Zoledronic Acid for the Treatment of Children With Refractory Central Giant Cell Granuloma

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.

Management of RANKL-mediated Disorders With Denosumab in Children and Adolescents: A Global Expert Guidance Document

CONTEXT

Denosumab is an effective treatment for many receptor activator of nuclear factor kappa-B ligand (RANKL)-mediated disorders but there are potential safety considerations and limited data to guide its use in children and adolescents.

OBJECTIVE

This document seeks to summarize the evidence and provide expert opinion on safe and appropriate use of denosumab in pediatric RANKL-mediated disorders.

PARTICIPANTS

Ten experts in pediatric bone and mineral medicine from 6 countries with experience in the use of denosumab participated in the creation of this document.

EVIDENCE

Data were sourced from the published literature, primarily consisting of case reports/series and review articles because of the lack of higher level evidence. Expert opinion of the authors was used substantially when no published data were available.

CONCLUSION

Denosumab is an effective treatment for RANKL-mediated disorders in children and adolescents but is often not curative and, in some cases, is best used in conjunction with surgical or other medical treatments. Careful multidisciplinary planning is required to define the goals of treatment and expert oversight needed to manage the risk of mineral abnormalities. Substantive, collaborative research efforts are needed to determine optimal treatment regimens and minimize risks.

Response of Central Giant Cell Granuloma of the Jaw to Imatinib

Central giant cell granuloma of the jaw (CGCJ) can be locally aggressive and result in facial and dental deformity. A child with CGCJ was treated surgically and with denosumab with a response but life-threatening toxicity. Imatinib, a tyrosine kinase inhibitor, was prescribed based on clinical similarities between CGCJ and cherubism, for which Imatinib has been effective. Within 2 months, a computed tomographic scan showed significant ossification, which increased over the following 8 months. This case suggests that tyrosine kinase inhibitors may be an effective option, and one with limited toxicity, for CGCJ.

Central Giant Cell Reparative Granuloma (CGCRG) of the Jaw in Children Treated with Neoadjuvant Bisposphonates: Review and a Case Report

Central giant cell reparative granuloma (CGCRG) of the jaw is a neoformation localized in the mandible or in the maxillary bone and characterized by fibrous tissue, osteoclast-like giant cells and reactive bone formation. The CGCRG is a less frequent benign tumor but sometimes it is characterized by an aggressive behavior with a very rapid growth. It affects the young adults mainly and the children occasionally. Nowadays no medication therapy is approved for CGCRG in pediatric cases. We present a case of an aggressive form of a mandibular CGCRG in a 5-year child with Arnold-Chiari syndrome. This case is unique for the use of bisphosphonates (BPs) as neoadjuvant therapy in pediatrics. The therapy were administrated with the purpose of arresting the rapid growth of the tumor in order to avoid a demolitive surgery to the young patient. The child was without symptoms and presented an unusual swelling in the left mandible developed in a few weeks. The lesion was diagnosed by a CT scan and it was confirmed by a biopsy performed for histopathological assessment a few days later. The drug therapy consisted of seven cycles iv of Zoledronate associated to Calcium Gluconate. The child was closely observed through clinical and serological evaluations during the following months. About five months after the last cycle of BPs the child underwent CT scan and a conservative surgical treatment, consisted in a deep curettage, was programmed. Seven months after surgery the aesthetic profile of the patient improved and CT scan reported a significant calcic neoapposition in the area of the previous bone lesion. After more than one year from surgery, no relapse was observed. This case report demonstrates that BPs can be used safely in pediatric patients with CGCRG. Especially BPs could have a role as neoadjuvant therapy: If administrated before surgical treatment BPs avoid the necessity of resective surgery and reduce the risk of recurrence in pediatric CGCRG after conservative curettage.

Medication Management of Selected Pathological Jaw Lesions

Most jaw lesions are treated surgically. Areas of abnormal proliferation or destruction in bone are commonly treated by regional curettage, excision, or resection. However, surgery is invasive and leaves a defect where the lesion was removed. Surgical trauma to adjacent healthy tissue, including vital neurovascular bundles is often unavoidable, and can be especially traumatizing to the pediatric patient. Select jaw lesions with well-studied nonsurgical pharmaceutical treatments are presented here.

Locally aggressive orbital giant cell reparative granuloma in an infant: case report and literature review

Giant cell reparative granuloma (GCRG) is a non-neoplastic hyperplasia of bones that mostly happens in the mandible and maxilla in any age group but has a predilection for children and young adults. GCRGs that cause bone destruction are of very low frequency. Orbital-involved cases have been rarely reported since 1981, especially in children. We now report a 1-year-old girl with a rapidly enlarging post-traumatic orbital mass. CT scan and surgical resection showed a well-defined mass occupying the upper right orbit, causing bone destruction. Microscopically there was a proliferation of histocytes and some osteoclast-like multinucleated giant cells with hemosiderin, finally confirmed to be GCRG. 22 months' follow up showed no evidence of recurrence. This case suggests infant orbital GCRG can be locally aggressive.

Central giant cell granuloma mimicking a periapical lesion of endodontic origin: A case report

This paper aims to report a case in which central giant cell granuloma (CGCG) mimicked a periapical lesion of endodontic origin. An 18-year-old female patient was referred for diagnosis and treatment of extensive radiolucent periapical lesion involving 31, 32, 33, 34 and 35 teeth. Clinically, the patient presented slight facial asymmetry and healthy teeth on the affected side with positive response to thermal vitality tests. Thus, an incisional biopsy was performed, which presented a histopathological picture characteristic of a CGCG. The endodontic treatment of the involved teeth was followed by surgical curettage of the lesion. After two years of follow-up, the patient was asymptomatic, with marked improvement in mandibular symmetry and adequate healing of the lesion. Therefore, the diagnosis of radiolucent periapical lesions must include lesions of endodontic and non-endodontic origin for better treatment planning and execution.

Making sense of giant cell lesions of the jaws (GCLJ): lessons learned from next-generation sequencing

Next-generation sequencing has revealed mutations in several bone-related lesions and was recently used to uncover the genetic basis of giant cell lesions of the jaws (GCLJ). Consistent with their benign nature, GCLJ show a low tumor mutation burden. They also harbor somatic, heterozygous, mutually exclusive mutations in TRPV4, KRAS, or FGFR1. These signature mutations occur only in a subset of lesional cells, suggesting the existence of a 'landscaping effect', with mutant cells inducing abnormal accumulation of non-mutant cells that form the tumor mass. Osteoclast-rich lesions with histological similarities to GCLJ can occur in the jaws sporadically or in association with genetically inherited syndromes. Based on recent results, the pathogenesis of a subgroup of sporadic GCLJ seems closely related to non-ossifying fibroma of long bones, with both lesions sharing MAPK pathway-activating mutations. In this review, we extrapolate from these recent findings to contextualize GCLJ genetics and we highlight the therapeutic implications of this new information. © 2019 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Radiotherapy for recurrent central Giant cell granuloma: a case report

Background

Central giant cell granuloma (CGCG) is a rare, non-neoplastic, benign lesion that exhibits expansive and osteolytic biological behavior. CGCG treatment and management is challenging for clinicians.

Case presentation

This report presents the treatment and management of recurrent, aggressive CGCG after surgical resection. After informed consent was obtained, the patient underwent radiotherapy. The lesion size was reduced significantly, with no evidence of recurrence or malignant transformation.

Conclusions

This treatment experience indicates that radiotherapy can be used as a rescue treatment for complicated CGCG involving vital neurovascular structures of the cranial base.

Minimally effective concentration of zoledronic acid to suppress osteoclasts in vitro

Zoledronic acid is regarded as the most potent bisphosphonate and is widely used in patients with osteoporosis; however, its side effects, including acute-phase reactions, gastrointestinal complaints, renal dysfunction and bisphosphonate-associated osteonecrosis impair the safety and quality of life of patients. The present study was designed to determine the minimal effective concentration of zoledronic acid through testing the dose-dependent effects of zoledronic acid on osteoclast suppression. A primary culture of bone marrow mononuclear cells obtained from C57 mice (age, 6 weeks) was established and induced to form osteoclasts. The number of multinuclear cells was determined by tartrate-resistant acid phosphatase staining and compared among cultured marrow cells treated with different concentrations of zoledronic acid. Furthermore, the cellular properties, including adhesion, migration and bone resorption, were compared at the minimal effective concentration. At a concentration of 1×10⁻⁶ mol/l, zoledronic acid significantly inhibited the formation of osteoclasts. This inhibitory effect was further enhanced at the concentration of 1×10⁻⁵ mol/l. However, the inhibitory effect of zoledronic acid tapered at the concentration of 1×10⁻⁴ mol/l and there was no further dose-dependent increase. In addition, the concentration of 1×10⁻⁶ mol/l was sufficient to alter cellular functions, including cell adhesion, migration and bone resorption. In conclusion, zoledronic acid was effective in reducing osteoclast formation and suppressing cellular functions. The minimal effective concentration of zoledronic acid in vitro was 1 µmol/l. Based on these results, a comparable dosage should be explored in clinical applications.

Central giant cell granuloma: a case report

Introduction: Central giant cell granuloma (CGCG) is an uncommon benign bony lesion that occurs in the mandible and maxilla. Observation: A 30-year-old woman was evaluated for a radiolucent lesion of the mandible, which was discovered by chance. This image was associated with a painless swelling covered by normal mucosa. No symptoms were associated. After surgical excision, histological examination of the surgical specimen concluded a CGCG. Surgical follow-up was simple, and the first radiological test performed 3 months after confirming the onset of bone healing. Comments: The clinical behavior of CGCG ranges from a slow-growing asymptomatic swelling to an aggressive lesion with pain, local osteolysis, root resorption and tooth displacement. Therapeutic options have greatly varied in recent years. Nonsurgical treatments with alpha-interferon, calcitonin, and corticosteroids have been described and their benefits may be worthy of consideration. Conclusion: A surgical approach is considered as the traditional treatment and is still the most accepted one. However, in some publications, authors disagree on the type of surgery that should be performed.

Recurrent multilocular mandibular giant cell granuloma in neurofibromatosis type 1: Evidence for second hit mutation of NF1 gene in the jaw lesion and treatment with curettage and bone substitute materials

Giant cell granuloma (GCG) of the jaw is a rare, well-known feature of neurofibromatosis type 1 (NF1), an inborn multisystem disorder. Recently, the development of GCG in NF1 was attributed to second hit mutations in the NF1 gene. The treatment of GCG is pragmatic with a preference for local curettage of lytic osseous areas. This report describes the surgical therapy of an NF1-affected female with multilocular mandibular GCG and hypodontia who additionally suffered from a brain tumour and Hashimoto's thyroiditis. Although local recurrence of GCG was noted, augmentation of the curetted cavities with a bone substitute in successive interventions successfully restored the extensive periradicular local defects and stabilised the teeth. A meticulous in vitro study of the GCG specimen revealed a second hit mutation in the NF1 gene in the GCG spindle-cells. This study contributes to the increasing knowledge of the molecular basis for GCG in the jaw of NF1 patients, indicating that it is a neoplasm.

[Central giant cell granuloma in children: Presentation of different therapeutic options]

Central giant cell granuloma (CGCG) is a benign tumor that may be subdivided in a non-aggressive form and an aggressive form. In aggressive forms, tumor size and high recurrence risk need large surgical resections. In order to minimize surgical morbidity, especially in children, medical treatments acting on the tumor proliferation are currently being assessed: steroids (triamcinolone), anti-osteoclastic drugs (calcitonine, alendronate, denosumab), anti-angiogenic drugs (interferon α). However to date, there is no evidence for any superiority of medical over surgical treatment. Complete response is rarely obtained and additional surgery is often necessary to remove the tumor in case of tumor progression, to remove a remnant or to remodel bone. Moreover, these drugs have frequent local or systemic side effects such as osteonecrosis and growth deficiencies.