Radiographic diagnoses of jaw sarcomas
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Transcript of Radiographic diagnoses of jaw sarcomas
Original Article
Radiographic Diagnoses of Jaw Sarcomas
Part I Relationship between Radiographic
Grades and Prognosis
Gang ZHANG, D.D.S., M.S., Xu-chen MA, D.D.S., Ph.D.
and Zhao-ju ZOU, D.D.S., F.I.C.D.
Department. of Oral Radiology, School of Stomatology, Beijing Medical University, Beijing, China
(Received : Sept. 25, 1989, Accepted : May 12, 1990)
Key Words : Jaw sarcomas, Radiologic diagnosis, Radiographic grade, Prognosis
The radiographic manifestat ions and the relationship between radiographic grades and prognosis
of 76 cases of jaw sarcomas were analysised in the present study. The authors thought that the
radiographic grades of jaw sarcomas suggested by authors could be used in the clinical practice to
predict the prognosis of the patients. The higher the radiographic grade is, the lower the 5-year
suvival rate will he. It was worth notic ing that the prognosis of the patients with "peeling-like
resorption" of the dental roots was very poor. The extent of mandibular canal change as usually more
extensive than the bony destructive extent showed on radiographs.
It is well known that sarcomas of the
jaws could be divided into osteosarcoma,
chondrosarcoma and fibrosarcoma according
to their histological classification. However,
it is usually difficult to differentiate them
exactlyl-4)and to predict their prognosis
based on their radiographic manifestations.
Seventy-six cases with jaw sarcoma
were included in the present study. The
authors tried to find a rad iographic
classification of jaw sarcomas which could be
used to predict their prognosis.
M a t e r i a l s a n d M e t h o d s
Seventy-six cases with jaw sarcoma,
Oral Radiol. Vol.6 No.1 1990(i~7
treated in our hospital from 1954-1988, were
included in the present study. The clinical,
pathological and radiographic materials of
all the cases were available. Of the 76 cases,
31 were osteosarcomas (OS), 33 cases were
fibrosarcomas (FS) and the other 12 cases
were chondrosarcomas (CS).
1. The clinical histories of all 76 cases were
reviewed and 70 cases were followed-up;
2. Pathological examination: Pathological
sections of all cases were reviewed and tumor
differentiation was divided into three degrees.
The pathological reviews were finished with-
out knowing the clinical history and radiogra-
phic manifestation;
1
3, Radiographic analysis: Radiographic
manifestations of all the cases were analysed
and divided into four grades;
4. Statistical analysis: Kaplan-Meier living
curves were made for the patients with jaw
s a r c o m a s of d i f f e r e n t h i s t o l o g i c a l
classification. Log-rank test and multiple
stepwise regression analysis were used in the
present study.
Results
1, Age, Sex and Location
The ages of the 76 cases ranged from six
months to 81 years (Table 1) and the average
was 34.9 years. The sex distribution of the
76 cases and the locations of the tumors are
shown on Table 2. The peak of jaw sarcoma
occurrence was f rom 30 to 40 years: 24 cases
(32%). Male to female was 1.9 to 1.
2. The interval f rom the first symptOm until
the first therapeutic a t tempt varied from 10
days to 4 years and the average was 6.5
months.
3. Pathologic grades
Table 1 Age of 76 cases with jaw sarcoma
Age- OS ~ C S FS Total
0--9 i 0 4 5 10--19 4 2 4 10 20--29 7 2 3 12 30--39 10 6 8 24 40--49 6 1 2 9 50--59 1 0 8 9 60--69 1 0 3 4 70-- 1 1 1 3
Total 31 - - 1 2 ~ - - 3 ~ - - 76
Grade I: the most differentiated tumor,
28 cases (36.8%),
Grade II: the middle differentiated tumor,
40 cases (52.6%),
Grade III: the least differentiated tumor,
8 cases (10.5%).
4. Radiographic manfestat ions
1 ) Bony Destruction: The degree of destruc-
tion of the bone could be divided into two
kinds:
A. The tumor was located within the
maxil lary sinus or alveolar process or within
the scope of the mandibular cortical bone for
27 cases (35.5%) (Fig. 1A);
B. The bony wall of the maxil lary sinus
or the cortical bone of the mandible had been
destroyed by the tumor in 49 cases (64.5%)
(Fig. 1B).
Statistical results showed that there was
no significant difference among osteosar-
coma, chondrosarcoma and fibrosarcoma in
degree of bone destruction showed on radio-
graphs (x ~ = 1.680, p > 0.25).
2) Radiopaque condition of the tumor
region
The 76 cases were divided into sclerotic
(15 cases), osteolytic (35 cases) and mixed
types (26 cases).
3) Periosteal reaction
The frequency of periosteal reaction of
chondrosarcoma (7/12) was higher than
osteosarcoma (13 / 31) and fibrosarcoma
(6/33).
Two kinds of periosteal reaction could
be seen in our group. One showed a little
Table 2 Sex and location of the tumor
l OS M/F M ~ CS F ~ ~ Total Location M F F M/F M F M F M/F
Maxilla 14 1 14~- } 1 3 0.3 13 1 14 2.0 12 1.8 Mandible 1.3 } 6 2 3.0 7 3 I 2 2 ~ 22 [
Total 2.9 ~ 5 1.4 20 13~ 1.5 ~ _ ~ _ 26 1.9
2
linear-shape periosteal react ion which was
parallel to the cort ical bone (Fig. 2A).
Another showed a mult i- layer periosteal reac-
tion which was parallel to the cort ical bone
(Fig. 2B).
4 ) Resorption or displacement of the teeth
in the tumor region. Twen ty one of the 76
cases showed the displacement and loosening
of the teeth and 20 cases showed the resorp-
tion of the dental roots in the tumor region.
Statistics results showed tha t there was no
significant difference in resorpt ion or dis-
placement of the teeth among osteosarcoma,
f ibrosarcoma and chondrosa rcoma @2= 0.630,
p>0.05). However , it is wor th noticing that
13 cases (CS 2 cases, OS 5 cases, and FS 6
cases) showed a special resorption pat tern of
teeth roots, namely "peeling-like" resorption.
The peripheral par t of the tooth root became
radiolucent (Fig. 3). The results of the
follow-up showed no pat ient with this kind
resorption of the teeth root was alive more
than two years.
5) Changes of the periodontal l igament
space
Fig. 1A Chondrosarcoma of the maxilla. Waters' projection showed that the tumor was located within the maxillary sinus ( ~ ).
Fig. 2A Osteosarcoma of the mandible. Standard mandibular occlusal projection showed a little linear-shape periosteal reaction (Q).
Fig. 1B Fibrosarcoma of the maxilla. Water's pro- jection showed that the bony wall of the maxillary sinus had been destroyed and the surrounding tissues had been involved ( ~ ).
Fig. 2B Chandrosarcoma of the mandible. Stan- dard mandibular occtusal showed multi- layer periosteal reaction (0).
Fig. 3 Fibrosarcoma of the mandible. Lateral oblique projection of body of mandible showed the so called "peeling-like" resorp- tion of the dental root (O).
Fi f ty six of the total cases showed unilat-
eral (6 cases) or bi lateral widening (16 cases)
or i rregular destruct ion (34 ca se s ) . o f the
p e r i o d o n t a l space . S t a t i s t i c a l r e s u l t s
showed that there was significant difference
in the change of the periodontal space
between osteosarcoma, chondrosarcoma and
f ib rosarcoma (x 2=7.621, p<0.025) . T h e
change of the per iodontal space of fibrosar-
coma (28/33) was more than for chondrosar-
coma (8/12) and os teosa rcoma (20/31).
6 ) Changes of the mandibular canal
Th i r ty two of the 34 cases with the sar-
comas of the mandible showed ill-defined
margins of one or both sides of the man-
dibular canal, or showed widening of the
A C
Fig. 4 Radiographic grades:
4
B
A. Grade I, B. Grade II, C. Grade III D. Grade IV.
D
mandibular canal (CS 7/8, OS 15/16 and FS
10/10). Fifteen cases showed that the extent
of the mandibular canal change was more
extensive than the extent of the bony destruc-
tion. In the follow-up study, the authors
found that 4 cases showed recurrence of the
tumor in the region having the same changes
of the mandibular canal showing on the pre-
operative rediographs. There were not
enough cases for statistical analysis.
7) Radiographic grades
All the cases were divided into four
grades according to the radiographic features
as folllws:
Grade I (20 cases): It shows expansion of
the cortical bone an sclerosing interface zone
could be seen in the margin of the tumor (Fig.
4-A);
Grade II (15 cases): The destructed mar-
gin was well-defined and there was almost no
remaining trabeculae in the region of the
tumor (Fig. 4-B);
Grade III (23 cases): The bony destruc-
tion showed an irregular ill-defined moth-
eaten zone that could be seen in the margin of
the tumor (Fig. 4-C);
Grade IV (18 cases): The bony destruc-
tion showed permeat ive or meshlike changes.
No definite margin of the tumor could be seen
(Fig. 4-D).
5 ) The relationship between the radiogra-
phic manifestation and the prognosis
S e v e n t y c a s e s of th i s g r o u p w e r e
followed-up and the rate of follow-up was
92.1%. Fifty of the 70 cases were treated only by r a d i c a l s u r g e r y and 42 c a s e s w e r e
followed-up more than 5 years. The 5-
year survival rate was 44.8% for osteosar-
comas, 53.3% for chondrosarcomas and
42.8% for fibrosarcomas respectively. The
5-year survival rate of the total patients was
46.7~. The Kaplan-Meier survival curves of
the osteosarcomas, f ibrosarcomas and chon-
drosarcomas were very similar (Fig. 5) and
statistical results showed that there was no
significant difference in survival rate among
os teosarcoma, f i b rosa rcoma and chon-
drosacoma (x2=0.032, p=0.984). There was
significant difference in the 5-year survival
rate among the cases with different radiogra-
phic grades, and also between the two kinds
of different destructive degrees. However,
there was no significant difference in the
5-year survival rate among the different loca-
tions of the tumor (x2=1.286, p=0.268) and
among the different radiopaque conditions of
the tumor region (x2-2.428, p=0.298).
Moreover, the relationships between the
prognosis and the location of tumor, the
destructive degree, the radiopaque condition,
the periosteal reaction, the changes in teeth,
the changes of the periodontal space, the
radiographic grades, the pathologic grades,
and the histological classification were
analysed with multiple stepwise regression
analysis for the 42 cases. The results
showed that there was the most highly corre-
lation between radiograhiic grades and prog-
nosis in the patients t reated by radical sur-
gery (F=75.819, Standard partial egression
coefficient = 0.739; F of regression = 31.288,
~oo
8o
60
5o
40
3o
2O
10
0
..... , OS .** ...... CS
6 t ~ , ~ e F S
. " ' * J S
~ e e ~ e e ~ e ~ e ~ ..........
Non,ha
Fig. 5 Kap lan -Meie r su rv iva l curve of osteosar-
coma, f ib rosa rcoma and chondrosarcoma.
5
standard error of estimate = 12.235, R =
0.879).
Discussion
1. Clinical significance of radiographic
grades of jaw sarcomas.
It is difficult to differentiate osteosar-
coma, chondrosarcoma and fibrosarcoma of
the jaw according to the radiographic
manifestationsl-4L Based on our materials,
there were almost no significant difference in
radiographic grades, destructive degree,
teeth changes, tumor location, and also in the
Kaplan-Meier survival curve among osteosar-
coma, chondrosarcoma and fibrosarcoma of
the jaw. In addition, according to the con-
ven t iona l r a d i o g r a p h i c c lass i f i ca t ion ,
osteogenic sarcoma could be divided into
sclerotic, osteolytic and mixed sarcoma.
However, it is impossible to predict their
prognosis with this classification. Actually,
some authors have reported quite different
results about the relationship between any
kind of jaw sarcomas and their prognosis ~-~).
T h e r e f o r e , n e i t h e r a h i s t o l o g i c
classification nor a conventional radiographic
classification could predict the prognosis of
the patients. Based on our results, there
were highly significant differences in the 5-
year survival rate among the different radio-
graphic grades (X2=21.690, p<0.001). The
higher the radiogra0hic grade is, the lower
the 5-year survival rate will be. We suggest
that this classification could be used in the
clinical practice to predict the prognosis of
the tumor.
It is well known that the bony destruc-
tive pattern of the tumor and the interface
between the pathologic area and the normal
bone tissues show the growing characteristics
of the tumor and the reaction of the bone to
tumor developing. Thus the bony destruc-
rive pattern (such as local sclerosis, moth-
eaten, or permeating destruction) generally
showed the biologic behavior of tumor
growth rather than the different stages of
bony destruct ion. T h e i r r ad iog raph ic
grades could be very convenient and useful to
predict the prognosis.
2. Mandibular canal changes
The pathological changes of the man-
dibular canal had not been paid attention for
a long time until 1985. Yagan reported that
osteosarcoma could result in an ill-defined
margin and widening of the mandibular
canaP ~. Linquist (1986) reported that the
extent of mandibular canal change was more
extensive than the bony destructive extent
showed on the radiograph 9/. Our findings
supported Yagan and Linquist's view-points.
We also found that the area with mandibular
canal change was usually the place where the
tumor recurred. Therefore, the radiogra-
phic manifestation of the mandibular canal
change should be put into the surgeon's con-
sideration when they perform the operative
procedure on the patients.
Conclusions
1. The radiographic manifestat ion of
osteosarcoma, chondrosarcoma and fibrosar-
coma of the jaw included different degree of
bony destruction with different marginal fea-
tures, periosteal reaction, tumorous bone for-
mation, teeth changes, periodontal space
changes and mandibular canal changes. No
special radiographic manifestation could be
regarded as specific differentiated evidence
among the three jaw sarcomas;
2. The radiographic grades of jaw sarcoma
suggested by the present study could be used
in the clinical practice to predict the progno-
sis of the patients;
3. Jaw sarcomas could cause the displace-
ment, loosening, so-called "peeling-like resorp-
tion" of the dental roots. It was worth
noticing that the prognosis of the patients
with "peeling-like resorption" of the roots
was very poor;
4. The extent of mandibular canal change
was usally more extensive than the bony
destructive extent showed on radiographs.
Consequantly, this pathological change
should be put into the surgeon's consideration
when they perform surgery on these patients.
Acknowledgement: The authors wish to thank Professor
Wu, Qi-guang and Messrs. San, Guang-xi, Zhang, Yu-zhu and Wang, Chang-fu for taking the radiographs and Dr.
Zhang, Jian-guo for providing some clinical materials.
References 1 ) Finklestein J.B.: Osteosarcoma of the jaw bones.
Radio. Clini. North Am. 8: 425-443, 1971
2 ) Sherman R.S. and Melamed: Roentgen characteristics of osteogenic sarcoma of jaw. Radiology 64: 519-527, 1955
3 ) Murray R.O. and Jacobson H.G.: The Radiology of Skeletal Disorders. ed 2, Vol 1, pp. 592-607, 1979, Churchill-Living Stone, London
4 ) Garrinton G.E. and Collett W.K.: Chondrosarcoma II:
Chondrosarcoma of the jaw analysis of 37 cases. J. Oral Pathol. 17: 12-20, 1988
5 ) Huvos A.G.: Bone Tumors. ed 1, pp. 47-264, i979, W. B. Sanders Co., Philadelphia
6 ) Mc Call Jo and Wald S.S.: Clinical Dental Roent- genology, ed 4, pp. 364-369, 1957, W. B. Sanders Co., Philadelphia
7) Garrinton G.E., et al.: Osteosarcoma of the jaws: analysis of 56 cases. Cancer 20: 377-391, 1967
8 ) Yagan R., et al.: Involvement of the mandibular-canal: early sign of osteogenic sarcoma of the mandible. Oral Surg. 60: 56, 1985
9 ) Linqvist C., et al.: Osteosarcoma of the mandible. J. Oral Maxillofac. Surg. 44: 759-764, 1986
Reprint requests to: Xu-chen MA, D.D.S., Ph.D. Department of Oral Radiology, Stomatological Hospital, Beijing Medical University Haidian District, Beijing 100081, The People's Republic of China