Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Dentistry
Year : 2012 | Month : May | Volume : 6 | Issue : 4 | Page : 753 - 757

Osteosarcoma of Mandible: A Case Report and Review of Literature

Anitha Bojan, Winnifred Christy, Sumathy Chanmougananda, Kannan Ashokan

1. Reader, Meenakshi Ammal Dental College and Hospital. 2. Reader, Thai Moogambikai Dental College and Hospital. 3. Senior Lecturer, Meenakshi Ammal Dental College and Hospital. 4. Senior Lecturer, Meenakshi Ammal Dental College and Hospital.

Correspondence Address :
Dr. Anitha Bojan
No 316/3 HIG Flats, Belly Area, Annanagar,
Chennai, India- 600040
Phone: 9841988751
E-mail: Anithapraburam@gmail.com

Abstract

Osteosarcoma is a bone tumour and it can occur in any bone, usually in the extremities of the long bones, near the metaphyseal growth plates. Osteosarcomas of the jaws are rare and they are highly malignant neoplasms of the bone whose diagnoses are challenging. In the initial phase, they may present as nondescript, bony swellings with an indolent growth, only to become malignant towards the later stages. Osteosarcomas of the jaw are rare and they differ from osteosarcomas of the long bones in their biological behaviour, even though they have the same histological appearance. The purpose of this study was to report a mandibular osteosarcoma in a 50-year old, which presented as a bony mass which mimicked a periapical infection.

Keywords

Osteosarcoma, Sunray appearance, Codman’s triangle, Radical surgery

Introduction
Osteosarcoma of the jaws (JOS) is a rare, aggressive, malignant mesenchymal tumour which is characterized by the formation of osteoid tissue, which constitutes 5% to13% of all the cases of skeletal osteosarcomas (1),(2),(3),(4). The estimated incidence of the new cases of JOS per year is 0.07 in 100,000 (1).

Jaw osteosarcomas usually present in the third and fourth decades of life, almost a decade after their presentation in the long bone tumours (1),(2),(3). The maxilla and the mandible are equally involved. The mandibular tumours arise more frequently in the posterior body and in the horizontal ramus, whereas the maxillary tumours are discovered more commonly in the alveolar ridge, the sinus floor, and the palate (1),(2),(3),(4),(5).

The main clinical manifestations of JOS 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 tumours, and nasal obstruction in the maxillary tumours (1),(2),(3).

The radiological appearances manifest as mixed, radiolucent/ radiopaque lesions, periodontal ligament widening, radiopaque masses with a moth eaten appearance, Codman’s triangle and sunburst appearance (3),(5).

The aetiology of osteosarcoma remains unknown. However, ionizing radiations (irradiation sarcoma), fibrous dysplasia and Paget’s bone disease (Paget’s sarcoma) of the bone are considered to be the predisposing factors. Patients with chromosomal aberrations in the p53 and the retinoblastoma genes which are localized to 17p13 and 13q14 and patients with the Li-Fraumeni syndrome or hereditary retinoblastoma have an increased risk for developing osteosarcoma. The current knowledge on JOS has indicated that certain other factors which appeared to co-relate with the occurrence of osteosarcoma included linear bone growth and genetic and environmental factors (4),(5),(6).

The differential diagnosis of JOS should include chondrosarcoma, Ewing’s sarcoma, bone metastasis , fibrous dysplasia ,osteomyelitis, and even lesions that do not usually affect the jaw bones, such as fibrosarcomas, leiomyosarcomas, or rhabdomyosarcomas (7).

The WHO has listed several variants that differed in the location, clinical behaviour and the level of cellular atypia. Classical osteosarcoma is the most frequent variant which develops in the medullary region of the bone and it can be subdivided into the osteoblastic, chondroblastic and the fibroblastic histologic types, depending upon the type of the extracellular matrix which is produced by the tumour cells. The other histological variants include the telangiectatic type, small cell osteosarcoma, the giant cell and the large cell predominant type, etc. (1), (2), (8).

JOS differs from osteosarcoma of the long bones in its biological behaviour, thus presenting a lower incidence of metastasis and a better prognosis (3),(4). Early diagnosis and adequate surgical resection are the keys to high survival rates (6). The treatment protocols for osteosarcoma include radical or conservative surgery which is complemented by radiotherapy and/or chemotherapy (2),(8).

Dental professionals may be the first to detect jaw osteosarcomas in their initial stages. Regardless of its favourable biological behaviour, the patients of jaw osteosarcoma usually exhibit advanced tumour, as it often goes unnoticed by the dental professional, thus stressing on the need for an early diagnosis of the lesion. The aim of this case report was to draw attention to the possibility of diagnosing this tumour based on its clinical and radiographical characteristics before its confirmation by histology.

Case Report

A 50-year old male patient reported to the Department of Oral Medicine and Radiology, Ragas Dental College and Hospital, Chennai, India, with a chief complaint of swelling in his lower right jaw for 15 days. The pain was severe, pricking, and continuous in nature and it did not subside with medication. The pain was associated with a swelling which gradually increased in size in 15 days. According to the patient, the swelling was evident extra-orally since 10 days. The patient also expressed a difficulty in chewing food on the affected side. His past dental history revealed previous restoration of the 48 tooth after the occurrence of dental caries (Table/Fig 1).

His extra-oral examination revealed a 2 x 2 cm in size, ill defined swelling which was seen at the lower 1/3rd of the right side of the face, which extended superoinferiorly, 3 cm from the right zygoma to 1 cm above the inferior mandibular border and antero posteriorly, 2 cm from the angle of the mouth to 3 cm from the angle of the mandible (Table/Fig 2). On palpation, the swelling was found to have a smooth surface and it was warm, tender, bony hard and not movable in both the anteroposterior and the lateral directions. The right sub-mandibular lymph nodes were palpable, soft to firm, mobile and tender. Intra orally, a 2 x 2 cm round, well defined swelling which extended from the free gingival groove to the vestibule, which obliterated the buccal vestibule, was seen in relation to the 47, 46, 45, 44 region. Also, a 0.5 to 0.5 small bony elevation with normal overlying mucosa and indistinct margins was seen on the lingual alveolar mucosa in relation to the 47, 46, 45 region. The swelling had distinct margins, a smooth surface and the normal colour of the overlying mucosa. On palpation, buccal and lingual cortical plate expansion was evident and the swelling was found to be tender, bony hard and not movable in the anteroposterior and the lateral directions. The tooth numbers, 47, 46, 45, 44 were tender on percussion (Table/Fig 3).

The radiographic evaluation included a intra-oral periapical radiograph (IOPA), a panoramic radiograph and a mandibular cross-sectional radiograph. The IOPA revealed widening of the periodontal ligament space with an irregular absence or attenuation of the lamina dura in relation to 47, 48 (Table/Fig 4). The panoramic radiograph revealed an ill defined, mixed, radiolucentradiopaque lesion along the right body of the mandible, denoting irregular areas of osteolysis (Table/Fig 5). The cross-sectional occlusal radiograph of the right side of the mandible showed bicortical expansion and the presence of radial spicules which spread outside the jaw bone on the lingual side, giving a “sunray appearance” in relation to the 48, 47 teeth region (Table/Fig 6). The non-contrast, multislice spiral CT scan of the mandible and the face revealed an expansile mass lesion which involved the right side of the mandible (Table/Fig 7). Based on the clinical and radiological findings, a provisional diagnosis of malignancy of the right body of the mandible was given.

The differential diagnosis included cellulitis which involved the right buccal, vestibular and the submandibular space and a vascular lesion (hemangioma). An incisional biopsy revealed hyperchromatic, pleomorphic cells which were associated with extravasated RBCs. The decalcified tissue section showed vital bone with marrow spaces which exhibited proliferation of the angular cells, some of which were in the lacunar spaces, some in association with amorphous eosinophilic material which was suggestive of an osteoid (Table/Fig 8). These histological features were suggestive of osteosarcoma of the right mandible. The patient was referred to an oncology centre, and the treatment regimen which was prescribed was radical surgical resection along with a margin of the normal surrounding tissue, followed by radiotherapy.

Discussion

Although osteosarcoma is generally the most common malignant bone tumour, the lesions of the jaw are rare (3) and despite its histopathologic similarities with osteosarcoma of the long bones, it is biologically different (1). Therefore, small retrospective studies and case reports are opportunities to report and discuss issues of clinical and diagnostic significance.

Osteosarcomas arise in several clinical settings, which include pre-existing bone abnormalities such as Paget’s disease, fibrous dysplasia, giant cell tumour, multiple osteochondroma, bone infarct, chronic osteomyelitis, osteogenesis imperfecta, and a history of radiation exposure (3),(9),(10). In the present case, however, the aetiology remained unknown.

The clinical characteristics of the case which has been reported were in agreement with those of previous studies, regarding the age and chief clinical features (1),(3),(4),(5). Although the radiological and histopathological findings had strongly suggested an osteosarcoma of the jaw, the initial findings of the lesion were probably less suggestive. There is a need to be more conscious while such patients are being diagnosed, as they often go undiagnosed for a significant period of time. This is so, because some of these signs and symptoms can be produced by a number of different developmental infections, benign neoplastic diseases, or malignancies. Further, its presentation is similar to that of osteomyelitis with proliferative periostitis, suppurative osteomyelitis, ossifying fibroma, osteoblastoma, and even fibrous dysplasia, which has often caused an osteosarcoma to be delayed in its diagnosis (6),(8). Several diseases should be included in the differential diagnosis of JOS, since its most common symptom is a jaw swelling and as its radiological appearance may be a radiolucent, radiopaque, or mixed area (9),(10).

The diagnosis of osteosarcoma is typically suspected by the radiographic appearance of the affected bone. Ossification in the soft tissue component of the bone, which manifests as a “sunburst” pattern is classic for osteosarcoma, but is not a sensitive or specific feature. Periosteal new born formation with lifting of the cortex leads to the appearance of a Codman’s triangle. Garrington et al. mentioned that the roentgenographic evidence of a symmetrically widened periodontal membrane space was a significant early finding in osteosarcoma of the jaw, although the same features had been seen in some chondrosarcomas (Garrington et al). In the present case, the intraoral periapical radiograph didn’t show any changes and the occlusal radiograph of the mandible showed the sunburst pattern. The extent of the tumour in both the bone and the soft tissue was best appreciated as was shown by cross sectional imaging techniques such as computerized tomography (CT) or magnetic resonance imaging( MRI). This is particularly important prior to a definitive surgery. A CT scan of an osteosarcoma often shows the formation of irregular endosteal and extracortical bone as well as a destroyed or obliterated cortex. However, CT scan cannot differentiate between osteosarcoma and fibrous dysplasia. Atypical sunray spiculations were seen in this case, which were highly suggestive of osteosarcoma (12),(13),(14),(15),(16).

Although MRI is generally accepted to be superior to CT scanning in the evaluation of the local tumour spread, Panicek and colleagues showed that CT scanning and MRI were equally accurate in the staging of the local disease in bone tumours (Panicek et al) (17). However, in the present case, MRI could not be done due to financial limitations, as the patient belonged to a lower socioeconomic group. In the present case, it was observed that the lesion was mixed (radiolucent-radiopaque) in appearance, which was in accordance with the finding of Clark et al. classification (18).

Histologically, osteosarcomas can be classified according to their cellular differentiation as osteoblastic, chondroblastic and fibroblastic. In the osteoblastic type, the atypical neoplastic osteoblasts exhibit considerable variation in their shapes and sizes, showing large deeply staining nuclei which are arranged in a disorderly fashion and this type constitutes 60% of the jaw lesions. The chondroblastic type has been described to occur predominantly in the head and neck region and it was found to consist of atypical chondroid areas which were composed of pleomorphic (1),(16). and atypical binucleate cells which had large hyperchromatic nuclei and prominent nucleoli. The fibroblastic type is rare, especially in the jaws. In the myxomatous type, there is atypical myxoid proliferation. A majority of the tumours are heterogenous, reflecting the pleuripotency of the proliferating mesenchymal cells. The other histologic types include a malignant fibrous histiocytoma like osteosarcoma which shows spindle anaplastic cells. In large cell predominant osteosarcoma, there are large cells with prominent nucleoli. Giant cell predominant osteosarcoma is characterized by anaplastic stromal cell producing streams of osteoid, along with giant cells. This type of a tumour may be confused with a giant cell tumour. In small cell or round cell predominant type osteosarcoma, osteoid producing, small malignant cell and primitive bone tissues are the characteristics, whereas in telangiectatic osteosarcoma, anaplastic cells are present along with the osteoid. In our case, histologically, the tumour was composed of hyperchromatic cells and pleomorphic cells which were associated with extravasated RBC. The decalcified tissue section showed vital bone with marrow spaces which exhibited the proliferation of the angular cells, some of which were in the lacunar spaces, some in association with an amorphous eosinophilic material which was suggestive of an osteoid, which was suggesitive of chrondroblastic osteosarcoma (17),(18).

The treatment for osteosarcoma has been well established in the long bones, but it is not well understood when the condition involves the mandible or the maxilla (5),(18). It is clear that chemotherapy is beneficial for OS of the long bones, leading to significant changes in the disease-free survival rate (from 20% in the 1960s to 70% in the 1980s). This improvement did not include OS of the jaw, due to its rare occurrence and due to lack of standardized chemotherapy protocols, which made it difficult to evaluate the efficiency of the adjuvant therapy (3). In most of the cases, the therapy of choice is radical surgical excision, since it provides a 5-year survival rate of over 80%. As for chemotherapy, it seems that it does not have much impact on the survival rates of the patients with OS 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 (3). In the present case, the patient had a radical surgical resection of the right mandible along with a margin of the normal surrounding tissue, followed by radiotherapy (17),(18).

The prognosis of jaw osteosarcoma is better than that of the long bone osteosarcomas. This could be due to the histologically better differentiation of the jaw osteosarcomas than that of the long bone osteosarcomas (19). As jaw osteosarcomas occur at higher mean ages, the patients have less chances of developing metastases.

Conclusion

It is very obvious that due to the common clinical presentations of pain and swelling, the patients with osteosarcoma usually will report to a dental professional first. Despite their adequate skill and knowledge, it is challenging for the dental professionals, as they usually come across osteosarcoma cases which have reached advanced stages and the prognosis in such patients is very poor. It can be concluded that misdiagnosis is very common in osteosarcoma of the jaw. Besides adding this case of osteosarcoma of the mandible in the dental literature, this article would catch the attention of the dental professionals so that they may approach such cases with greater concern and diagnose them at an early stage, which can lead to a better prognosis.

References

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DOI and Others

ID: JCDR/2012/4207:0058

Date of Submission: Feb 28, 2012
Date of peer review: Mar 29, 2012
Date of acceptance: Apr 16, 2012
Date of Publishing: May 31, 2012

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