|Year : 2015 | Volume
| Issue : 3 | Page : 88-91
Aggressive central giant cell granuloma of the mandible, a diagnostic dilemma
Pavitra Baskaran1, Margathavalli Gopal2, Varun Rastogi3, Satya Ranjan Misra4
1 Department of Oral Medicine and Radiology, Saveetha Dental College and Hospitals, Chennai, Tamil Nadu, India
2 Department of Oral Medicine and Radiology, Meenakshi Ammal Dental College, Chennai, Tamil Nadu, India
3 Department of Oral and Maxillofacial Pathology, Kalka Dental College, Meerut, Uttar Pradesh, India
4 Department of Oral Medicine and Radiology, Institute of Dental Sciences, Siksha O Anusandhan University, Bhubaneswar, Odisha, India
|Date of Web Publication||27-Nov-2015|
Dr. Satya Ranjan Misra
Department of Oral Medicine and Radiology, Institute of Dental Sciences, K-8 Kalinganagar, Bhubaneswar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
Central giant cell granuloma (CGCG) of the jaw bones is a rare benign intraosseous lesions that is commonly seen as indolent lesions in the mandible anterior to the first molar. It is a localized osteolytic lesion with the varied biologic behavior of aggression which affects the jaw bones. There is much controversy regarding it arising as a result of trauma and its connection with the giant cell lesion seen in the long bones. Since the lesion is uncommon, does not possess any characteristic clinical or radiologic features, and resembles neoplasms, the diagnosis is initially some odontogenic or non-odontogenic neoplasm till a definitive histologic diagnosis of CGCG is made. CGCG is divided into a rare aggressive variant and a common nonaggressive variant based on the clinical and radiographic features. The present case is a rare aggressive CGCG seen in the posterior mandible associated with mandibular swelling, rapid growth, pain, paraesthesia, and cortical bone perforation.
Keywords: Aggressive jaw lesion, giant cell lesion, histopathologic diagnosis, multilocular radiolucency
|How to cite this article:|
Baskaran P, Gopal M, Rastogi V, Misra SR. Aggressive central giant cell granuloma of the mandible, a diagnostic dilemma. J Oral Maxillofac Radiol 2015;3:88-91
|How to cite this URL:|
Baskaran P, Gopal M, Rastogi V, Misra SR. Aggressive central giant cell granuloma of the mandible, a diagnostic dilemma. J Oral Maxillofac Radiol [serial online] 2015 [cited 2019 Apr 25];3:88-91. Available from: http://www.joomr.org/text.asp?2015/3/3/88/170614
| Introduction|| |
Central giant Cell Granuloma (CGCG) is a benign, proliferative, intraosseous and non-odontogenic lesion of unknown etiology.  The term giant cell reparative granuloma (GCRG) was first used by Jaffe in 1953, to distinguish these lesions from giant cell tumor of long bones.  He described it as a reactive lesion of the jaw bones occurring due to trauma, resulting in intraosseous hemorrhage and containing giant cells. Later the term GCRG was changed to CGCG,  deleting the word reparative owing to the destructive rather than the reparative nature of CGCG.  According to World Health Organization 1992 classification, CGCG is defined as "an intraosseous lesion consisting of more or less fibrous tissue containing multiple foci of hemorrhage, aggregates of multinucleated giant cells, some amount of trabeculae of woven bone forming within the septa of more mature fibrous tissue that may traverse the lesion." 
| Case Reports|| |
A 32-year-old female patient reported to the dental hospital with a complaint of growth in the left lower jaw since 1-month. History revealed the growth was rapidly growing in size, associated with pain, and numbness the mandible on the affected side. The patient's medical, dental, personal, and family histories was noncontributory.
On examination, a single diffuse swelling was seen on the left body, and ramus of the mandible measuring 4 cm × 2 cm in size, [Figure 1] and [Figure 2] bony hard and mildly tender on palpation. Intraoral examination revealed an exophytic growth obliterating the gingivobuccal sulcus in relation to 37 regions, hemorrhagic, a soft in consistency, slightly tender on palpation with the expansion of the alveolar ridges [Figure 3]. Correlating the history and clinical features, a provisional diagnosis of aggressive bony neoplasm was made.
|Figure 1: Frontal picture showing diffuse swelling in the left body of the mandible|
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|Figure 2: Diffuse swelling in the left body of the mandible extending beyond the inferior border|
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|Figure 3: Intraoral picture showing growth in the gingiva, buccally in relation to 37 with expansion of the buccal cortex and obliteration of the buccal sulcus|
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The periapical radiograph revealed a well-defined radiolucency in relation to 35, 37. The mandibular lateral occlusal radiograph revealed a well-defined radiolucent lesion with the expansion of the buccal cortex. Lateral oblique view of the body of left mandible showed a well-defined multilocular radiolucency in the mandible. A panoramic radiograph revealed a well-defined multilocular radiolucency in the left body-ramus of the mandible [Figure 4]. Computed tomography scan of the mandible revealed an expansile lytic lesion in the left mandible body and ramus of the mandible with cortical perforation buccally [Figure 5] and [Figure 6]. Serum calcium, phosphorous, and parathyroid hormone assay were in normal limits.
|Figure 4: Panoramic radiograph showing a multilocular radiolucency in the left mandibular premolar-molar region displacing the inferior alveolar canal below|
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|Figure 5: Axial computerized tomography scan showing expansion of buccal cortex of the left side with cortical perforation|
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|Figure 6: Three dimensional computerized tomography scan showing expansion of buccal cortex of the left side with cortical perforation|
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The differential diagnosis was listed based on the clinic-radiologic manifestations, included ameloblastoma, odontogenic myxoma, CGCG, central hemangioma, aneurysmal bone cyst, and brown tumor of hyperparathyroidism.
Incision biopsy revealed fibrous connective tissue stroma containing numerous multinucleated giant cells [Figure 7]a. The multinucleated giant cells are of the osteoclastic type containing >10 nuclei [Figure 7]b. Areas of osteoid formation [Figure 7]c, mild chronic inflammatory cell infiltrate, moderate vascularity, and hemorrhage are evident [Figure 7]d.
|Figure 7: (a) Fibrous connective tissue stroma containing numerous multinucleated giant cells, (b) multinucleated giant cells are of osteoclastic type containing more than ten nuclei (c) areas of osteoid formation and (d) mild chronic inflammatory cell infiltrate with moderate vascularity and hemorrhage are evident|
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Hemimandibulectomy of the left side was performed followed by surgical reconstruction. The patient was followed up after 6 months, and postoperative check-up revealed no recurrence.
| Discussion|| |
Giant cell lesions of the maxillofacial region generally present as an asymptomatic slowly growing lesion to aggressive neoplasm like rapid expansive progression characterized by root resorption and pain and associated with recurrence after treatment.
Giant cell granulomas of the jaws arise either peripherally in the periodontal ligament, mucoperiosteum, or centrally in the bone. CGCG is a disease of unknown etiology occurring mostly in young adults and has a predilection for females.  The mandible anterior to the first molar is the frequently affected site, and the lesion has a tendency to cross the midline. 
Though CGCG is a benign reactive osseous lesion, it has been classified into two types based on its clinic-radiologic features into a slow growing asymptomatic, nonaggressive lesion, and an aggressive type encountered in younger patients which is painful grows rapidly into a large size, perforating the cortex causing root resorption, and has a tendency to recur.  The rate of recurrence is as high as 13-49%. These aggressive lesions may also displace anatomical structures such as teeth, mandibular canal, and floor of the maxillary antrum.  Radiographically, CGCG appears as a lytic expansile lesion with a soap bubble multilocular radiolucency.  This radiographic feature is not pathognomonic for CGCG but also shown by other lesions such as ameloblastoma, brown tumor of hyperparathyroidism, aneurysmal bone cyst, odontogenic myxoma, and cherubism; hence, needs to be differentiated from such lesions. ,
Histologically, CGCG is characterized by two characteristic types of cells: Multinucleated giant cells and spindle-shaped stromal cells distributed in a collagenous stoma. The multinucleated giant cells are of a foreign body type or osteoclast-like having up to 30 nuclei and fairly evenly distributed around the lesion. The stromal cells are considered to be the proliferating cells, which are osteoblast-like and induce osteoclast formation from mononuclear blood cells via receptor activator of nuclear factor kB ligand interaction.  The stromal cells may be of two types - one type may resemble myofibroblast having oval to spindle-shaped with a cigar shaped nucleus and exhibiting coarse chromatin; the other type resembles macrophages having smaller round nucleus and exhibiting dense chromatin. Areas of hemorrhage, hemosiderin pigment, thin-walled vascular spaces, and trabeculae of woven bone may be seen in the connective tissue stroma.  Similar histological features are also seen in the following lesions such as a brown tumor of hyperparathyroidism, aneurysmal bone cyst, and cherubism needs to be differentiated from such lesions. 
Management of CGCG comprises of both surgical and nonsurgical treatment. Surgical treatment includes enucleation, curettage, peripheral osteotomy, and en bloc resection.  Excision using jaw resection needs reconstruction using autogenous iliac crest graft, dental implants, and over denture prosthesis.  Nonsurgical treatments include intralesional injections of steroids, calcitonin, and bisphosphonates, which inhibit osteoclastic activity and alpha interferons due to its anti-angiogenic effects and even bisphosphonates. ,
Department of Oral Medicine and Radiology, Saveetha Dental College and Hospitals, Chennai, Tamil Nadu.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jaffe HL. Giant-cell reparative granuloma, traumatic bone cyst, and fibrous (fibro-oseous) dysplasia of the jawbones. Oral Surg Oral Med Oral Pathol 1953;6:159-75.
Shah UA, Shah AK, Kumar S. Giant cell reparative granuloma of the jaw: A case report. Indian J Radiol Imaging 2006;16:677-8.
Güngörmüs M, Akgül HM. Central giant cell granuloma of the jaws: A clinical and radiologic study. J Contemp Dent Pract 2003;4: 87-97.
Barnes L, Everson JW, Reichart P. WHO Classification of Tumours. Pathology and Genetics of Head and Neck Tumours. Lyon: IARC Press; 2005. p. 324-5.
Wood NK, Goaz PW. Differential Diagnosis of Oral Lesions. 5 th
ed. St. Louis: Mosby; 2007. p. 393-5.
Stavropoulos F, Katz J. Central giant cell granulomas: A systematic review of the radiographic characteristics with the addition of 20 new cases. Dentomaxillofac Radiol 2002;31:213-7.
De Lange J, Van den Akker HP. Clinical and radiological features of central giant-cell lesions of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:464-70.
Chuong R, Kaban LB, Kozakewich H, Perez-Atayde A. Central giant cell lesions of the jaws: A clinicopathologic study. J Oral Maxillofac Surg 1986;44:708-13.
Murphey MD, Nomikos GC, Flemming DJ, Gannon FH, Temple HT, Kransdorf MJ. From the archives of AFIP. Imaging of giant cell tumor and giant cell reparative granuloma of bone: Radiologic-pathologic correlation. Radiographics 2001;21:1283-309.
Motamedi MH, Eshghyar N, Jafari SM, Lassemi E, Navi F, Abbas FM, et al.
Peripheral and central giant cell granulomas of the jaws: A demographic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e39-43.
Miyamoto N, Higuchi Y, Tajima M, Ito M, Tsurudome M, Nishio M, et al.
Spindle-shaped cells derived from giant-cell tumor of bone support differentiation of blood monocytes to osteoclast-like cells. J Orthop Res 2000;18:647-54.
Kruse-Lösler B, Diallo R, Gaertner C, Mischke KL, Joos U, Kleinheinz J. Central giant cell granuloma of the jaws: A clinical, radiologic, and histopathologic study of 26 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:346-54.
Ustündag E, Iseri M, Keskin G, Müezzinoglu B. Central giant cell granuloma. Int J Pediatr Otorhinolaryngol 2002;65:143-6.
Ebrahimi H, Yazdani J, Pourshahidi S, Esmaeli F, Zenouz AT, Mehdipour M. Central giant cell granuloma of the posterior maxilla: A case report. J Dent Res Dent Clin Dent Prospects 2008;2:71-5.
Infante Cossío P, Martínez de Fuentes R, Carranza Carranza A, Torres Lagares D, Gutiérrez Pérez JL. Recurrent central giant cell granuloma in the mandible: Surgical treatment and dental implant restoration. Med Oral Patol Oral Cir Bucal 2007;12:E229-32.
Kaban LB, Troulis MJ, Ebb D, August M, Hornicek FJ, Dodson TB. Antiangiogenic therapy with interferon alpha for giant cell lesions of the jaws. J Oral Maxillofac Surg 2002;60:1103-11.
Harris M. Central giant cell granulomas of the jaws regress with calcitonin therapy. Br J Oral Maxillofac Surg 1993;31:89-94.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]