Bilateral central giant cell granulomas of the mandible in an 8-year-old girl with Noonan syndrome (Noonan-like/multiple giant cell lesion syndrome)

Multiple central giant cell granuloma of the jaws: diagnostic signposts of Noonan syndrome and RASopathy

Noonan syndrome (NS) is a phenotypically variable inherited multi-system disorder. Maxillofacial findings can be diagnostic, especially in the evaluation of discrete facial dysmorphia. Diagnostic landmark findings of therapeutic relevance for the jaws such as central giant cell granuloma (CGCG) are rare in NS. However, recent molecular genetic studies indicate that these rare, benign lesions are neoplasms and more common in specific syndromes grouped under the umbrella term RASopathies. A specialist surgical diagnosis can be helpful in identifying the underlying disease. This report outlines diagnosis and treatment of a case of CGCG for which jaw diagnosis became the key to identifying a syndromic disease.

Aggressive Multiple Central Giant Cell Granulomas of the Jaws

Central giant cell granuloma (CGCG) is considered a benign intraosseous lesion with a varied range of clinical features in two subtypes, including aggressive and non-aggressive lesions. This study presents a 9-year-old boy with multiple bilateral CGCG in the mandible without any systemic disease or specific syndrome. Clinical, radiographic, and histopathological findings demonstrated the aggressive lesions. It is discussed how the differential diagnosis and treatment can be determined based on the patient's age as well as the size and manner of the lesion.

Contrast-enhanced multidetector computed tomography features and histogram analysis can differentiate ameloblastomas from central giant cell granulomas

BACKGROUND

No qualitative or quantitative analysis of contrast-enhanced computed tomography (CT) images has been reported for the differentiation between ameloblastomas and central giant cell granulomas (CGCGs).

AIM

To describe differentiating multidetector CT (MDCT) features in CGCGs and ameloblastomas and to compare differences in enhancement of these lesions qualitatively and using histogram analysis.

METHODS

MDCT of CGCGs and ameloblastomas was retrospectively reviewed to evaluate qualitative imaging descriptors. Histogram analysis was used to compare the extent of enhancement of the soft tissue. Fisher’s exact tests and Mann–Whitney U test were used for statistical analysis (P < 0.05).

RESULTS

Twelve CGCGs and 33 ameloblastomas were reviewed. Ameloblastomas had a predilection for the posterior mandible with none of the CGCGs involving the angle. CGCGs were multilocular (58.3%), with a mixed lytic sclerotic appearance (75%). Soft tissue component was present in 91% of CGCGs, which showed hyperenhancement (compared to surrounding muscles) in 50% of cases, while the remaining showed isoenhancement. Matrix mineralization was present in 83.3% of cases. Ameloblastomas presented as a unilocular (66.7%), lytic (60.6%) masses with solid components present in 81.8% of cases. However, the solid component showed isoenhancement in 63%. No matrix mineralization was present in 69.7% of cases. Quantitatively, the enhancement of soft tissue in CGCG was significantly higher than in ameloblastoma on histogram analysis (P < 0.05), with a minimum enhancement of > 49.05 HU in the tumour providing 100% sensitivity and 85% specificity in identifying a CGCG.

CONCLUSION

A multilocular, lytic sclerotic lesion with significant hyperenhancement in soft tissue, which spares the angle of the mandible and has matrix mineralization, should indicate prospective diagnosis of CGCG.

Multiple versus solitary giant cell lesions of the jaw: Similar or distinct entities?

The majority of giant cell lesions of the jaw present as a solitary focus of disease in bones of the maxillofacial skeleton. Less frequently they occur as multifocal lesions. This raises the clinical dilemma if these should be considered distinct entities and therefore each need a specific therapeutic approach. Solitary giant cell lesions of the jaw present with a great diversity of symptoms. Recent molecular analysis revealed that these are associated with somatic gain-of-function mutations in KRAS, FGFR1 or TRPV4 in a large component of the mononuclear stromal cells which all act on the RAS/MAPK pathway. For multifocal lesions, a small group of neoplastic multifocal giant cell lesions of the jaw remain after ruling out hyperparathyroidism. Strikingly, most of these patients are diagnosed with jaw lesions before the age of 20 years, thus before the completion of dental and jaw development. These multifocal lesions are often accompanied by a diagnosis or strong clinical suspicion of a syndrome. Many of the frequently reported syndromes belong to the so-called RASopathies, with germline or mosaic mutations leading to downstream upregulation of the RAS/MAPK pathway. The other frequently reported syndrome is cherubism, with gain-of-function mutations in the SH3BP2 gene leading through assumed and unknown signaling to an autoinflammatory bone disorder with hyperactive osteoclasts and defective osteoblastogenesis. Based on this extensive literature review, a RAS/MAPK pathway activation is hypothesized in all giant cell lesions of the jaw. The different interaction between and contribution of deregulated signaling in individual cell lineages and crosstalk with other pathways among the different germline- and non-germline-based alterations causing giant cell lesions of the jaw can be explanatory for the characteristic clinical features. As such, this might also aid in the understanding of the age-dependent symptomatology of syndrome associated giant cell lesions of the jaw; hopefully guiding ideal timing when installing treatment strategies in the future.

Dental and maxillofacial features of Noonan Syndrome: Case series of ten patients

Noonan syndrome (NS) is a relatively common congenital multiple-anomaly syndrome, resembling Turner syndrome, but without chromosomal anomaly. Besides the unusual facies, the maxillofacial and dental features of patients with NS are not well-summarized in the literature. The aim of this study was to describe these features and propose specific treatment guidelines for practitioners involved in oral and maxillofacial care. A retrospective multicentric study was conducted of 14 patients who were referred for NS screening. In total, 10 patients were found to carry a mutation involved in NS or NS-related disorders. Fifty percent of the mutations affected PTPN11. All patients presented with the typical extraoral features, such as macrocephaly, hypertelorism, ptosis, triangular face shape and ear dystrophy. Intraoral manifestations, including malocclusion (maxillary transversal deficiency, crossbite, anterior open-bite and class II malocclusion), dental anomalies (delayed eruption, agenesis and dystrophy, odontoma) and radiologic jaw lesions were identified in five out of 10 patients. These findings were searched in a review of the literature to obtain a comprehensive description of oral and maxillofacial features in patients with NS. The proposed treatment guidelines emphasize frequent coagulation anomalies that need to be considered prior to surgery. Early dental assessment and yearly follow-up with oral prophylaxis are recommended. Orthodontics and orthognathic surgery are also of primary importance in the management of NS patients.

Bilateral Central Giant Cell Granuloma of the mandibular angle in three females from the same family

In literature there are few reports about multiple CGCG. But this is the first report of bilateral CGCG of the mandibular angles in three females from the same family.This report describes three cases of females from the same family - a mother and two young daughters - with bilateral CGCG in their jaw angles. All the lesions were surgically removed and the histopathologic diagnosis was always identical: giant cell central granulomas, with patterns that were absolutely superimposable between them and with that of the mother.The hypothesis is that this presentation of CGCG may be defined as hereditary bilateral CGCG of the mandibular angles (or also, cherubism-like lesions).

Central giant cell lesion of the jaws: An updated analysis of 2270 cases reported in the literature

PURPOSE

To review all available data published on central giant cell lesion (CGCL) of the jaws into a comprehensive analysis of its clinical/radiological features, with emphasis on the predictive factors associated with its recurrence.

METHODS

An electronic search was undertaken in 5 databases (February/2018), looking for reporting cases of CGCLs.

RESULTS

A total of 365 publications were included, comprising 2270 lesions. CGCLs were more prevalent in women and the mandible. Cortical bone perforation occurred in 50% of the cases. Marginal/segmental resection was more often performed in larger lesions, and drug therapy was more frequent in small lesions. Recurrence was reported in 232 of 1316 cases (17.6%). The recurrence rate of the aggressive lesions (22.8%) after surgical treatment was higher than non-aggressive lesions (7.8%). Four of 5 CGCLs showed partial/total regression with pharmacological treatment. Aggressive lesions showed a worse response to corticosteroids than non-aggressive lesions. For the lesions submitted to surgery as the first treatment, curettage, enucleation, or marginal resection in relation to segmental resection, aggressive lesions, cortical bone perforation, and tooth root resorption were associated with increased recurrence rate. Recurrence related to a combination of surgical/pharmacological treatment could not be evaluated due to the variety of protocols.

CONCLUSIONS

Aggressive CGCLs recur more often than the non-aggressive ones. Despite sometimes showing poor response to corticosteroid injection or surgical curettage, a combination of both treatment strategies should be considered in aggressive cases to reduce morbidities associated with radical surgery. The best protocol to manage aggressive and non-aggressive lesions remains to be determined.

Insight into the pathogenesis and nature of Central Giant Cell Lesions of the Jaws

Central giant cell lesions of the jaws are not uncommon. While the majority of these represent single, sporadic lesions, histologically identical lesions are seen in association with a number of other bone lesions, as well as in certain syndromes. This manuscript offers a brief update on recent developments in this area that provide new insight into the pathogenesis and nature of Central Giant Cell Lesions of the Jaws.

Key words:Central giant cell lesion, RASopathy

Bilateral inflammatory cysts of the jaw: report of an unusual case

Radicular cyst is the most common odontogenic cyst occurring in the jaws. The cyst is commonly found in relation to the maxillary anterior teeth in the third and fifth decade of life. Although multiple radicular cysts are not uncommon in the jaws, bilaterally symmetrical representation of these cysts is rare. Radiographs prior to extraction help in diagnosis of these cysts and thereby prevent further morbidities. We report a case of 16-year-old male patient who presented bilateral radicular cysts symmetrically in the mandible.

Cherubism: best clinical practice

Cherubism is a skeletal dysplasia characterized by bilateral and symmetric fibro-osseous lesions limited to the mandible and maxilla. In most patients, cherubism is due to dominant mutations in the SH3BP2 gene on chromosome 4p16.3. Affected children appear normal at birth. Swelling of the jaws usually appears between 2 and 7 years of age, after which, lesions proliferate and increase in size until puberty. The lesions subsequently begin to regress, fill with bone and remodel until age 30, when they are frequently not detectable.

Fibro-osseous lesions, including those in cherubism have been classified as quiescent, non-aggressive and aggressive on the basis of clinical behavior and radiographic findings. Quiescent cherubic lesions are usually seen in older patients and do not demonstrate progressive growth. Non-aggressive lesions are most frequently present in teenagers. Lesions in the aggressive form of cherubism occur in young children and are large, rapidly growing and may cause tooth displacement, root resorption, thinning and perforation of cortical bone.

Because cherubism is usually self-limiting, operative treatment may not be necessary. Longitudinal observation and follow-up is the initial management in most cases. Surgical intervention with curettage, contouring or resection may be indicated for functional or aesthetic reasons. Surgical procedures are usually performed when the disease becomes quiescent. Aggressive lesions that cause severe functional problems such as airway obstruction justify early surgical intervention.

Central giant cell lesion

A classic case of central giant cell lesion (CGCL) is presented with emphasis on clinical, radiologic, and histologic features. The differential is discussed including peripheral giant cell granuloma, brown tumor of hyperparathyroidism, and giant cell tumor of bone. The molecular pathway of osteoclastogenesis is selectively reviewed and applied to suggest possible etiologies of the giant cell lesions. CGCL syndromes and treatment are also discussed.

Central Giant Cell Granuloma of the Jaws: A Clinical Study of 17 Cases and a Review of the Literature

Objectives:

The aim of this prospective study was to evaluate the outcome of treatment of a group of 17 patients with central giant cell granuloma (CGCG) who were treated in our clinic.

Methods:

A group of 17 patients with CGCG were treated in the Clinic of Oral and Maxillofacial Surgery of the “G. Papanikolaou” hospital in Thessaloniki. The age range was from 7 to 60 years. Eight patients were male and 9 patients were female. Because most of our patients (11) were less than 30 years old, the aim of the treatment was to eradicate the lesions without functional problems. All of the patients were treated by excision via curettage without a continuity defect and peripheral osteotomy. For 2 patients, the treatment was continued (after the first recurrence) with salmon calcitonin.

Results:

The follow-ups ranged from 1 to 15 years. All of the patients were free of the disease, without features of recurrence and without functional or aesthetic problems.

Conclusions:

Surgery has usually been considered to be the best method of treatment for CGCG. Most authors have proposed conservative surgical procedures (excision via curettage), especially for young patients. For aggressive lesions, supplementary treatment with calcitonin would provide good results.

Idiopathic bilateral central giant cell reparative granuloma of jaws: a case report and literature review

OBJECTIVES

The central giant-cell reparative granuloma has been defined as a localized benign but sometimes aggressive osteolytic proliferation consisting of fibrous tissue with hemorrhage and hemosiderin deposits, presence of osteoclast-like giant cells and reactive bone formation. It is a benign lesion usually appears as solitary, multilocular, radiolucencies, located in the mandible and maxilla. Multiple CGCRGs of the jaw bones is very rare and, if it occurs, it is usually associated with hyperparathyroidism in majority of the cases .This report presents an unusual case of a 12-year-old girl who has idiopathic, bilateral giant cell granulomas of the angulus mandible.

METHODS

A 12 year-old girl was admitted to our department with complain of swelling on both right and left side of her lower jaw. There was no history of trauma, dental problem or neck infection. Blood chemistry, including calcium, alkaline phosphatase and inorganic phosphorus was normal. Patient had not family history, clinical appearance like cherubism or noonan syndrome and systemic anomalies. MRI showed, in right ramus mandible, 37 x mm x 35 mm x 28 mm size mass and in lenf ramus mandible, an expansile, 30 mm 38 mm x 12 mm size mass. The patient underwent surgical curettage of the lesion through an intraoral approach under general anesthesia.

RESULT

The histopathologic examination of the lesion was reported as 'giant cell reparative granuloma.

CONCLUSION

Our patient had multiple CGCRG in her jaw. In literature there is several reports about multiple CGCRG but unlike of that report our patient had no syndromes like Cherubism, Noonan syndrome, neurofibromatosis type-1 and systemic disease like hyperparathyroidism ,fibrous dysplasia. So we define this case as Idiopathic bilaterally central giant cell reparative granuloma of jaw.

Clinically aggressive central giant cell granulomas in two patients with neurofibromatosis 1

BACKGROUND

Neurofibromatosis 1 (NF1) is an autosomal dominantly inherited disorder caused by a spectrum of mutations affecting the Nf1 gene. Affected patients develop benign and malignant tumors at an increased frequency. Clinical findings include multiple cutaneous café-au-lait pigmentations, neurofibromas, axillary freckling, optic gliomas, benign iris hamartomas (Lisch nodules), scoliosis, and poorly defined soft tissue lesions of the skeleton. Kerl first reported an association of NF1 with multiple central giant cell granulomas (CGCGs) of the jaws. There have since been 4 additional published cases of NF1 patients with CGCGs of the jaws.

CLINICAL CASES

We report on 2 patients who presented with NF1 and aggressive CGCGs of the jaws. In both cases, the clinical course was characterized by numerous recurrences despite mechanical curettage and surgical resection.

CONCLUSIONS

We review proposed mechanisms to explain the apparent association between NF1 and an increased incidence of CGCGs of the jaws. While the presence of CGCGs of the jaws in patients with NF1 could represent either a coincidental association or a true genetic linkage, we propose that this phenomenon is most likely related to NF1-mediated osseous dysplasia. Compared to normal bone, the Nf1-haploinsufficient bone in a patient with NF1 may be less able to remodel in response to as of yet unidentified stimuli (e.g. excessive mechanical stress and/or vascular fragility), and consequently may be more susceptible to developing CGCG-like lesions. Alternatively, the CGCG in NF1 patients could represent a true neoplasm, resulting from additional, as of yet unidentified, genetic alterations to Nf1-haploinsufficient bone.