|Year : 2015 | Volume
| Issue : 1 | Page : 156-159
Central giant cell granuloma: A report of 2 cases and review of literature
Abhijeet Alok1, Indra Deo Singh2, Shivani Singh3, Mallika Kishore4
1 Department of Oral Medicine and Radiology, Sarjug Dental College and Hospital, Darbhanga, Bihar, India
2 Department of Psychiatry, Sri Krishna Medical College and Hospital, Muzaffarpur, Bihar, India
3 Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly, , Uttar Pradesh, India
4 Department of Oral Medicine and Radiology, Yashoda Hospital, Ghaziabad, Uttar Pradesh, India
|Date of Submission||10-Sep-2014|
|Date of Acceptance||13-Jul-2015|
|Date of Web Publication||12-Oct-2015|
Department of Oral Medicine and Radiology, Sarjug Dental College and Hospital, Hospital Road, Laheriasarai, Darbhanga - 846 003, Bihar
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Central giant cell granuloma (CGCG) is a non-neoplastic lesion which exhibits a spectrum of clinical behavior ranging from non-aggressive to aggressive variants. The etiopathogenesis of CGCG is still not properly known. In the maxillofacial region, CGCG most commonly occurs in the jaw bones as an asymptomatic swelling. Radiographically, it presents as either unilocular or multilocular radiolucent lesions in the maxilla or mandible. Treatment of CGCG varies from local curettage to wide surgical excision depending upon the extent and progression of the lesion. This paper presents two cases of CGCG having different clinical presentation which resembled varied conditions leading to misdiagnosis (in one case), but was found to be CGCG on histopathologic examination.
Keywords: Giant cell granuloma, immunohistochemical staining, mandible, multinucleated giant cells, non-neoplastic lesion
|How to cite this article:|
Alok A, Singh ID, Singh S, Kishore M. Central giant cell granuloma: A report of 2 cases and review of literature. J Indian Acad Oral Med Radiol 2015;27:156-9
|How to cite this URL:|
Alok A, Singh ID, Singh S, Kishore M. Central giant cell granuloma: A report of 2 cases and review of literature. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2019 Sep 20];27:156-9. Available from: http://www.jiaomr.in/text.asp?2015/27/1/156/167152
| Introduction|| |
Central giant cell granuloma (CGCG) is a non-neoplastic proliferation of fibroblasts and multinucleated giant cells (MCGs). Young adults are commonly affected by CGCG. Females are more commonly affected than males.  CGCG accounts for less than 7% of all benign lesions which occur in the jaws.  In the orofacial region, mandible is affected more than maxilla in the ratio of 2:1-3:1.  Central giant cell granuloma is a reparative lesion as it develops in response to trauma and secondary to hemorrhage.
| Case Reports|| |
A 12-year-old female patient reported to the Department of Oral Medicine and Radiology with the chief complaint of swelling in the upper front teeth region since 2 months. History of present illness revealed that initially the swelling was of peanut size and it gradually increased to the present size. Extraoral examination revealed a diffuse swelling present on the upper left front tooth region, extending antero-posteriorly 0.5 cm from the midline to the corner of the mouth and superior-inferiorly from the nasolabial fold to the corner of lips [Figure 1]. Overlying mucosa appeared normal. On palpation, it was non-tender; there was no rise in temperature. Intraoral examination revealed a solitary diffuse swelling present in the left upper anterior region, roughly oval in shape and 1 × 3 cm in diameter, extending from mesial aspect of 21 to distal aspect of 25 [Figure 2]. Palatally it extended 1.5 cm toward midline. Ill-defined margins were present. Overlying mucosa appeared smooth; color varied from white on the labial side to pink on the palatal side. On palpation, it was non-tender, firm in consistency, and palatal mucosa was raised on palpation. On hard tissue examination, mobility was present with reference to 21 and 62. Based on the clinical findings and history, a provisional diagnosis of radicular cyst involving the left maxillary region was made. Radicular cyst was suspected because it is a common cyst occurring in the maxilla, especially incisors and canines. These cysts are generally asymptomatic, but become symptomatic when secondarily affected. Differential diagnosis of adenomatoid odontogenic tumor, calcifying epithelial odontogenic cyst (CEOC), and desmoplastic ameloblastoma was given. The investigations included radiographs and excisional biopsy. Orthopantomogram (OPG) revealed an ill-defined radiolucency present on the left anterior maxillary arch, roughly oval in shape and 1 × 2.5 cm in diameter, extending from distal aspect of 21 to mesial aspect of 24. The internal structure appeared to be completely radiolucent [Figure 3]. The lesion was surgically excised and sent for histopathologic investigations. Histopathologic report revealed giant cells and highly cellular stroma. Abundant giant cells with multiple nuclei were visible. Endothelial cells lining the blood vessels were seen [Figure 4]. All these features were suggestive of CGCG. So the final diagnosis of a CGCG involving the left maxillary anterior region was given.
A 40-year-old female patient reported to the Department of Oral Medicine and Radiology with the chief complaint of swelling in the lower front tooth region since 1 1 / 2 months. History of present illness revealed that initially the swelling was smaller in size, but it gradually increased to the present size. There was no history of trauma. She had difficulty in mastication. Extraoral examination revealed a diffuse swelling present in the mandibular anterior region, which was roughly oval in shape with ill-defined margins; overlying surface appeared smooth. On palpation, the swelling was hard and non-tender; there was no local rise in temperature [Figure 5]. Intraoral examination revealed that a diffuse swelling was present, roughly oval in shape and 1 × 3 cm in diameter, extending from mesial aspect of 34 to distal aspect of 44. Overlying mucosa appeared smooth. On palpation, it was soft in consistency and non-tender; tooth mobility was present with reference to 31, 32, 41, and 42, not associated with any discharge [Figure 6]. Based on the clinical findings, a provisional diagnosis of CGCG was given with a differential diagnosis of central hemangioma and ameloblastoma. Investigations included radiographs and excisional biopsy. The OPG revealed an ill-defined radiolucency roughly oval in shape and 1 × 3 cm in diameter, extending from distal aspect of 34 to distal aspect of 44. The internal structure appeared completely radiolucent. Also, 31, 32, 33, 41, 42, and 43 were displaced from their normal position. Sclerotic borders were present. Generalized bone loss could be seen with reference to 44, 45, 46, 47, 48, 38, 37, 36, 35, and 34 [Figure 7]. The lesion was surgically excised and sent for histopathologic investigation, which showed histological features similar to case 1.
|Figure 7: OPG showing the lesion in the mandibular anterior region (Case 2)|
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| Discussion|| |
Central giant cell granuloma is defined by the World Health Organization as an intraosseous lesion consisting of cellular fibrous connective tissue that contains multiple foci of hemorrhage, aggregates of MCGs, and occasionally trabeculae of woven bone.  Jaffe, in the year 1953, described CGCG for the first time as "Central Giant Cell Reparative Granuloma."  In mandible, the anterior portion is more commonly affected, with the lesion frequently crossing midline. Rarely, the lesions involve the posterior jaws, including the ramus and condyle, but gross soft tissue involvement is rare as it often remains limited to its effects on periosteum. Usually, as seen in both the cases, CGCG lesions are asymptomatic and do not include paresthesia, but 5-11% of these lesions are painful.  Based on the clinical and radiographic features, CGCG can be divided into two types: Aggressive and non-aggressive. The aggressive form of CGCG is characterized by pain and rapid growth of the lesion which leads to cortical perforation as well as resorption of root. The aggressive form has marked tendency to recur after treatment, compared to the non-aggressive form. The non-aggressive form is slow growing and exhibits no symptoms.
Radiographic appearance of CGCG varies according to the size and nature of the lesion. Small lesions usually appear on radiographs as unilocular radiolucent lesions. Large lesions appear as unilocular or multilocular radiolucent lesions. In some lesions, there are few internal wispy septa; however, crenations produce scalloping of the margins. These septae are a characteristic radiographic feature of CGCG.  In the cases reported here, unilocular radiolucency was seen in OPG of both cases. Whitaker and Waldron reported tooth displacement and root resorption in 36% and 43% of the cases, respectively; in the reported cases, lesion-related tooth displacement was found in both the cases. Histologically, CGCGs are characterized by the presence of numerous MCGs which are concentrated in the areas of hemorrhage and distributed in a collagenous stroma. Concentric areas of hemorrhage with liberation of hemosiderin pigment and newly formed osteoid or bone are often seen. Similar histologic features were seen in our cases. 
The treatment of choice is typically surgical curettage of the involved area. The recurrence rate given in various literature reports after conventional surgical curettage ranges from 11 to 49%.  Traditionally, surgical curettage has been relied upon as the treatment of choice for CGCGs. In some cases, curettage combined with adjunctive therapies comprising peripheral osteotomy, cryotherapy with liquid nitrogen, use of Carnoy's solution, radiotherapy, or postoperative use of interferon alpha; all provide satisfactory to excellent results. Intralesional injections of an aqueous solution of triamcinolone with either 2% lidocaine or bupivacaine, 50% mixture by volume, are used. The solution is administered with a 5-cm disposable syringe, delivering a dose of 30 mg in adults and 25 mg in children. The site of injection is gauged by clinically estimating the site where the cortical bone is more expanded and thinnest and once inside the lesion, small amounts are injected into different areas. These injections are repeated every 3 weeks and the treatment is limited when there is a significant amount of resistance caused by the bone being formed and calcified. No side effects are reported.
It has been suggested that immunohistochemical staining for glucocorticoid and calcitonin receptors on the mononuclear or multinucleated cells in giant cell lesions can help in choosing the most appropriate conservative, medical therapy. It has also been shown that osteoclastogenesis is under the influence of osteoprotegrin (inhibition of bone resorption) and its antagonist osteoprotegrin ligand (initiation of resorption) via osteoclast receptor proteins that have been found to be present in CGCG and are known as receptor activator of nuclear factor kappa-B (RANK). Osteoprotegrin as a pharmacologic agent has been proposed to inhibit bone resorption. However, the utility of osteoprotegrin is untested, and the systemic effects have not been evaluated. The future holds promise for the therapy of CGCG, as the ongoing clinical and laboratory research on the gene and protein expression of these tumors can lead to identification of therapeutic targets.
| Conclusion|| |
The relatively high frequency of CGCGs in the population makes it important for clinicians to understand their clinicoradiologic presentation and clinical behavior. Classifying these lesions as "aggressive" or "non-aggressive" can help in choosing the most appropriate treatment. The clinical behavior of this lesion is quite variable and difficult to predict. Hence, we suggest clinicians should consider all the possible differential diagnoses and must rule them out one by one considering all diagnostic points, so that proper treatment of lesion can be planned. In conclusion, though CGCG has a marked propensity to occur in the mandibular anterior region, it should also be considered in the differential diagnosis of swelling in the maxillary anterior region.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]