Cytological findings in cases of marsupialized odontogenic cysts

j. max.-fac. Surg. 9 (1981)

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J. max.-fac. Surg. 9 (1981) 35-41 © 1981 Georg Thieme Verlag Stuttgart • New York

Summary

Cytological Findings in Cases of Marsupialized Odontogenic Cysts A contribution to early diagnosis of malignant changes Peter Schulz, Hildegard yon Skerst, Hans Hartmut Rummel, Karlheinz Wurster Department of Oral and Maxillo Facial-Surgery (Head: Prof. K. Kristen M.D., D.M.D.) Department of GynaecologicaI Morphology (Head: Prof. H. H. Rmnmel M.D.) [nstitute of Pathology (Head: Prof. W. Doerr, M.D.), University Hospital, Heidelberg, W-Germany

The early diagnosis of a malignant or premalignant change in cyst epithelium in the follow-up control of fenestrated odontogenic cysts can easily be made using exfoliative cytology. This investigation reveals the findings in 408 cytosmears of 89 patients. Only in one case was the cyst epithelium free of pathological signs. 405 cyto-smears showed very variable inflammatory changes. The smears of one patient were typical for an ameloblastoma, microscopically smears of three patients showed keratinised epithelium. If the radical removal of an odontogenic cyst is not possible, cyto-smears should be applied and randomly repeated. Thus the possible change of cyst epithelium via inflammation or dysplasia to malignancy can be detected and treated earlier.

Key-Words Cytology of cyst epithelium; Odontogenic cysts; Early diagnosis of malignant changes in cyst epithelium

Introduction According to Banoczy (1960 b, 1961), Cardozo (1975) and Pape (1970) oral cytology today has several indications: one application (nos. 1 to 5) directly concerns the discipline of stomatology: 1. Differential diagnosis of inflammatory diseases of the oral mucosa 2. Recognition of premalignant and malignant lesions of the oral cavity 3. Follow-up care of tumour patients 4. Differential diagnosis of diseases of the salivary glands 5. Periodontology 6. Chromosomal sex determination (Barr-Test) 7. Estimation of sex hormonal changes 8. Sputum diagnosis of internal diseases. The observation of some cases of carcinoma arising in the epithelium of a fenestrated odontogenic cyst by Schulz and Wurster (1975) motivated us to use exfoliative cytology as a diagnostic aid for the investigation of these intracystic epithelia. To attain a reliable picture of the cell differentiation of the epithelium in cysts, exfoliative cytology presents itself as a simple method. It can be deduced from the exfoliated cells whether a normal epithelium or metaplasia, dysplasia or malignant alteration of epithelial cells is present. Before any cyst operation the content of cysts can be sampled by needle aspiration, from which a smear can be made and stained, after fixation with 95% alcohol, (Papanicolaou's method 1925, 1941) for further investigation. The cytodiagnosis should preferably be done by an experienced cytologist. It is advisable to cooperate with a gynaecologist or pathologist, who has extensive experience in recognizing the various atypical cells in cytological smears.

Material and Methods Exfoliative cytology was employed in 89 patients, 60 male and 29 female, aged from 9 to 81 years, as a diagnostic aid for investigation of the status of the epithelium of marsupialized odontogenic cysts, which remained in the jawbones. These patient were treated as in-patients over a 0301-0503/81

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period of two years in the Universit~its-Kieferktinik in Heidelberg. In 79 cases marsupialization was performed and in 10 cases ennucleation. In the latter cases only smears were analyzed. The cysts investigated had an average size of that of a plum, the description varied from cherry-size to giant-cysts. Depending upon the number of cytological groups we had three groups of patients: 1.2 x 2-6 x 2 smears from the cyst epithelium from 43 patients, 2. 1 x 2 smears from 36 patients, 3. only smears from the puncture-sediments were analyzed. A total of 424 cytological preparations of smears and aspirate-sediments were performed. Some specimens could not be evaluated because of inadequate technical quality, damage caused by air drying, too little cell material, or too many admixed erythrocytes. 408 smears remained for evaluation. The smears were removed with cotton-sticks (Fig. l a and b), which do not cause bleeding, spare the surrounding tissues and enable withdrawal of cell material from a sufficiently large epithelial area. One can unroll the (handmade or manufactured) cotton-sticks using light traction in the reverse direction to that used during the withdrawal from the cyst epithelial surface. In this way a sufficient number of cells may be rolled off on the object slide. The slides should be prepared as follows: 1. Marking with pencil or glass-cutter: (designations with pencils interfere with the subsequent fixation and Papanicolaou's staining procedure). 2. Cleaning and removal of fat with alcohol. The smears were fixed with 95% ethyl alcohol (Durfee 1968) (Fig. 2): really good fixation- and staining results will be guaranteed by this method. The fixation most follow immediately after removal of the cell material, because the cells will dessicate after 30-60 sec in air and become uninterpretable by Papanicolaou's stain-

Georg Thieme Verlag Stuttgart - New York

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J. max.-fac. Surg. 9 (1981)

P. SchuLz et al. Fig. 1 Cyto-smear from the inner surface of a fenestrated cyst with cotton-stick with a light, wiping action (a) and unrolling of the cell material in the reverse direction on to the object slide (b)

Fig. 1 a

Fig. 1 b

Epithelial cells

Fig. 2 Fixation in alcohol 95 %, drying, marking with pencil or glasscutter; cytological investigation

ing. The cytological examination has to be performed as soon as possible. Our smears were examined in the cytological laboratory of the Univ. Frauenklinik Heidelberg. We subdivided the cytological findings into 5 groups (Rummel 1972): Group I: The smear contains exclusively normal cells and shows no manifestation of inflammation (Fig. 4). Diagnosis: No suspicion of malignancy. Group II: Epithelial cells appear with leucocytes added, signs of inflammation, (Fig. 5). Diagnosis! No suspicion of malignancy. Group IIw: Cells show marked inflammatory alterations: the cytoplasm is changed in colour (eosinophilia of the

Fig. 3 ST 2

=

ST 1 IT2 IT 1 OBT BT

= = = = =

Epithelial cells, schematic, Superficial squamous cells without nucleus Superficial squamous cells with pyknotic nucleus (Intermediate squamous ceils (superficial layer) Intermediate squamous cells (deep layer) Parabasal squamous cells of various sizes Basal cells

deeper cell layers) and form lobed ramifications. The cell's nucleus is "bulged" and reddish tinged. (The "W" means repetition (= Wiederholung) of the smear within a certain interval) (Fig. 6, 8, 9). Diagnosis: No suspicion of malignancy. Group IIID: Cells are suspect on the basis of dysplastic alterations ("D" means dysplasia). Diagnosis: Suspect. Group III: Smear can not be interpreted exactly, because alterations of cells and nuclei are neither clearly indicative of malignancy nor of innocence. Diagnosis: Suspect: immediate repetition of smear necessary. Group IVa: Obviously dysplastic cell alterations which are typical of carcinoma in situ. Diagnosis: Positive. Group IVb: Alterations of cells and nuclei which are

Cytological Findings in Marsupialized Odontogenic Cysts

Fig. 4a Fig. 4

Superficial cells without nucleus;

J. max.-fac. Surg. 9 (1981)

Fig. 4b

Superficialeosinophilcells;

Fig. 4d

Basalcyanophil cells.

Papanicolaoustaining:

Fig. 4c Intermediate cyanophil squamou s cells lymphocytes and leucocytes with nuclear polymorphisms

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Fig. 5 Parabasal and intermediate squamous cells, leucocytes with nuclear polymorphism; on the left margin of the microscopic picture an intermediate cyanophil cell with duplicated nucleus. (Papanicolaou, 350 ×).

Fig. 6 Metaplasia of the parabasal cell layer; cytoplasm alteration of the cell structure caused by inflammation (Papanicolaou, blue filter; 350 x).

indicative of an invasive carcinoma (Fig. 7). Diagnosis: Positive. Group V: Definite invasive carcinoma. Diagnosis: Positive.

50 years ago by Papanicolaou (1925, 1941), into the early diagnostic system of carcinoma of the cervix uteri. Since the early 1950's exfoliative cytology has been utilized in stomatology as a diagnostic aid in pathological (carcinomatous) changes of the oral epithelium (Schneider 1952). The publications of Weinmann (1940) Montgomery (1951), Miller et al. (1951), Banoczy (1960a and b) and Hahn (1964) describe the cytodiagram of normal mucosa of the oral cavity, (Fig. 3, 4). Articles of Montgomery (1951) and v. Haam (1965), Silverman et al. (1958), Hahn (1962, 1964), Banoczy and Salley (1969) dealt with the diagnosis of premalignant lesions of the oral cavity by cytological examination of smears. Investigation of inflammatory mucosal processes of the oral cavity by Peters (1958), Hahn (1964), Sakai et al. (1960) and Jonek (1960) showed that the cytological picture was changed by vacuolization of the cytoplasm, leucocytic infiltration, cells with double nuclei and discrete nuclear staining. In particular, an eosinophilic staining was noticed in the deeper layers of epithelial cells, named therefore "pseudo-eosinophilia" of the cytoplasm. Cytodiagnosis seems to be of advantage compared with the more static histopathological findings, because cyto-smears are randomly repeatable and therefore may show the possible change from a premalignant lesion into a malignant stage (Schulz and Wurster 1975). Partsch published (1892) "L~ber Kieferzysten" the following: "The simplest and yet surest way for cure is based on the anatomical fact, which I think I have confirmed by the foregoing investigation: that the inner layer of the cyst is

Results

In a follow-up study (v. Skerst 1978) of several years a total of 408 interpretable smears were taken from the remaining epithelium and cytologically investigated. These data derived from 89 patients with odontogenic cysts. Only one patient could be classified as Papanicolaou I, i.e. free from pathological findings. Variable pronounced inflammatory alterations of the epithelium cells were found in all smears of patients undergoing long term treatment with an obturator. The changes did not disappear during long term follow up while an obturator was worn. The smear of one patient showed an analogy to the histological findings of typical cells of an ameloblastoma (see Fig. 10-12). Three cytograms showed microscopically keratinized epithelium. The great number of pathological findings demonstrate the importance of exfoliative cytology for follow-up investigations of marsupialized odontogenic cysts. The early diagnosis of a possibly malignant alteration of the remaining epithelium is necessary because various mutagens may change the cells to malignancy (Bauer 1963). Discussion

The exfoliative cytology smear - today a basic part of the gynaecological preventive examination - was introduced

Cytological Findings in Marsupialized Odontogenic Cysts

Fig. 7 Criteria for malignancy are: Anisonucleosis, nuclear polymorphism, hyperchromasia, atypical chromatin structures, cells with several nuclei, cell polymorphism, destruction of cell cytoplasm and cell membrane (Papanicolaou350 x )

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Fig. 8 Heavily thickened epithelium of an infiammed odontogenic cyst; the basal cell layer is increased; inflammatory infiltration of the subepithelial tissue (HE 85 x).

lined with an epithelial covering analogous to the oral epithelium. One can therefore expect fusion between the cyst epithelium and oral epithelium and so the cyst will change to a small indentation in the oral cavity." Partsch (1892) correctly realized the analogy between the epithelium of the cyst and the oral mucosa. One important fact, however, was not recognized by Partsch" numerous carcinogenic substances chemically related to cholesterol (Domagk 1956) are present in cysts and can have a longterm influence on the epithelium (Hensel 1966). Mechanical, chemical and bacterial inflammatory irritants are additional factors causing epithelial degeneration in marsupialized cysts. There seems to be a difference between the mouth and cyst epithelium reaction before and after marsupialization. Cyst epithelium is under more unfavourable conditions, because adverse factors can be operating for years before a cyst is diagnosed and treated. Nowadays the extirpation of the smaller cyst is more often recommended (Schulte 1959, Pape 1970, 1972, and others). But the majority of oral and maxillo-facial surgeons still prefer the method of marsupialization especially for large cysts to avoid damage to neighbouring organs.

• Fig. 9 Cyto-smear from cyst epithelium of the patient in fig. 8: Large quantities of intermediate cells with inflammatory alteration, vacuolized cytoplasm, pseudo-eosinophilia of cytoplasm; some superficial cells; numerous leucocytes (Papanicolaou85 x)

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Fig. 10 Orthopantomogram of a cystic ameloblastoma in the left ascending ramus mandibulae

Fig. 11 Microscopic section of ameloblastoma shown above in fig. 10: partly solid, partly cystic ameloblastoma in the epithelium of an odontogenic cyst altered by inflammation (HE 85 x)

Fig. 12 Cytological findings of patient shown in fig. 10 and 11 : in the centre of the cyto-smear a spindle-shaped "ameloblastoma cell" with thickened nuclear membrane, prominent nucleoli and abnormal dark staining of nucleus and cytoplasm (Papanicolaou350 x)

The follow-up treatment of those marsupialized cysts generally lasts months or even years. Since we (Schulz and Wurster 1975 and 1976) and other authors have observed a carcinoma arising in the epithelium of a marsupialized cyst, the necessity for periodical clinical follow-up examinations is evident. The first report of carcinoma originating in an odontogenic cyst is said to be that published by Herrmann (1887), cit. by Koedel (1961). Since then numerous papers describing carcinoma arising in the epithelium of cysts have been published. (e.g.: Koedel 1964, Kramer 1970, Kramer and Toiler 1973, Angelopoulos et al. 1966, Meadow 1966). It is not feasible to perform a biopsy at every follow-up

examination. Usually one will be restricted to clinical investigations, and X-ray, and if necessary to the reduction of the size of the obturator. Within such an "artificiallyproduced sinus of the oral cavity" tissue proliferations are conspicuous, then histological examination and subsequent a radical surgical intervention will be mandatory. Conclusion According to these cytological findings, radical removal of the whole odontogenic cyst must be recommended, in conformity with numerous authors, if the removal is performable without damaging neighbouring organs.

C y t o l o g i c a l F i n d i n g s in M a r s u p i a l i z e d

Odontogenic

Cysts

For the f o l l o w - u p control of m a r s u p i a l i z e d o d o n t o g e n i c cysts, exfoliative cytology presents itself as a reliable method for early diagnosis of c a r c i n o m a in the e p i t h e l i u m of cysts.

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