Ameloblastoma classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2] Vamsikrishna Gunnam M.B.B.S[3]

Overview

Ameloblastoma may be classified based on histopathology into six subtypes: follicular, plexiform, acanthomatous, basal cell, granular cell, and desmoplastic. Based on the location, ameloblastoma may be divided into either intra-osseous or extra-osseous. Based on the radiologic features, ameloblastoma may be classified into four groups: solid or multicystic, unicystic, peripheral, and malignant.

Classification

Ameloblastoma may be classified into following subtypes based on the location:[1][2][3][4][5]

Based on histology, intraosseous ameloblastoma may be subclassified into two groups which includes the following:

  • Solid/multicystic
    • More commonly reoccur
  • Unicystic.
    • Unlikely to reoccur
    • Classically found in younger individuals.

Ameloblastoma may be classified into following subtypes based on the clinicoradiologic into four groups:[6][1][2][3][4][7]

  • Solid or multicystic
    • Solid ameloblastoma is the most common form of the lesion.
    • Approximately 86% of the ameloblastoma are solid. It has a tendency to be more aggressive than the other types and has a higher incidence of recurrence.
    • Multicystic ameloblastomacan infiltrate into the adjacent tissue and can metastasize and has the ability to recur.
    • Its prevalence is a slightly older age group than the unicystic ameloblastoma.
    • Radiographically, the appearance is generally multilocular or unilocular.
  • Unicystic
    • Unicystic ameloblastomahas a large cystic cavity with intraluminal, luminal, or mural proliferation of ameloblastic cells.
    • Unicystic ameloblastoma is a less aggressive variant and it has a low rate of recurrence although lesions showing mural invasion are an exception and should be treated more aggressively.
    • The unicystic ameloblastoma usually appears as a “cystic” lesion with either an intramural or an intraluminal proliferation of the cystic lining.
    • Radiographically, it can resemble a well-circumscribed slow-growing radiolucency.[7]
  • Peripheral.
  • Malignant
    • The malignant ameloblastoma is a rare entity. It is defined as an ameloblastoma that has already metastasized but still maintains its classical microscopic features.
    • The WHO classification of odontogenic tumors (2005) defines malignant ameloblastoma as, “an ameloblastoma that metastasizes in spite of a benign histological appearance".
    • Even if metastasis is absent, ameloblastoma with cytological atypia is defined as ameloblastic carcinoma.
    • Thus, malignant ameloblastoma is defined as a retrospective diagnosis that can only be made when metastasis occurs.
    • In majority of cases, it not only maintains the histological characteristics of the parent tumor but also continues to display similarly indolent clinical behavior.

Differentiating features of three different subtypes of ameloblastoma is shown below in a tabular form:

Subtypes of Ameloblastoma Percentage of Ameloblastoma Age Sites affected Additional features
Multicystic/Conventional Ameloblastoma (also known as Solid Ameloblastoma)
  • The tumor is usually seen in middle-aged adults, around the age of 40 years
  • It is more prevalent among african americans
Unicystic Ameloblastoma (also known as Cystic Ameloblastoma)
  • It affects men more than women, with 65% of the affected individuals being males
  • It is usually seen in younger individuals with an average age of 25 years
  • A majority of these tumors occur in the lower jaw (over 90%)
Peripheral Ameloblastoma:
  • Peripheral ameloblastoma typically affect individuals aged between 40-60 years
  • Both men and women are equally affected

Based on histology ameloblastoma is classified into six subtypes:

The following six histopathologic subtypes have been identified for ameloblastoma:[8]

Subtypes of Ameloblastoma Features
Follicular
  • Histologically, follicular ameloblastoma are the most common type of ameloblastoma.
  • The follicular pattern consist of islands of epithelial cells with a central mass of polyhedral cells or loosely arranged angular cells resembling stellate reticulum, which are surrounded by well organized single layer of cuboidal or tall columnar cells with nuclei placed at the opposite pole of basement membrane resembling pre-ameloblasts.
  • This peripheral cell layer tends to show cytoplasmic vacuolization. Cystic formation is often seen in the center of the epithelial islands due to degeneration of stellate reticulum like cells.
Plexiform
  • The tumor epithelium is arranged in form of trabeculae which is bound by a layer of cuboidal or columnar cells and stellate reticulum like areas are usually minimal.
  • Cyst formation occurs but is usually due to stromal degeneration rather than cystic change in the epithelium. The stroma consists of loose, vascular sparsely cellular connective tissue.
Acanthomatous
Granular cell
  • The tumors are referred to as granular cell ameloblastoma, when the central stellate reticulum cells show extensive granular cell transformation i.e. in the form of sheets of large eosinophilic granular cells.
  • Ultrastructurally, it is seen that the granules consist of pleomorphic, osmiophilic, lysosome like organelles.
Basal cell
  • This variant shows predominant basaloid pattern consisting of darkly stained cells with minimal cytoplasm and little evidence of palisading at the periphery resembling those seen in basal cell carcinoma.
Desmoplastic
  • Desmoplastic ameloblastoma is characterized by extensive stromal collagenization or desmoplasia surrounding compressed small/irregular islands of odontogenic epithelium making it a distinct entity.
  • Cyst formation is common and ameloblast like areas are present only in small foci.
  • Calcification in the fibrous stroma and occasional bone formation can also be seen.
  • Histochemical evaluation of the collagen suggests that the dense stroma is not scar tissue but represents active de novo synthesis of extracellular matrix proteins.
  • It typically presents radiographically as a mixed radiolucency and radiopacity mimicking a fibro osseous lesion.
  • In contrast to typical ameloblastoma, this variant frequents the maxilla and the anterior region of the jaws.
Unicystic
  • Unicystic ameloblastoma is considered as an in-situ or superficially invasive form of ameloblastoma and consists of a single cyst lined by ameloblastic epithelium.
  • It presents clinically similar to a dentigerous cyst and is usually associated with an impacted tooth (usually 3rd molars).
  • They are usually seen in younger patients with an average age of diagnosis being 22 years and generally involve the mandible.
  • It histologically presents as a single cyst lined by ameloblastomatous epithelium and is divided into several subgroups based on pattern and extent of ameloblastomatous proliferation in relation to cyst wall.
  • Unicystic ameloblastoma may be classified into four subtypes based on a classification by Reichart et al. which was modified by Ackermann et al.
    • 1. Luminal unicystic ameloblastoma: It is a cystic lesion lined by epithelium which exhibits columnar differentiation and reverse polarization of the basal cell layer. The connective tissue adjacent to the epithelium often exhibits a uniform, thin band like area of hyalinization.
    • 1.2. Luminal and intraluminal unicystic ameloblastoma: It is the simple type but exhibits one or more nodules projecting into the lumen. No extension is seen into the surrounding connective tissue wall. Occasionally, this form of unicystic ameloblastoma can produce an intraluminal plexiform pattern of odontogenic epithelium that lacks typical ameloblastomatous differentiation and is called as unicystic plexiform ameloblastoma.
    • 1.2.3. Luminal, intraluminal and intramural unicystic ameloblastoma: Here there is occurrence of intramural proliferation of ameloblastoma along with subgroup 1.2 features.
    • 1.3. Luminal and intramural unicystic ameloblastoma: It exhibits a cyst with a luminal lining in combination with intramural nodules of SMA tissues. The intramural ameloblastoma tissue may be seen as an infiltration from the cyst lining or as free islands of follicular ameloblastoma.
Peripheral
  • Peripheral ameloblastoma present histologically with follicular or plexiform pattern as well as acanthomatous pattern. In most cases, the tumor is well separated from the overlying epithelium but many are confluent with the overlying mucosa.
Other rare varients
  • Clear cell variant which may contain clear PAS positive cells are localized in the stellate reticulum like areas.
  • Papilliferous keratoameloblastoma show occurrence of areas of ameloblastoma with keratinisation, tumor islands with papilliferous appearance along with cystic areas resembling odontogenic keratocysts.
  • Mucous cells can also be demonstrated rarely in ameloblastoma.

References

  1. 1.0 1.1 Singh M, Shah A, Bhattacharya A, Raman R, Ranganatha N, Prakash P (2014). "Treatment algorithm for ameloblastoma.". Case Rep Dent. 2014: 121032. PMC 4274852Freely accessible. PMID 25548685. doi:10.1155/2014/121032. 
  2. 2.0 2.1 Gümgüm S, Hoşgören B (2005). "Clinical and radiologic behaviour of ameloblastoma in 4 cases.". J Can Dent Assoc. 71 (7): 481–4. PMID 16026635. 
  3. 3.0 3.1 Toledo-Pereyra LH, Bergren CT (1987). "Liver preservation techniques for transplantation.". Artif Organs. 11 (3): 214–23. PMID 3304226. 
  4. 4.0 4.1 Poser CM (1973). "Demyelination in the central nervous system in chronic alcoholism: central pontine myelinolysis and Marchiafava-Bignami's disease.". Ann N Y Acad Sci. 215: 373–81. PMID 4513681. 
  5. Ameloblastoma. Libre pathology(2015) http://librepathology.org/wiki/index.php/Ameloblastoma Accessed on December 25, 2015
  6. Laborde, A.; Nicot, R.; Wojcik, T.; Ferri, J.; Raoul, G. (2017). "Ameloblastoma of the jaws: Management and recurrence rate". European Annals of Otorhinolaryngology, Head and Neck Diseases. 134 (1): 7–11. ISSN 1879-7296. doi:10.1016/j.anorl.2016.09.004. 
  7. 7.0 7.1 Ameloblastoma. Radiopedia(2015) http://radiopaedia.org/articles/ameloblastoma Accessed on December 25, 2015
  8. Masthan KM, Anitha N, Krupaa J, Manikkam S (April 2015). "Ameloblastoma". J Pharm Bioallied Sci. 7 (Suppl 1): S167–70. PMC 4439660Freely accessible. PMID 26015700. doi:10.4103/0975-7406.155891. 

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