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An Official Publication of the Indian Association of Oral and Maxillofacial Pathologists


 
CASE REPORT Table of Contents   
Year : 2003  |  Volume : 7  |  Issue : 1  |  Page : 11-14
 

Central giant cell granuloma - a case report


Department of Oral Pathology, Tamil Nadu Govt. Dental College, Chennai, India

Correspondence Address:
Shaheen Ahmed
Department of Oral Pathology, Tamil Nadu Govt. Dental College, Chennai
India
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   Abstract 

Central Giant Cell Granuloma (CGCG) is a non-neoplastic intra osseous lesion, which occurs almost exclusively in the jaws, anterior to the molars and more commonly in the mandible. An unusual case of CGCG which occurred in the posterior region of maxilla was encountered. Biopsy was taken with a provisional diagnosis of adenoma. But histopathology confirmed the case as CGCG.


Keywords: Giant cells, CGCG, benign, intraosseous lesions.


How to cite this article:
Ahmed S, Babu I, Priya S P. Central giant cell granuloma - a case report. J Oral Maxillofac Pathol 2003;7:11-4

How to cite this URL:
Ahmed S, Babu I, Priya S P. Central giant cell granuloma - a case report. J Oral Maxillofac Pathol [serial online] 2003 [cited 2019 Nov 13];7:11-4. Available from: http://www.jomfp.in/text.asp?2003/7/1/11/40999



   Introduction Top


Central Giant Cell Granuloma is uncommon lesion accounting for less than 7% of all benign jaw lesions found predominantly in children and young adults with a female predilection of about 2:1 ration [1] . For many years this lesion has been discussed (with great controversy) with giant cell tumor of bone and other related lesions such as hyper parathyroidism, reparative response to injury, aneurysmal bone cyst, fibrous dysplasia, non­ossifying fibroma. and cherubism (14) . All these manifest as intrabony lesion showing giant cells microscopically.

Jaffe (1953) first reported CGCG of the jaws as a distinct entity. It has been proposed that the process represents an attempt of reparative response to intrabony hemorrhage and inflamma­tion. But, since it is a more destructive lesion than repair process, many regard this as a reactive lesion. A proven etiology does not exist, till date.

The World Health Organization has defined it as an intraosseous lesion consisting of cellular fibrous tissue that contains multiple foci of hemorrhage, aggregations of multinucleated giant cells and occasionally trabeculae of woven bone [1] .

A rare and an unusual case of CGCG in the posterior maxilla has been reported in Tamilnadu Government Dental College and Hospital


   Case Report Top


A 35-year-old female reported to the TNGDC & 1-1 with complaints of loosening of teeth and bleeding gums in the right upper posterior region for about 10 days duration and an associated painless swelling with a duration of 4 months. There was no history of trauma, or history of previous dental treatment.

On examination intraorally a swelling measuring about 2 x 1.5 cms extending from 16 to 18 region was seen with expansion more palatally than buccally. Mucosa over the swelling was apparently normal. On palpation the swelling was firm to hard in consistency with mild tenderness. There was no caries in the associated teeth but I8 was periodontally very weak with grade III mobility, 16 exhibited grade II and 17 showed grade I mobility.[Figure 1]

Radiograph showed a radiolucent lesion with ill-defined borders in the region of 16 to 18. Aspiration was negative. Differential diagnosis of Adenoma of the palate and aneurysmal bone cyst were given and patient was advised for incisional biopsy.[Figure 2],[Figure 3]

The histopathology revealed fibrous connective tissue with collagen fibers, numerous vascular channels and abundant multinucleated giant cells throughout the connective tissue. Giant cells were aggregated more around the vascular channels and hemorrhagic areas. Chronic inflammatory cells were also dispersed throughout the lesion.

A diagnosis of central giant cell lesion was arrived at, and the patient was advised to undergo blood investigations to rule out hyperparathyroidism. The results were as follows

Alkaline phosphatase 96 u/I (a 25°C (normal 60 to 170u/1@ 25°C)

Serum calcium 9.93 mg % (normal 8.1 10.4 mg %)

The patient was treated by surgical curettage successfully and no recurrence is evident till date.[Figure 4],[Figure 5]


   Discussion Top


CGCG generally occurs in children and young adults with a definite female predilection. Regezi and Sciubba proposed three probable theories, which are as follows.

  1. Response to previous traumatic or inflammatory episode.
  2. A true neoplastic process.
  3. A developmental anomaly closely related to aneurysmal bone cyst.


This case had no history of trauma. CGCG usually occurs anterior to the molars, but the case reported herewith presented in the posterior maxilla. CGCG has also been associated with lesions like fibrous dysplasia, ossifying fibroma, Pagets disease, fibro osseous lesions. odontogenic fibroma and neurofebromatosis. Studies regarding the origin of the giant cells have reported that they resemble monohistiocyte-like cells and also osteoclast-like cells.

The Electron microscope and immuno histochemical analysis correlates with the histiocytic origin but the presence of calcitonin receptors and response to treatment with calcitonin, ability to resorb bone favors for osteoclastic origin.

The table given below discusses the similarities and dissimilarities of histiocytes and osteoclasts. It has been proposed that the Osteoclasts may originate from mononuclear precursors with phagocytic potentialities [18] .[Table 1]

Aggressive CGCG are usually treated by thorough curettage or by surgical resection. Few cases which present with highly aggressive nature could suggest that they arc probably low grade osteosarcoma. Non-aggressive lesions are usually treated by surgical curettage and intralesional [16] or­ systemic administration ofcorticosteroids [1] .

Recently a case that did not respond to corticosteroids was treated successfully with calcitonin (0.5 mg-s) subcutaneous injection every day for 1l months. The post treatment biopsy revealed fewer amounts of soft tissues without giant cells and areas of reossification. This treatment was started after confirming the presence of calcitonin receptors in the giant cells by a RT PCR Study [10], [15] .

Peripheral giant cell lesion and central giant cell lesions were compared with immunohistochemical expression of p53, MDM2, Ki-67, PCNA and the histochemical expression of argyrophilic nuclear organizer region (AgNOR). Although CGCG presents a more aggressive clinical behaviour, it has decreased proliferative activity compared to PGCL. But p53, MDM2, PCNA, Ki-67 immunohistochemical expression and AgNOR histochemical expression do not reflect their distinct biological behaviour [2] . A case of central giant cell granuloma of the maxilla associated with pyknodysostosis has been reported [3] .

Role of Tc-99m-M DP three-phase bone scan in diagnosing recurrent CGCG lesions of the hard palate has been discussed [17] .

lmmunohistochemical expressions of p53, MDM2, Ki-67 and PCNA in CGCG and GCT have been studied [4] . The results demonstrated that despite the lack of p53 immunoreactivity, all the samples showed wide expression of MDM2. The percentage of Ki-67 and PCNA positive cells in CGCG was statistically higher than that of GCT. This shows that CGCG has a higher proliferative activity when compared to GCT. It also suggests that p53 inactivation by MDM2 expression may be involved in the pathogenesis of giant cell lesions of the jaws and long bones. immunocytochemistry of fine needle aspirates from central giant cell granuloma have revealed mononucleated and multinucleated cells [8] .

Unusually occurrence of bilateral central giant cell granulomas in a patient with neurofibrornatosis has been reported [5] . Combined central odontogenic fibroma and giant cell granuloma like lesion of the mandible has also been reported [6] . Another unusual form of recurrent giant cell granuloma of the mandible and lower extremities in a patient with neurofibromatosis type I has been reported [7] .

A Parathyroid carcinoma diagnosed on the basis of a giant cell lesion of the maxilla has also been reported [9] . Very small lesions with radiographic similarity to a routine inflammatory periradicular lesion led not only to delay in diagnosis, but also further delay in successful treatment [11] .

The prosthodontic rehabilitation of a patient with a huge recurrent maxillary CGCG by constructing a bar-retained definitive obturator markedly improves the patient's speech, mastication, and deglutition [12] . A child with central giant cell granuloma in the early mixed dentition can be treated conservatively to preserve the developing dentition [13] .


   Conclusion Top


The diagnosis of almost all the lesions is confirmed with histopathology except in a few cases like CGCG. Even with advanced diagnostic aids we are sometimes unable to diagnose these lesions. CGCG is one of those lesions which have obscure etiopathogenesis with differing clinical presentations and treatment modalities.

 
   References Top

1.Adornato MC. Paticoff K.A. Intralesional corticosteroid injection for treatment of central giant cell granuloma. Journal of the American Dental Association. 132(2): 186-90.2001 Feb.  Back to cited text no. 1    
2.Souza PE. Mesquita RA. Gomez RS, Evaluation of p53, PCNA, Ki-67, MDM2 and AgNOR in oral peripheral and central giant cell lesions. Oral Diseases. 6(l ): 35-9.2000Jan.  Back to cited text no. 2    
3.Thomas N. Seshadri MS. Thomas G. Chacko R. Samraj T. Nair S. Ponnaiya J. Cherian T. Association of central giant cell granuloma of the maxilla with pyknodysostosis. British Journal of Oral & Maxillofacial Surgery. 38(2): 159-60, 2000 Apr.  Back to cited text no. 3    
4.De Souza PE. Paim JF. Carvalhaid JN. Gomez RS. Immunohistochemical expression of p53, MDM2, Ki-67 and PCNA in central giant cell granuloma and giant cell tumor. Journal of Oral Pathology &Medicine. 28(2): 54-8, 1999 Feb.  Back to cited text no. 4    
5.Ardekian L. Manor R. Peled M. Laufer D. Bilateral central giant cell granulomas in a patient with neurofibromatosis: report of a case and review of the literature. [Review] [24 refs Journal of Oral & Maxillofacial Surgery. 57(&): 869-72, 1999 Jul.  Back to cited text no. 5    
6.Mosqueda Taylor A. Bermudez Flores V. Diaz Franco MA. Combined central odontogenic fibroma and giant cell granuloma like lesion of the mandible report of a case and review of the literature. [Review] [24 refs]. Journal of Oral &. Maxillofacial Surgery. 57(10): 1258-62, 19990ct.  Back to cited text no. 6    
7.Ruggieri M. Pavone V. Polizzi A. Albanese S. Magro G. Merino M. Duray PH. Unusual form of recurrent giant cell granuloma of the mandible and lower extremities in a patient with neurofibromatosis type I . Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology & Endodontics. 87(1): 67-72, 1999 Jan.  Back to cited text no. 7    
8.Castro WH. Filho EC. De Souza PE. Gomez RS. Immunocytochemistry of fine needle aspirates from central giant cell granuloma. British Journal of Oral & Maxillofacial Surgey. 36(4): 301-3, 1998 Aug.  Back to cited text no. 8    
9.Vikram HR. Petito A. Bower BF. Goldberg Mil. Parathyroid carcinoma diagnosed on the basis of a giant cell lesion of the maxilla. Journal of Oral & Maxillofacial Surgery. 58(5):567-9,2000 May.  Back to cited text no. 9    
10.Porgel MA. Regezi JA. Harris ST. Goldring SR. Calcitonin treatment for central giant cell granulomas of the mandible: report of tow cases. Journal of Oral & Maxillofacial Surgery. 57(7): 848-53, 1999 Jul.  Back to cited text no. 10    
11.Selden II.S. Central giant cell granuloma: a troublesome lesion. .Journal of Endodontics 26(6): 371-3,2000Jun.  Back to cited text no. 11    
12.Markt JC. An endosseous, implant retained obturator for the rehabilitation of a recurrent central giant cell granuloma: a clinical report. .Journal of Prosthetic Dentistry. 85(2): 116­20.2001 Feb.  Back to cited text no. 12    
13.Martin JP. Unkel JH. Fordjour I. Preservation of the dentition following removal of a central giant cell granuloma: a case presentation. Journal of Clinical Pediatric Dentistry. 24(1):35-7, 1999 Fall.  Back to cited text no. 13    
14.Kerley TR. Schow CE Jr. Central giant cell granuloma or cherubism. Report of a case. Oral Surgery, Oral Medicine. Oral Pathology. 51(2): 128-30,1981 Feb.  Back to cited text no. 14    
15. de Lange .I. Rosenberg A.I. Van den Akker HP. Koole R. Wirds JJ. Van den Berg H Treatment of central giant cell granuloma of' the jaw with calcitonin.[Review][27 refs]  Back to cited text no. 15    
16.Rajeevan NS. Soumithran CS. Intraesional corticosteroid injection for central giant cell granuloma. A case report. International Journal of Oral & Maxillofacial Surgery. 27(4):303-4,1998 Aug.  Back to cited text no. 16    
17.Kumar R. Marwah A. Gupta R. Chaudhary B. Sharma S. Recurrent giant cell reparative granuloma of hard palate: role of Tc-99nt­MDP three-phase bone scan. Clinical Imaging. 24(3): 143-5, 2000 May-Jun.  Back to cited text no. 17    
18.S.C. Marks JR J. of Pathology 1983: 12 (226 256) The origin of osteoclasts review article.  Back to cited text no. 18    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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    Abstract
    Introduction
    Case Report
    Discussion
    Conclusion
    References
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