Maxillofacial challenge: Rare presentation of central giant cell tumor involving both maxilla and mandible

INTRODUCTION AND IMPORTANCE

Central giant cell tumor (CGCT) of bone is an uncommon yet locally aggressive neoplasm originating from undifferentiated mesenchymal cells in bone marrow. This case report explores a rare presentation in the maxilla extending to the mandible, emphasizing the complexity of CGCT management and the need for a multidisciplinary approach.

CASE PRESENTATION

A 35-year-old female presented with a progressively enlarging non-tender, firm swelling on the left maxilla and a similar mandibular swelling. Paraesthesia of the left lower lip and chin accompanied the mandibular swelling. CT scans and 3D reconstructions revealed expansive osteolytic defects affecting the maxilla and mandible. Biochemical tests supported a central giant cell tumor diagnosis. Histopathology confirmed spindle cell proliferation and multinucleated giant cells in both lesions. Surgical intervention involved excision and reconstruction. A five-month follow-up showed no recurrence, affirming the treatment's success.

CLINICAL DISCUSSION

Central giant cell tumors (CGCTs) of bone are primarily benign, arising from undifferentiated mesenchymal cells. While mostly benign, they carry a rare potential for malignancy. Diagnosis involves imaging (CT, MRI, bone scintigraphy) and confirmation through biopsy. Surgical resection is the standard treatment, with radiotherapy considered in challenging cases. Recurrence rates vary with the extent of surgical intervention. Alternative treatments like cryotherapy and chemotherapy show varying success.

CONCLUSION

This case emphasizes the necessity of precise histopathological diagnosis for CGCT management. The intricate nature of maxillary involvement, coupled with mandibular association, mandates a multidisciplinary approach. Surgery, while the primary treatment, should be judiciously determined based on tumor characteristics and recurrence.

Central giant cell granuloma: Off-label treatment with Denosumab in a patient with Noonan syndrome

This study aims to describe the utilization of Denosumabࣨ, a human monoclonal antibody against the RANK-L receptor, in a mandibular giant cell granuloma (GCG) with a significant local aggressiveness component that was unresponsive to surgical treatment. We present a case of a 19-year-old male patient diagnosed with Noonan syndrome, who presented a multifocal giant cell granuloma with aggressive behaviour resistant to surgical treatment. Due to the functional and aesthetic implications associated with a surgical procedure, a decision was made to initiate medical treatment using Denosumabࣨ. Throughout the treatment, the patient presented excellent clinical and analytical tolerance, with no reported adverse effects. Surgical intervention remains the preferred approach for GCG. Denosumabࣨ emerges as an alternative, either as neoadjuvant treatment or as definitive therapy for unresectable or resectable tumors associated with significant morbidity. It leads to size stabilization and regression of the tumour stage.

Morphological analysis of cell cannibalism: An auxiliary tool in the prediction of central giant cell granuloma clinical behavior

Central giant cell granuloma (CGCG) is a benign jaw lesion with variable clinical behavior. Cell cannibalism is a cellular process associated with aggressiveness and invasion in malignant neoplasms. Here, we morphologically investigated cell cannibalism as an auxiliary method to predict CGCG clinical behavior. Cell cannibalism was quantitatively evaluated in 19 cases of peripheral giant cell granuloma (PGCG), 38 cases of CGCG (non-aggressive and aggressive), and 19 cases of giant cell tumor of bone (GCT) stained with hematoxylin and eosin. T-test was performed to assess the differences between the variables analyzed (p ≤ 0.05). Cell cannibalism was identified in 21% of non-aggressive CGCGs and 68.4% of aggressive CGCGs. A significantly higher amount of cannibal multinucleated giant cells (CMGC) was observed in aggressive CGCG compared to PGCG and non-aggressive CGCG (p = 0.042; p = 0.044, respectively). There were no significant differences in the CMGC index between non-aggressive CGCG and PGCG (p = 0.858) and between aggressive CGCG and GCT (p = 0.069). CGGC cases that exhibited rapid growth and tooth displacement and/or root resorption had a higher amount of CMGC (p = 0.035; p = 0.041, respectively). Cell cannibalism can be identified in CGCG through routine anatomopathological examination. The quantification of CMGC can help to predict the clinical behavior of central giant cell granuloma.

Oral giant cell tumor or giant cell granuloma: How to know?

Introduction

The distinction between giant cell tumors and giant cell granulomas is challenging, as both entities have overlapping diagnostic criteria, especially in oral locations. The two entities have similar clinical and radiological presentations, but they differ in their prognoses.

Objective

The main objective of this study was to list the clinical, radiological, histological, and prognostic features of maxillomandibular giant cell tumors and giant cell granulomas cases n order to assess their value as a diagnostic referral factor that may allow the distinction between maxillo-mandibular giant cell granuloma and giant cell tumor.

Study design

Data of maxillomandibular giant cell granulomas and giant cell tumors were assessed through a scoping review and a pre-existing systematic review of literature. We have also realized a bicentric retrospective study.

Results

Various criteria facilitate the differential diagnosis like age, size, locularity and presence of necrosis zone but not the gender. The most discriminating factors was symptomatology (reported in 72% of GCTs while only 15% of GCGs) and the distribution pattern of giant cells in the stroma (homogeneously dispersed in 80% of GCTs versus grouped in clusters in 86.7% of GCGs). Recurrences were most described for giant cell tumors than giant cell granulomas. Malignant transformation and pulmonary metastasis were exclusively reported for giant cell tumors.

Conclusion

As clinical and radiological elements are not sufficient to distinguish between these two entities, immunohistochemistry and molecular genetics can be represent diagnostic biomarkers to distinguish giant cell granulomas and giant cell tumors in oral cavity. We have attempted to define the main criteria for the differentiation of giant cell tumor and giant cell granuloma and propose a decision tree for the management of single maxillomandibular giant cell lesions.

Non-surgical treatment as an alternative for the management of central giant cell granuloma: a systematic review

OBJECTIVE

To evaluate the effectiveness of non-surgical treatment as an alternative in the management of central giant cell granuloma (CGCG).

MATERIAL AND METHODS

A literature search was carried out in accordance with the PRISMA statement in order to answer the question "Are non-surgical treatments effective as an alternative in the treatment of CGCG?". Two examiners independently assessed eligibility, risk of bias, and extracted data, which included therapeutic protocol, side effects, and need for surgical supplementation.

RESULTS

Among 1712 studies, 15 were included, totaling 145 patients. Calcitonin, intralesional corticosteroids, and denosumab were the medications used. For calcitonin (n = 61), complete remission was found in 30 cases. For intralesional triamcinolone (n = 68), reduction in size was observed in most cases (n = 39). Four cases received subcutaneous denosumab and showed absence of active bone metabolism in the region, of which three presented ossification. Combination of drug therapies (n = 29) was reported in one study and included subcutaneous interferon and oral imatinib. More and less side effects were found for interferon and corticosteroids, respectively. Forty percent of patients required additional surgical treatment.

CONCLUSION

Despite the side effects presented and the need for additional surgery in some patients, in general, all non-surgical treatments could provide positive results as an alternative for the management of CGCG, especially with regard to reducing the size of the lesion.

CLINICAL RELEVANCE

CGCG is a benign bone lesion that mainly affects young individuals. Although the most common therapy is surgery, its contraindication in some patients, the large extension, and high recurrence rate of the aggressive variant have led the search for non-surgical therapies.

Giant Cell-Rich Tumors of Bone

The term giant cell-rich tumors of bone refers to a shared morphologic pattern in a group of different osseous lesions, that is, the abundance of osteoclastlike giant cells. Fitting with a broad spectrum of clinical presentations and biological behavior, the recent detection of characteristic molecular alterations in giant cell tumor of bone (H3-3), nonossifying fibroma (KRAS, FGFR1), giant cell granuloma of the jaws (KRAS, FGFR1, TRPV4), and aneurysmal bone cyst (USP6) have contributed significantly to the biological understanding of these morphologically related but clinically distinct lesions and their systematic classification, highlighting differences and pathogenic relationships.

A Literature Review of the Rare Coexistence of Central Giant Cell Granuloma with Aneurysmal Bone Cyst: A Case Report

Introduction:

Central giant cell granuloma (CGCG) is a benign bone tumor that occurs more in young females and anterior of the mandible. It can be unilocular or multilocular with wispy-septation, undulating borders, cortical expansion, and perforation. Central giant cell granuloma in association with other benign lesions of the jaws is named hybrid lesion. An aneurysmal bone cyst (ABC) is a rare, rapidly growing benign tumor that is commonly developed in young females and the mandible molar and ramus regions. It is usually a well-defined cyst-like expansile lesion with an internal structure similar to CGC lesions in radiographic features.

Case Report:

A 17-year-old girl was referred to the radiology department for panoramic radiography at the end of orthodontic treatment. The complete opacification of the right maxillary sinus, root resorption, and periodontal ligament widening was evident in panoramic radiography. Cone-beam computed tomography revealed a soft-tissue mass and displacement of the lateral nasal wall. The lesion was multilocular with wispy septation and ground glass in some parts. On T2-weighted magnetic resonance imaging, a heterogeneous mass with low to intermediate signals and fluid-fluid levels were observed. The patient underwent surgical curettage, and the histopathological diagnosis was the coexistence of CGCG and ABC.

Conclusion:

An unusual view of the coexistence of CGCG and ABC could be a lesion with ground glass pattern calcification. Hybrid lesions with the coexistence of CGCG and ABC are rare, and only six cases are reported in the literature in this regard.

KRAS Mutation in an Implant-associated Peripheral Giant Cell Granuloma of the Jaw: Implications of Genetic Analysis of the Lesion for Treatment Concept and Surveillance

The aim of this case report was to detail diagnosis and therapy in a case of implant-associated peripheral giant cell granuloma (IA-PGCG) of the jaw. Case Report: The 41-year-old female attended the outpatient clinic for treatment of recurrent mandibular IA-PGCG. The lesion was excised and the defect was closed with a connective tissue graft of the palate. Healing of oral defects was uneventful, and no local recurrence has occurred during a follow-up of 7 months. Genetic examination of the lesion identified a somatic mutation in KRAS. Conclusion: The lesions are assessed as reactive-inflammatory changes in the mucous membrane of the oral cavity. The cause of the lesion is unknown. KRAS mutations are commonly found in various cancer tissues, but also in germline and mosaic RASopathies. Recently, KRAS mutations have been identified in several IA-PGCG. The clinical course of a frequently locally recurring lesion gives rise to the assumption that lesions of this type show characteristics known in benign neoplasms.

Assessment of Tumor Angiogenesis by Expression of CD 105 in Ameloblastoma, Odontogenic Keratocyst and Central Giant Cell Lesion

Background:

Angiogenesis is critical for tumor growth and reflects the aggressive behavior of invasive odontogenic lesions [like amelogenesis (AM) (AM), Odontogenic Keratocyst (OKC) and Central giant cell lesion (CGCL)]. Mean vascular density (MVD) shows the angiogenic potential and CD105 is an ideal endothelial biomarker due to its specificity to new blood vessels for MVD detection. The aim of the study was to compare the MVD (angiogenic potential) among AM, OKC and CGCL in comparison to Pyogenic Granuloma (PG) using CD105 biomarker.

Methods:

Sixty-four primary cases of odontogenic invasive tumors (AM, OKC and CGCL) and PG, diagnosed clinically and histologically were included in the study, with 16 samples in each group. Tissue samples of peripheral AM, Peripheral GCL of jaws, malignant AM, and specimen with insufficient tissue were excluded. Tissue sections were embedded, processed and stained using Hematoxylin and Eosin (H and E). Immunohistochemistry was performed using antibodies against CD105, with positive brown cytoplasmic staining in the endothelial cells of neo-vasculature. Distinct countable, positively stained endothelial cell or clusters were evaluated under light microscope for identification of MVD. ANOVA and t-test were applied for statistical analysis of data.

Results:

Highest MVD was displayed in CGCL (32.99±0.77) and the minimum was observed in OKC (7.21± 0.75) respectively. CGCL showed significantly higher MVD to AM, OKC and PG lesions (p<0.05). AM (8.07± 0.36) and Odontogenic Keratocyst (7.21± 0.75) showed comparable MVD, which was lower than PG (14.7± 0.96) and CGCL vascular density (p < 0.01) respectively.

Conclusion:

CGCL was most aggressive, with highest MVD among the investigated odontogenic lesions (OKC, AM and PG). The proliferative aggressive behavior of Odontogenic Keratocyst is comparable to AM due to comparable mean vascular density.

Central Odontogenic Fibroma with Giant Cell Granuloma-Like Lesion: A Report of an Additional Case and Review of Literature

Central odontogenic fibroma is a rare benign odontogenic tumor that relies on clinical-radiographic-histological correlation to reach its diagnosis, especially its rare variants. Of these rare types is the coexistence of giant cell granuloma-like lesion, with the characteristic odontogenic epithelial rests. The presented case is a 33 years old female complaining of asymptomatic mandibular bony swelling. Radiographically, the lesion is unilocular radiolucent, without root resorption. Histological examination revealed the presence of multinucleated giant cells within the diagnosed central odontogenic fibroma. Immunohistochemical staining highlighted the presence of both components.

Adjunctive Strategies for Benign Maxillofacial Pathology

Benign cysts and neoplasms of the maxillofacial region can vary in behavior, with some growing rapidly and resulting in destruction of surrounding structures. Despite their benign histology, many require often-morbid treatment to prevent recurrence of these lesions. Several less invasive and adjunctive medical treatments have been developed to lessen the morbidity of surgical treatment. As the molecular and genomic pathogenesis of these lesions is better understood, more directed treatments may lessen the burden for patients.

[Giant cell granuloma in the jaw in a 6-year-old child: A case report]

Giant cell granuloma represents a non-odontogenic tumor. It is located inside the endosteum of the jaws (central) or in the periosteum (peripheral). Although it is a benign disease process, it can also be locally destructive. This condition is a slow-growing, asymptomatic lesion that usually affects children and young adults, predominantly females in its peripheral presentation and males in its central presentation. The mandible, the region of the incisors, canines and premolars are more affected. The etiology of the giant cell granuloma still remains to be defined. It has been reported that the origin of this lesion could be triggered by trauma or inflammation and hormonal factors. A 6-year-old patient presents a slow-growing lesion in the tooth extraction's region, two months ago. The treatment is surgical. It is important to have an early diagnosis because of the high local destructive behavior and timely referral because the treatment is surgical.

Lumps and Bumps of the Gingiva: A Pathological Miscellany

Lesions of the gingivae are amongst the commonest lesions seen in patients and the vast majority are reactive hyperplasias, related to a number of chronic irritant stimuli. However, there are a number of entities that have a predilection for the gingivae, which are much less common in other parts of the oral cavity. The purpose of this paper is to discuss the clinical and histological differential diagnoses when presented with a lump on the gingivae, including the approach to diagnosis and diagnostic pitfalls.

Giant Cell Granuloma: Two Expressions in Pediatric Population

A granuloma is a collection of epithelioid histiocytes that is often associated with multinucleated giant cells, and is considered widely to be a non-neoplastic lesion, although some lesions demonstrate aggressive behavior similar to that of a neoplasm. The diagnosis of giant cell granulomas (central and peripheral) is confirmed by histopathologic examination. Early detection and excision are important to minimize potential dentoalveolar complications. The following article consists of case reports of central and peripheral giant cell granuloma (PGCG), and discussion about the diagnosis and management of such lesions. How to cite this article: Mukherjee CG, Mukherjee U, Bansal A, Mukhopadhyay M. Giant Cell Granuloma: Two Expressions in Pediatric Population. Int J Clin Pediatr Dent 2018;11(1):46-49.

Radiation-Induced Giant Cell Granuloma Mimicking Relapsed Hodgkin Lymphoma at FDG-PET/CT

A 22-year-old woman was diagnosed with intermediate risk stage II Hodgkin lymphoma and treated with three cycles of adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by involved-field radiation therapy. A complete metabolic remission was achieved after two cycles of ABVD, which was maintained until three years after completion of treatment. Follow-up FDG-PET/CT four years after completion of treatment, however, showed a new FDG-avid (Deauville score of 4) lesion in the right scapula, suggesting relapsed disease. Computer tomography (CT)-guided biopsy of this lesion was performed and subsequent histological examination revealed a radiation-induced giant cell granuloma.

Bone-Related Lesions of the Jaws

The jaws combine several unique properties that mainly result from their distinct embryonic development and their role in providing anchorage for the teeth and their supporting structures. As a consequence, several bone-related lesions almost exclusively develop in the jaws (eg, osseous dysplasias, ossifying fibromas), have distinct clinical features (eg, osteosarcoma), or hardly ever occur at this location (eg, osteochondroma, enchondroma). The specific characteristics of these tumors and tumorlike lesions are outlined in this article.

Multifocal tenosynovial giant cell tumors in a child with Noonan syndrome

Noonan syndrome is a genetic disorder with variable expression of distinctive facial features, webbed neck, chest deformity, short stature, cryptorchidism and congenital heart disease. The association of Noonan syndrome and giant cell granulomas of the mandible is widely reported. However, Noonan syndrome may also be associated with single or multifocal tenosynovial giant cell tumors, also referred to as pigmented villonodular synovitis. We report a child with Noonan syndrome, giant cell granulomas of the mandible and synovial and tenosynovial giant cell tumors involving multiple joints and tendon sheaths who was initially misdiagnosed with juvenile idiopathic arthritis. It is important for radiologists to be aware of the association of Noonan syndrome and multifocal giant cell lesions, which can range from the more commonly described giant cell granulomas of the mandible to isolated or multifocal intra- or extra-articular tenosynovial giant cell tumors or a combination of all of these lesions.

Management of central giant cell granuloma of the jaws with intralesional steroid injection and review of the literature

PURPOSE

We report the results of the intralesional steroid injections for the management of central giant cell granuloma (CGCG) of the jaws.

METHODS

Seven CGCGs were treated with intralesional injection of corticosteroids. To accomplish this, 3.5 mL of triamcinolone and 3.5 mL of 0.5 % marcaine with 1/200,000 epinephrine (total 7 mL) were mixed. An adequate amount of steroid was injected into different areas of the lesion. This procedure was repeated on a weekly basis for 6 weeks.

RESULTS

Clinical and radiological examination showed complete resolution and ossification of the lesions in four patients. Partial recovery was achieved in two patients. One patient did not respond to the treatment and underwent surgical curettage.

CONCLUSIONS

We suggest that intralesional steroid injection is safe and effective for the treatment of CGCG, especially in non-aggressive lesions.

Treatment of giant cell granuloma with intralesional corticosteroid injections: a case report

Giant cell granuloma is rare in the head and neck region and most commonly affects the maxilla and mandible. Giant cell granulomas are benign but occasionally aggressive lesions that are traditionally treated with surgery. Because it is a benign process, less radical and non-surgical treatment alternatives are required. Corticosteroid injection is a viable alternative in the treatment of central giant cell granuloma to avoid surgery. We aim to present a case which was successfully treated with intralesional corticosteroid injection in the maxilla.

Peripheral giant cell granuloma: This enormity is a rarity

Peripheral giant cell granuloma (PGCG) is an infrequent exophytic lesion of the oral cavity, also known as giant cell epulis, osteoclastoma, giant cell reparative granuloma, or giant cell hyperplasia. Lesions vary in appearance from smooth, regularly outlined masses to irregularly shaped, multilobulated protuberances with surface indentations. Ulcerations of the margin are occasionally seen. The lesions are painless, vary in size, and may cover several teeth. It normally presents as a purplish-red nodule consisting of multinucleated giant cells in the background of mononuclear stromal cells and extravasated red blood cells. This case report describes the unusual appearance of a PGCG extending from left maxillary interdental gingiva to palatal area in 32-year-old female patient.

Treatment of mouth and jaw diseases with intralesional steroid injection

Many lesions of the oral region are treated with surgical methods such as curettage and resection. Chemotherapy and radiation therapy with or without surgical intervention can be used as an adjunct in some cases. Intralesional steroid injection is a conservative procedure which is already used in various regions of the body and joints. This technique is used also for a number of mouth and jaw lesions. Localized langerhans cell histiocytosis, central giant cell granuloma, oral submucous fibrosis, oral lichen planus, lichen sclerosus of the oral mucosa, lymphatic malformations and orofacial granulomatosis can be considered among these diseases. The purpose of this review is to investigate the effects of intralesional steroid injections in the treatment of oral diseases.

Giant Cell Granuloma of the Anterior Skull Base: Need for Early, Maximal Surgical Excision: A Short Series of 3 Cases with Review of Literature

Giant cell granuloma is a rare benign granulomatous lesion of the bone. The local aggressiveness, potentiation with trauma and complex anatomy of the skull base makes the surgical management in this location challenging. We report a series of three cases along with the clinical presentation, radiological and histopathological findings and the management issues while dealing with this lesion. A review of literature reveals the rarity of the lesion, alternate management modalities and the outcomes for such lesion involving the jaw bones and the skull base. For best outcomes differential diagnosis from giant cell tumor and brown tumor of hyperparathyroidism is essential. Further it may be concluded that there is a need for maximal surgical excision to avoid recurrence as the second line management options are not as effective.

Surgical Management of Aggressive Central Giant Cell Granuloma of Maxilla through Le Fort I Access Osteotomy

Giant cell granuloma (GCG) is an uncommon bony lesion in the head and neck region, most commonly affecting the maxilla and mandible and has a female predilection. The clinical behavior of central GCG ranges from a slowly growing asymptomatic swelling to an aggressive lesion. The clinical, radiological, histological features and management of an aggressive GCG of maxilla in an 18-year-old female patient are described and discussed. It is emphasized that surgery is the traditional and still the most accepted treatment for GCG. Le Fort I osteotomy has been advocated as one of the access osteotomy for the surgical management of aggressive and extensive GCG involving the maxilla. The postoperative morbidity and recurrence have been discussed.

Giant cell reparative granuloma of the proximal phalanx: A case report and literature review

The present article is a case report of a 16-year-old boy who presented with a benign bony tumour, which on histological analysis suggested giant cell reparative granuloma (GCRG), but was not corroborate by blood tests. The implications of this type of tumour and the correct diagnostic requirements were investigated. The correct identification of GCRG from other giant cell-containing tumours is important because the treatment modalities for these tumours significantly differ from one another. In most cases, histological findings are sufficient to identify the tumours. In most GCRG cases, curettage is usually a curative treatment option. However, due to high recurrence rates of GCRGs, close follow-up of these patients is warranted. Also, due to osteoclastic activity of the giant cells in GCRGs, the use of drugs such as calcitonin or bisphosphonates, which inhibit osteoclast differentiation and activation, may have an important influence on future treatments or in reducing the recurrence rate of these tumours.

Reactive hyperplasia of the oral cavity: a survey of 197 cases in tabriz, northwest iran

Background and aims

Reactive hyperplastic lesions of the oral connective tissue are associated with injuries of soft tissue and have high prevalence rates and different involvement patterns in different parts of the world. The aim of this study was to analyze demographic data of a university department.

Materials and methods

Patient records of the Department of Oral Pathology during a four-year period were reviewed for diagnosis of oral connective tissue reactive hyperplastic lesion. Data including the area involved and the type of lesion were collected and analyzed using descriptive statistical methods and t-test with SPSS 15 statistical software.

Results

197 cases (mean age, 37.68±18.97; male: female ratio, 1.8:1) matched study criterion. The most common affected site was gingiva (83.9%) and the most common lesion was fibroma (45.2%). Giant cell granuloma and pyogenic granuloma were more common in the maxilla than in the mandible. Pyogenic granuloma was seen to be equally distributed in males and females.

Conclusion

The results of the present study are overall consistent with the findings of previous studies.

Hybrid central odontogenic fibroma with giant cell granuloma-like component: case report and review of literature

Central odontogenic fibroma (COF) is a rare benign ectomesenchymal tumor of the jaws. Only 12 cases of COF with giant cell granuloma (GCG)-like lesion have been reported in the English literature. Here, we present a new case of COF epithelium rich type with a GCG-like component. Radiographically, this lesion presented as a well defined unilocular radiolucency in the body of the mandible. Histologically, the lesion showed a unique confluence of odontogenic epithelial rests with multinucleated giant cells (MNGCs) in a highly cellular fibrous connective tissue stroma, with osteoid and cementoid deposits. A distinct area showed the typical histological picture of each component separately. Immunohistochemical staining with pancytokeratin (CK) highlighted the odontogenic epithelial component merging with the GCG component throughout most of the lesion. The significance of GCG-like areas within COF is the reported increased risk of recurrence following curettage, possibly necessitating more aggressive therapy.