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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 220-222

Aggressive central giant cell granuloma: A rare case report


Department of Oral Medicine and Radiology, Panineeya Mahavidyalaya Institute of Dental Sciences, Hyderabad, Telangana, India

Date of Submission25-Sep-2014
Date of Acceptance07-Nov-2017
Date of Web Publication20-Nov-2017

Correspondence Address:
Raj K Badam
Department of Oral Medicine and Radiology, Panineeya Mahavidyalaya Institute of Dental Sciences, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.JIAOMR_175_14

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   Abstract 

Giant cell granuloma is a benign proliferative pathological lesion of the bone accounting for less than 7% of lesions of the jaw, predominant in females and most commonly seen in anterior segment of jaws. Mandible is more commonly affected. Radiographically, the lesion may present with diffuse or irregular borders, sometimes leading to expansion of cortex, displacement of teeth, or root resorption. We present a case of aggressive central giant cell granuloma in a 45-year-old female patient in the right mandibular alveolar ridge presenting as an irregular mass causing displacement of teeth.

Keywords: Central giant cell granuloma, giant cell granuloma, mandible


How to cite this article:
Chavva S, Dhawalraj C, Badam RK, Chaitanya NC. Aggressive central giant cell granuloma: A rare case report. J Indian Acad Oral Med Radiol 2017;29:220-2

How to cite this URL:
Chavva S, Dhawalraj C, Badam RK, Chaitanya NC. Aggressive central giant cell granuloma: A rare case report. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2020 Nov 30];29:220-2. Available from: https://www.jiaomr.in/text.asp?2017/29/3/220/218715


   Introduction Top


Giant cell granuloma is a relatively uncommon benign proliferative pathological lesion of the bone accounting for less than 7% of all benign lesions of the jaw.[1] The clinical behavior of central giant cell granuloma (CGCG) of the jaw is variable and difficult to predict. Depending on the clinical and radiological features, it is classified as nonaggressive and aggressive lesion. Usually, the central lesions present no signs and symptoms clinically other than a diffuse swelling over the affected area. Radiographically, they may have diffuse or irregular borders, sometimes leading to expansion of cortex, displacement of teeth, or root resorption. It has been hypothesized that it is the mononuclear, spindle-shaped cell which controls the proliferative activity of this lesion, as opposed to the more frequently seen giant cell.


   Case Report Top


A 45-year-old female patient reported to the department with a swelling in the lower right back tooth region of jaw for 2 months. On eliciting the history of the presenting illness, the swelling was small initially, which gradually increased and attained the present size with loss of teeth associated in that area with no history of pain. Past medical and dental history was noncontributory. On examination, a solitary diffuse swelling measuring about 5 × 8 cm was seen in the right side of the mandible involving the midline, extending till the angle of mandible posteriorly. The swelling was firm to hard in consistency and was nontender [Figure 1]. On intraoral examination, a solitary lobulated swelling on the right mandibular alveolar ridge extending from symphysis to second molar region, measuring about 4 cm × 6 cm with expansion of buccal and lingual cortices was seen. Gross buccal displacement of the right second mandibular premolar was observed, and the first molar was mobile [Figure 2]. Based on the history and clinical examination, a provisional diagnosis of ameloblastoma of the right mandible was considered. A differential diagnosis of central giant cell granuloma, giant cell fibroma, intraosseous carcinoma, browns tumor of hyperparathyroidism, and ossifying fibroma were listed.
Figure 1: Extraoral photograph of the patient showing no marked asymmetry

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Figure 2: Intraoral swelling on the right side of the mandible

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Panoramic radiograph revealed a lytic lesion in the right body of the mandible. Cone-beam computed tomography revealed a hypodense lesion in the right body of the mandible with central cuffing of the alveolar ridge extending from left canine region to right third molar [Figure 3]. Incisional biopsy revealed nonkeratinized squamous epithelium with an underlying cellular lesion composed of uniformly arranged fibroblasts in a collagenous stroma along with hemosiderin laden macrophages and a large number of multinucleated giant cells suggestive of a giant cell lesion [Figure 4]. Because CGCG and brown tumor of hyperparathyroidism are histologically indistinguishable,[2] the patient was further subjected to biochemical investigations. Biochemical investigations revealed decreased parathormone (8.58 pg/ml), vitamin D (18.73 ng/ml) and normal calcium levels, ruling out hyperparathyroidism. Based on the clinical, radiographical, biochemical, and histopathologic findings, a final diagnosis of aggressive CGCG was given. The patient was referred to the endocrinologist for opinion and further management of decreased paratharmone and vitamin D levels. Marginal mandibulectomy was done leaving intact lower border [Figure 5]. Follow-up of the patient was done for 1 year with no recurrence of the lesion [Figure 6].
Figure 3: Cone-beam computed tomographic images of axial, coronal and sagittal sections showing hypodense areas in the right side of the mandible

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Figure 4: Incisional biopsy revealed nonkeratinized squamous epithelium with an underlying cellular lesion composed of uniformly arranged fibroblasts in a collagenous stroma along with hemosiderin laden macrophages and a large number of multinucleated giant cells

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Figure 5: Postoperative orthopantomograph revealing marginal mandibulectomy

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Figure 6: Follow-up intraoral photograph showing no recurrence

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   Discussion Top


CGCG was first described by Jaffe in 1953 as an idiopathic, non-neoplastic, proliferative lesion.[3] Chuong et al. classified CGCG into two aggressive and nonaggressive lesions based on signs and symptoms and histological features.[4] CGCG is defined by the World Health Organization as an intraosseous lesion consisting of cellular fibrous tissue containing multiple foci of hemorrhage, aggregations of multinucleated giant cells, and occasionally trabeculae of woven bone.[5] Aggressive lesions are characterized by one or more of the following features: pain, paresthesia, resorption of the root, rapid growth, cortical perforation, and high recurrence rate after curettage.[2] The clinical behavior ranges from slow growing asymptomatic swelling to an aggressive lesion that manifests with pain, local destruction of bone, root resorption, or displacement of teeth. In the present case, the patient was aware of the facial asymmetry because of the painless swelling on the right side of the jaw which was rapidly progressing. Radiological presentation of CGCG may occur initially as a unilocular, cyst-like radiolucency, however, as it grows larger, it frequently develops an architecture that causes a soap-bubble type of multilocular radiolucency.[6] The borders of the lesion have been reported as well-defined in 56% of cases, poorly defined in 30% of cases, and diffuse in the remaining 14%.[7] In the present case, ill-defined borders with evident cortical destruction and migration of associated teeth were seen. Serum chemistry for hyperparathyroidism and history of classic manifestations of stones (renal stones), bones (bone changes), moans (psychic moans), and groans (abdominal groans) should be done to exclude Brown tumor with a biopsy revealing giant cell granuloma.[2] Microscopic examination of giant cell granulomas shows numerous multinucleated giant cells and mononuclear cells (fibroblast and histiocyte-like cells and monocyte-macrophages) within a prominent fibrous stroma.[8] It has been reported that the multinucleated giant cells exhibit characteristics of the osteoclasts phenotype.[9] Some authors have suggested that these cells may be aligned more closely with macrophages.[10] The origin and nature of the multinucleated giant cells has been a subject of debate.[11] Taking into consideration the presentation and investigations of the lesion, a final diagnosis of CGCG was considered.


   Conclusion Top


Huge, irregular, intraoral swellings need proper history taking and thorough examination with relevant hematological, biochemical, serological, and histopathological investigations for proper diagnosis as they mimic other pathological conditions such as hyperparathyroidism and intralveolar carcinoma. Accurate diagnosis among the lesions presenting with giant cells is essentially by exclusion, and hence mandates a thorough evaluation. Although benign, the tumor may sometimes become aggressive causing considerably disfigurement and secondary pathologies; hence, an early diagnosis would help achieve a better treatment outcome to reduce the morbidity of patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Regezi JA. Odontogenic cysts, odontogenic tumors, fibrosseous and giant cell lesions of the jaws. Mod Pathol 2002;15:331-41.  Back to cited text no. 1
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2.
Chattha MR, Ali K, Aslam A, Afzal B, Shahzadl MA. Current concepts in central giant cell granuloma. Pak Oral Dent J 2006;26:71-8.  Back to cited text no. 2
    
3.
de Lange J, van den Akker HP, van den Berg H. Central giant cell granuloma of the jaw: A review of the literature with emphasis on therapy options. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:603-15.  Back to cited text no. 3
[PUBMED]    
4.
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.  Back to cited text no. 4
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5.
Kramer IR, Pindborg JJ, Shear M. Histological typing of odontogenic tumors. 2nd ed. Berlin: Springer-Verlag; 1991. p. 31.  Back to cited text no. 5
    
6.
Wood NK, Goaz PW, Kallal RH. Multilocular radiolucencies. In: Wood NK, Goaz PW, editors. Differential diagnosis of oral and maxillofacial lesions. 5th ed. St. Louis: Mosby; 1997. p. 333-55.  Back to cited text no. 6
    
7.
Kaffe I, Ardekian L, Taicher S, Ltittner MM, Buchner A. Radiologic features of central giant cell granuloma of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:720-6.  Back to cited text no. 7
    
8.
Florez-Moreno GA, Henao-Ruiz M, Santa-Saenz DM, Castaneda-Pelaez DA, Tobon-Arroyave SI. Cytomorphometric and immunohistochemical comparison between central and peripheral giant cell lesions of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:625-32.  Back to cited text no. 8
    
9.
Liu B, Yu SF, Li TJ. Multinucleated giant cells in various forms of giant cell containing lesions of the jaws express features of osteoclasts. J Oral Pathol Med 2003;32:367.  Back to cited text no. 9
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10.
Neville BW, Damm DD, Alien CM, Bouquot JE, editors. Oral & Maxillofacial Pathology. 2nd ed. Philadelphia: Saunders; 2002. p. 544-6.  Back to cited text no. 10
    
11.
Vered M, Buchner A, Dayan D. Giant cell granuloma of the jawbones-- A proliferative vascular lesion? Immunohistochemical study with vascular endothelial growth factor and basic fibroblast growth factor. J Oral Pathol Med 2006;35:613-9.  Back to cited text no. 11
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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