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