and Radiology, Yashoda Superspeciality Hospitals, Ghaziabad, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.195647

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   Abstract 

Osteosarcoma of the jaws is a rare, aggressive, malignant mesenchymal tumor with an estimated incidence of 5% in 100,000 of the new cases per year. Osteosarcoma of jaws is a very rare disease and may constitute approximately 1% of all head and neck cancers and only 0.14% of intraoral malignancies. Approximately 7% of all osteosarcomas arise in the jawbones. Diagnosis of the tumor is important, especially in early stages for improving prognosis. Here, we report a rare case of osteosarcoma of chondroblastic variant in a 20-year-old girl, who presented with a bony swelling in the right mandibular posterior region, with a radiographic presentation of sunburst appearance, and the histopathological examination confirmed the diagnosis.

Keywords: Osteosarcoma, periosteal reaction, sunburst


How to cite this article:
Kishore M, Panat SR, Alok A, Singhal K. Osteosarcoma: A rare case report and review of literature. J Indian Acad Oral Med Radiol 2016;28:320-3

How to cite this URL:
Kishore M, Panat SR, Alok A, Singhal K. Osteosarcoma: A rare case report and review of literature. J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2022 Oct 7];28:320-3. Available from: https://www.jiaomr.in/text.asp?2016/28/3/320/195647


   Introduction Top


Osteosarcomas of the jaws are deforming lesions, and hence affect the individual in many facets of life. This is what makes it a very challenging lesion.[1] The term osteosarcoma refers to a heterogeneous group of primary malignant neoplasms affecting bone forming or mesenchymal tissues that have histopathologic evidence of osteogenic differentiation.[2] Osteosarcoma of jaws accounts for approximately 20% of all the sarcomas and approximately 4–6% occur in the maxillofacial region. Mandibular and maxillary osteosarcomas account for 6–9% of all the osteosarcomas and only 0.14% of intraoral malignancies.[3] In this article, along with presentation of an osteosarcoma case, we wish to stress the importance of dentists in diagnosis and prognosis of oral malignancies.


   Case Report Top


A 20-year-old female patient reported to the Department of Oral Medicine and Radiology with a chief complaint of swelling on the right side of face since two months. History of the present illness revealed that that at first the swelling was little in size which expanded quickly to reach up to the present size. Pain was dull, intermittent in nature, and aggravated on consuming food. Patient also gave a history of difficulty in mouth opening and chewing of food. Extraoral examination revealed a solitary diffuse swelling on the right side of the face extending superoinferiorly from ala tragus line to 2 cm beyond the lower border of mandible and anteroposteriorly from the left corner of the mouth to right side of the ear lobule [Figure 1]. The color of the overlying skin was normal with a shiny, tensed appearance. It was roughly 8 × 9 cm in size in greatest dimension and roughly oval in shape. Intraoral examination revealed an ulceroproliferative growth on the right mandibular gingiva extending from the mesial aspect of mandibular lateral incisor to the retromolar pad area. The overlying mucosa was erythematous in color measuring approximately 3 × 2 cm in its greatest dimension. On palpation, all the inspectory findings were confirmed. The swelling was firm in consistency, tender, and fixed to the underlying bone. It was smooth, nonfluctuant, noncompressible, and nonreducible in nature. No pulsations were felt on palpation. Buccal and lingual cortical plate expansion was evident. Mouth opening of the patient was reduced by approximately 10 mm [Figure 2]. Tooth numbers 35, 36, and 37 were clinically missing. Tooth numbers 32, 33, and 34 were having Grade 3 mobility. Based on the history and clinical examination, a provisional diagnosis of ameloblastoma was considered with a differential diagnosis of central giant granuloma and metastatic carcinoma of jaws. Orthopantomogram of the patient revealed an ill defined mixed radiopaque radiolucent lesion in the right mandibular region extending from the mesial aspect of mandibular lateral incisor involving the body of the mandible. It had ragged borders with increase in the width of ramus and body of the mandible, due to which there was lowering of inferior border of mandible. Internal structure showed mixed radiopaque radiolucent area with a radiating pattern. Horizontal bone loss was present with respect to 31, 32, 41, 42, and 43 [Figure 3]. Posteroanterior view of the skull showed similar findings [Figure 4]. Contrast enhanced computed tomography (CT) scan of the patient revealed large bony expansile heterogeneous mass lesion involving the right hemimandible with adjacent soft tissue edema with multiple areas of calcification and necrosis [Figure 5]. In the investigation, incisional biopsy of the lesion and hemimandibulectomy was done, and the specimen was sent to histopathological examination, which revealed presence of tumor osteoid and bone formation with bony trabeculae consisting of atypical osteoblasts. Osteoblasts showed frequent bizarre mitosis, altered nuclear/cytoplasmic ratio, and hyperchromatism. Predominantly malignant cartilaginous material was evident. In few areas osteoblasts appeared to be epithelioid in shape [Figure 6]. A chest radiograph was then advised to check for any lung metastasis. Based on the histopathological findings with correlation of radiographic and clinical presentation, the final diagnosis of well-differentiated osteogenic sarcoma was made.
Figure 1: Extraoral extent of the swelling

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Figure 2: Ulceroproliferative growth on the right mandibular gingiva

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Figure 3: Orthopantomograph revealing an ill-defined mixed radiopaque radiolucent lesion in the right mandibular region

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Figure 4: Posteroanterior skull revealing an ill-defined mixed radiopaque radiolucent lesion in the right mandibular region

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Figure 5: CT scan revealing large bony expansile heterogeneous mass lesion involving the right hemimandible with adjacent soft tissue edema with multiple areas of calcification and necrosis

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Figure 6: Photomicrograph showing the presence of tumor osteoid and bone formation with bony trabeculae consisting of atypical osteoblasts. Osteoblasts showed frequent bizarre mitosis, altered nuclear/cytoplasmic ratio, and hyperchromatism

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   Discussion Top


Osteosarcomas arise in several clinical settings, which include pre-existing bone abnormalities such as Paget's disease, fibrous dysplasia, giant cell tumor, multiple osteochondroma, bone infarct, chronic osteomyelitis, osteogenesis imperfecta, and a history of radiation exposure.[4] In the present case, however, the etiology remained unknown. Males are affected more frequently (male: female ratio; 1.4:1), though the rate for girls up to approximately 13 years of age are roughly 30% higher than those for boys. In the 15–24-year-old age group, the rate of occurrence in males exceeds those in females by approximately 140%.[5] The maxilla and mandible are equally involved. The mandibular tumors arise more frequently in the posterior body and in the horizontal ramus, whereas the maxillary tumors are discovered more commonly in the alveolar ridge, the sinus floor, and the palate.[6] The main clinical manifestations of osteosarcomas of the joint are pain of variable intensity, swelling of the bone and the adjacent soft tissues, tooth bulging and dislocation, lack of healing and swelling at the site of the tooth extraction, trismus and hypoesthaesia or paresthaesia in the case of the mandibular tumors, and nasal obstruction in maxillary tumors.[7]

In these lesions, the radiographic characteristics can play a more significant role. Radiologically, osteogenic sarcoma can appear as osteolytic or osteoblastic type or can have a mixed pattern.[7] Radiographically, osteosarcoma can appear with a variable bone density depending on the amount of bone formed by the neoplasm. In some cases, the typical “sunray” appearance is observed at the periphery of the tumor. The changes may be very subtle and difficult to recognize in the early course of the disease. Widened periodontal ligament space has been described as a classical sign of early osteosarcoma.[8] The extent of the tumor in both the bone and the soft tissue was best appreciated, as shown by cross-sectional imaging techniques such as CT or magnetic resonance imaging (MRI). A CT scan of an osteosarcoma often shows the formation of irregular endosteal and extracortical bone as well as a destroyed or obliterated cortex.[9] In most of the cases, the therapy of choice is radical surgical excision because it provides a 5-year survival rate of over 80%. As for chemotherapy, it appears that it does not have a significant impact on the survival rates of the patients with osteosarcoma of the jaws. This can be explained on the basis of the fact that the metastases were rare and late, occurring in only 18% of the cases and that the local recurrence of the lesion was still the leading cause of death. Rate of metastasis in jaw osteosarcomas is lower than those of the long bones. It usually metastasizes approximately 1.5–2 years after the initial diagnosis.[10]


   Conclusion Top


Osteosarcoma of jaws is an uncommon tumor. The possibility of osteosarcoma should be considered in any patient with jaw swelling for appropriate management. Thus, dentists play an important role not only in the diagnosis of oral but also the maxillofacial lesions, and they should be able to distinguish lesions, especially malignant ones, by combining clinical and radiological findings. In addition, CT scans are excellent for demonstrating the degree of intramedullary extension, cortical involvement, and soft tissue involvement. Thus, the treatment and prognosis for osteosarcoma depends to a large extent on early diagnosis and radical surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Nthumba PM. Osteosarcoma of the jaws: A review of literature and a case report on synchronous multicentric osteosarcomas. World J Surg Oncol 2012;10:240.  Back to cited text no. 1
    
2.
Schajowicz F, Sissons HA, Sobin LH. The World Health Organization's histologic classification of bone tumors. A commentary on the second edition. Cancer 1995;75:1208-14.  Back to cited text no. 2
    
3.
Gorsky M, Epstein JB. Head and neck and intra-oral soft tissue sarcomas. Oral Oncol 1998;34:292-6.  Back to cited text no. 3
    
4.
Khorate MM, Goel S, Singh MP, Ahmed J. Osteosarcoma of the mandible: A case report and review of the literature. J Cancer Sci Ther 2010;2:122-5.  Back to cited text no. 4
    
5.
Clark JL, Unni KK, Dahlin DC, Devine KD. Osteosarcoma of the jaw. Cancer 1983;51:2311-6.  Back to cited text no. 5
    
6.
Bojan A, Christy W, Chanmougananda S, Ashokan K. Osteosarcoma of mandible: A case report and review of literature. J Clin Diagn Res 2012;6:753-7.  Back to cited text no. 6
    
7.
Doval DC, Kumar RV, Kannan V, Sabitha KS, Misra S, Vijay Kumar M, et al. Osteosarcoma of the jaw bones. Br J Oral Maxillofac Surg 1997;35:357-62  Back to cited text no. 7
    
8.
Anil S, Krishnan AP, Rajendran R. Osteosarcoma of the mandible masquerading as a dental abscess: Report of a case. Case Rep Dent 2012:635062.  Back to cited text no. 8
    
9.
Nakayama E, Sugiura K, Ishibashi H, Oobu K, Kobayashi I, Yoshiura K. The clinical and diagnostic imaging findings of osteosarcoma of the jaw. Dentomaxillofac Radiol 2005;34:182-8.  Back to cited text no. 9
    
10.
Thiele OC, Freier K, Bacon C, Egerer G, Hofele CM. Interdisciplinary combined treatment of craniofacial osteosarcoma with neoadjuvant and adjuvant chemotherapy and excision of the tumour: A retrospective study. Br J Oral Maxillofac Surg 2008;46:533-6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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