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Akriti Jindal1, Gargi Kapatia1, Manjit K Rana1, Nikhil Rajan2, Utkarshni Khera1
1 Department of Pathology, All India Institute of Medical Sciences (AIIMS), Bathinda, Punjab, India
2 Department of Otolaryngology and Head and Neck Surgery, All India Institute of Medical Sciences (AIIMS), Bathinda, Punjab, India
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Date of Submission27-Jul-2022Date of Decision15-Dec-2022Date of Acceptance02-Feb-2023Date of Web Publication10-Mar-2023 How to cite this article:Dear Sir,
A 55-year-old female presented with swelling on the left side of the palate for four months. It was associated with complaints of left-sided nasal obstruction and ear block. On contrast-enhanced computed tomography, there was a lobulated expansile lytic lesion measuring 5.1 × 4.4 × 4.3 cm arising from the left maxillary alveolus along the floor of the maxillary sinus. The lesion was occupying the entire left maxillary sinus. Multifocal areas of cortical erosions were also noted in radiology. On clinical examination, there was medialization of the left lateral nasal wall along with a smooth bulge in the hard palate. The swelling in the hard palate was well-defined and soft and was measuring 3 × 3 cm. On fine needle aspiration (FNA), a few drops of blood-mixed yellow color fluid was aspirated. FNA smears showed few cohesive clusters of basaloid ameloblast-like epithelial cells with peripheral palisading against a fluidic background. The individual cells were exhibiting high nucleocytoplasmic ratio, oval nuclei, and scant to moderate amounts of indistinct cytoplasm [Figure 1]a, [Figure 1]B, [Figure 1]c. Diagnosis of benign odontogenic neoplasm, possibly ameloblastoma was kept on cytology. After two weeks, a left-sided partial maxillectomy with excision of the mass was done. Histological sections exhibited islands of tumor lined by odontogenic epithelium showing reverse polarization and central loosely arranged stellate reticulum confirming the diagnosis of ameloblastoma, plexiform type [Figure 1d]. The patient is doing well on routine follow-up and is completely asymptomatic at present.
Figure 1: (a and b) Low-power and high-power view of fine needle aspiration (FNA) smears showing compact, cohesive, and three-dimensional clusters of tumor cells (Giemsa, 100X, 400X); (c) high-power view of FNA smear shows a cluster with peripheral palisading by round to oval cells with central nuclei, fine powdery chromatin, inconspicuous nucleoli and indistinct cytoplasm (Giemsa, 400X); (d) high-power view of the section shows central stellate reticulum with the peripheral lining of cells (H and E, 400X)Ameloblastoma is a benign tumor of odontogenic epithelium. It originates from the residual epithelium of the tooth germ, epithelium of odontogenic cysts, and enamel organ.[1] Ameloblastoma represents around 1% of oral tumors and 9%–11% of odontogenic tumors. It is a slow-growing but locally invasive tumor with a high tendency of recurrence.[1] Most tumors (80%) occur in the mandible while in a small proportion of cases (20%), lesion occurs in the upper jaw or maxilla. The incidence rates range from 1:8.8 to 1:58 in the maxilla and mandible respectively. The peak incidence of this tumor is in the third or fourth decade with male to female ratio of 1:1.[1] Maxillary ameloblastomas are more aggressive as compared to their mandible counterpart due to a lack of early symptoms, leading to diagnosis at an advanced stage. Due to the cancellous nature and abundant blood supply of the maxillary bone, it is easy for the tumor to invade and spread to adjacent structures.[2]
Cytological features of ameloblastoma are rarely described in the literature.[3],[4] The typical morphology of ameloblastoma shows tightly cohesive three-dimensional clusters of neoplastic cells simulating stellate reticulum lined by columnar cells with reverse nuclear polarity.[2],[3],[4],[5] The basaloid-like arrangement can be appreciated at the periphery of the cell clusters in the form of peripheral palisading. The neoplastic cells are small to medium-sized with centrally located nuclei and scant to moderate amounts of cytoplasm. Mitotic figures are not seen. Sometimes, marked squamous metaplasia and keratin pearls can also be noted, therefore, a thorough evaluation of the smears is necessary to rule out squamous cell carcinoma. Few of the ameloblastomas may show fusiform mesenchymal-like clusters.[5] These tumors are positive for cytokeratin 19 (CK, marker of odontogenic epithelium). The stellate reticulum stains for CK13 and calretinin and the peripheral lining cells are positive for CK14 and CD56.[2] It harbors SMO mutation followed by RAS, BRAF, and FGFR2 mutations.[2] In contrast to mandibular ameloblastoma, the treatment protocol for maxillary ameloblastoma is not well defined. More commonly, the radical approach is opted with bony margins to prevent a recurrence. Also, long-term follow-up is very important in these cases, as maxillary ameloblastomas recur after 25–30 years after primary treatment. To conclude, FNA plays a major role in the rapid and confident preoperative diagnosis of ameloblastoma.
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The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her 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.
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CheckDOI: 10.4103/joc.joc_106_22
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