Giant cell reparative granuloma of the orbit associated with cherubism

Orbital Giant Cell Reparative Granuloma: A Case Report

Giant cell reparative granuloma has a very low incidence and is thought to be a response to trauma. While there have been only a few reported cases of orbital giant cell reparative granuloma, we recently observed such a case and analyzed 16 previously reported cases of this type. It is important to note that further investigation is necessary to fully understand the relationship between giant cell reparative granuloma and trauma.

Giant Cell Reparative Granuloma of the Orbit: Clinicopathological Characteristics and Treatment

Giant cell reparative granuloma (GCRG) is a rare fibroosseous lesion uncommonly seen in the orbital area. Although benign, it is known to be recurrent and locally destructive. We report two cases of GCRG of the orbit. In both cases, computed tomography revealed a heterogeneously growing well-defined mass, arising from the roof of the orbit, affecting the cortex, and invading the orbit. In the first case, the mass extended into the anterior cranial fossa. Magnetic resonance imaging with gadolinium showed, in both cases, a cystic character of the lesion with fluid levels. The surgical treatment was performed via an upper crease incision. An ultrasonic aspirator system was used to remove the tumor tissue and its extension into cranial fossa. Careful histopathologic analysis established the diagnosis of GCRG. Symptoms resolved completely with no evidence of recurrence after a follow-up of 18 and 14 months, respectively. We present the clinicopathological and radiological findings, and we describe the surgical approach. As a rare entity, GCRG of the orbit should be considered in differential diagnosis of fibroosseous orbital masses. Complete surgical excision carries a low risk of recurrence.

SH3BP2-related fibro-osseous disorders of the maxilla and mandible: A systematic review

Cherubism is a disorder of bony overgrowth of the jaws that manifests in childhood. SH3BP2 gene variants have been associated with cherubism; this gene plays a major role in bone homeostasis. Due to its rare occurrence, there is as yet no comprehensive understanding of the natural history and clinical course of the disease. The aim of this review was to compile and analyze all cases of SH3BP2-related cherubism and cherubism-like disorders. Thirty publications were identified, including 92 individuals from 34 families, who were diagnosed with SH3BP2-related fibro-osseous lesions of the jaw. Only 15% of cases included in this review had no known family history of the disease. The distribution of cherubism was equal with respect to biological sex. Missing teeth were reported in 38% of cases. Lesions were restricted to the mandible in 36% of cases and involved both the maxilla and mandible in 54% of cases. The clinical phenotypes reported in the articles analyzed varied greatly in detail, making comparisons between studies and conclusive analysis difficult. Further work is necessary to describe the connection between SH3BP2 gene variants and cherubism in order to advance its diagnosis and treatment.

Proliferation and arrest: the genetics of orbital disorders

PURPOSE OF REVIEW

Oculoplastic genetic diseases can be divided into eyelid, lacrimal, and orbital disorders. The purpose of this review is to develop a rational approach to the categorization of genetic diseases that affect the orbit and review the most recent developments.

RECENT FINDINGS

Genetic disorders that affect the orbit can simply be divided into whether they cause proliferation or arrest of orbital structures. Proliferative conditions include vascular, neural, bony, mesenchymal, and lymphoid. Conditions that cause arrest can be subcategorized into whether they cause soft tissue or bony arrest of development. The genetics of many of these conditions have been elucidated and novel treatments, based on the molecular defects, have been utilized with some success.

SUMMARY

Molecular advances may result in substitution of a molecular categorization scheme for the one proposed in this manuscript. Delineation of the underlying molecular causes of these disorders will result in earlier, less invasive procedures than those that are currently employed.

Cherubism: report of three cases and literature review

PURPOSE

To report 3 cases of cherubism, one of whom underwent surgery for orbital manifestations, and to provide a literature review.

CASE REPORTS

Our patients were normal at birth and developed painless enlarging of the cheeks and jaws when they were 4-5 years old. Ophthalmologic examinations showed mild proptosis, superior globe displacement and inferior scleral show in all cases. Cases 2 and 3 had lower lid skin discoloration. Computed tomography (CT) scans demonstrated bilateral multicystic lesions in the maxilla and mandible with cortical thinning in all cases. In Case 3, left eye hyperglobus and anisometropic amblyopia was seen. In this case, the CT scan showed a round, well-defined and homogeneous mass, involving the anterior and superior walls of the maxillary sinus on the left side, extending into inferior orbit. Debulking of the mass was performed at the surgery. The pathologic findings were compatible with the diagnosis of giant cell reparative granuloma. He returned 1 year after surgery with recurrence of the mass.

DISCUSSION

A few cases were reported in the literature with histopathologically proven orbital cherubism. To our knowledge, lower lid skin discoloration in Cases 2 and 3 and anisometropic amblyopia in case 3 were not described elsewhere in cherubism cases. We recommend that all cases with cherubism must be examined by an ophthalmologist to diagnose and treat possible orbital manifestations.

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.

Cherubism: case report with review of literature

Cherubism is a rare hereditary fibro-osseous lesion characterized by painless expansion of jaws in childhood and is known to regress without treatment after puberty. Wait and watch approach has been advocated by many authors. The disease starts early in life manifesting itself fully in the second decade of life and is almost regressed in the third decade. Here, we report two cases of cherubism with clinico-radiographic presentation of its classical features in their third and fourth decade of life respectively and review the literature.

New retinal findings in cherubism

PURPOSE

To report three new retinal findings in a patient with cherubism.

PARTICIPANT

An 18-year-old male patient.

METHODS

Clinical examination and retinal scanning with spectral domain optical coherence tomography.

RESULTS

The spectral domain optical coherence tomography revealed inner retinal striae in the posterior pole of both eyes and a subfoveal vitelliform deposit in the left eye. There was an inferior retinoschisis in the left eye.

CONCLUSIONS

The inner retinal striae, subretinal vitelliform deposit, and retinoschisis extend the scale of retinal findings associated with orbital (facial) cherubism.

SH3BP2 is rarely mutated in exon 9 in giant cell lesions outside cherubism

Giant cell tumor of bone and giant cell reparative granuloma are benign lesions with prominent giant (multinucleated) cells, and an understanding of the molecular biology and genetics of these lesions will likely aid in more effective treatment. Cherubism is a benign lesion of the maxilla and mandible histologically similar to giant cell tumor of bone and giant cell reparative granuloma. Germline mutations in exon 9 of the gene encoding Src homology 3 binding protein 2 (SH3BP2) occur in most patients with cherubism. We therefore hypothesized SH3BP2 and its putative downstream effector nuclear factor of activated T cells c1 isoform (NFATc1) are highly expressed in sporadic nonsyndromic giant cell lesions and associated with somatic SH3BP2 mutations. We analyzed giant cell lesions for SH3BP2 and NFATc1 expression by RNA blot and/or immunohistochemistry and for exon 9 SH3BP2 mutations. We found the SH3BP2 transcripts and protein were abundantly expressed in giant cell tumors of bone, as well as NFATc1 protein. Sequencing of exon 9 of SH3BP2 was normal in all sporadic nonsyndromic giant cell lesions. Although many multinucleated giant cell lesions of bone share histologic features, the primary genetic defect in cherubism and these other giant cell lesions appears different.

Aggressive case of cherubism: 17-year follow-up

Cherubism is an autosomal dominant disorder in which the normal bone is replaced by cellular fibrous and immature bone, resulting in painless symmetrical enlargement of the jaws. An aggressive case of cherubism with extensive swelling on several facial bones in a 19-year-old boy is reported. The disorder was diagnosed 15 years ago, but the patient has not been submitted to any type of surgery so far. The highlights of this case are the great proportion of the lesions, the enormous functional and emotional disturbances brought about by these lesions, and the difficulty to choose the most appropriate age and form of treatment.