Giant cell tumor of the jaws associated with Paget disease of bone. Report of two cases and review of the literature

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.

Benign fibro-osseous lesions of the craniofacial complex. A review

Benign fibro-osseous lesions of the craniofacial complex are represented by a variety of disease processes that are characterized by pathologic ossifications and calcifications in association with a hypercellular fibroblastic marrow element. The current classification includes neoplasms, developmental dysplastic lesions and inflammatory/reactive processes. The definitive diagnosis can rarely be rendered on the basis of histopathologic features alone; rather, procurement of a final diagnosis is usually dependent upon assessment of microscopic, clinical and imaging features together. Fibrous dysplasia and osteitis deformans constitute two dysplastic lesions in which mutations have been uncovered. Other dysplastic bone diseases of the craniofacial complex include florid osseous dysplasia, focal cemento-osseous dysplasia and periapical cemental dysplasia, all showing a predilection for African descent individuals; although no specific genetic alterations in DNA coding have yet to be uncovered and most studies have been derived from predominant high African descent populations. Ossifying fibromas are neoplastic lesions with four subtypes varying with regard to behavior and propensity for recurrence after surgical excision. The clinicopathologic and molecular features of this unique yet heterogeneous group of diseases are reviewed.

Zentrales Riesenzellgranulom des Unterkiefers

The synopsis of radiographic examination (uni- or multilocular radiolucency), histologic findings (giant cells throughout a benign fibroblastic matrix), blood chemistry analysis (normal serum parathyroid hormone) and clinical features provides the definitive diagnosis of giant cell granuloma, allowing the clearly defined surgical management of this lesion. The case history of a 48-year-old female patient who presented with a giant cell granuloma in the right mandible is used to illustrate this controversially discussed intra-osseous lesion. The potential therapeutic change from radical operative treatment, including functional maintenance, to conservative procedures is emphasized.

Factors in the pathogenesis of tumors of the sphenoid and maxillary sinuses: a comparative study

OBJECTIVES/HYPOTHESIS

To explain the processes that lead to the development of tumors in the maxillary and sphenoid sinuses.

STUDY DESIGN

A 32-year review of the world's literature on neoplasms of these two sinuses and a randomized case-controlled study comparing the normal mucosal architecture of the maxillary to the sphenoid sinus.

METHODS

Analysis of a 32-year world literature review reporting series of cases of maxillary and sphenoid sinus tumors. Tumors were classified by histological type and separated into subgroups if an individual incidence rate was reported. Histomorphometry of normal maxillary and sphenoid sinus mucosa was performed in 14 randomly selected patients (10 sphenoid and 4 maxillary specimens). Specimens were fixed in 10% formalin, embedded in paraffin, and stained with periodic acid-Schiff (PAS) and hematoxylin. Histomorphometric analysis was performed with a Zeiss Axioscope light microscope (Carl Zeiss Inc., Thornwood, NY) mounted with a Hamamatsu (Hamamatsu Photonics, Tokyo, Japan) color-chilled 3 charge coupled device digital camera. The images were captured on a 17-inch Sony (Sony Corp., Tokyo, Japan) multiscan monitor and analyzed with a Samba 4000 Image Analysis Program (Samba Corp., Los Angeles, CA). Five random areas were selected from strips of epithelium removed from each sinus, and goblet and basal cell measurements were made at magnifications x 100 and x 400.

RESULTS

The literature review revealed that the number and variety of tumors in the maxillary sinus are much greater than those in the sphenoid. The incidence of metastatic lesions to each sinus is approximately equal. No recognized pattern of spread from any particular organ system could be determined. On histomorphometric study there were no statistically significant differences between the sinuses in the concentration of goblet cells, basal cells, or seromucinous glands.

CONCLUSIONS

Factors involved in the pathogenesis of tumors of the maxillary and sphenoid sinuses include differences in nasal physiology, embryology, morphology, and topography. There are no significant histological differences in the epithelium and submucous glands between the two sinuses to explain the dissimilar formation of neoplasms.

Giant cell tumour of the temporal bone presenting as vertigo

We report a case of giant cell tumour of the temporal bone arising in a 31-year-old man. The presenting symptoms were unusual, being rotational vertigo, unilateral tinnitus, and hearing loss. A computed tomography (CT) scan showed a large mass within the right temporal bone and the infratemporal fossa. The radiological appearance was suggestive of an aggressive primary neoplasm arising within bone. Biopsy and subsequent resection showed a giant cell tumour of bone. The tumour was histological grade 1. At two-year follow-up, there was no evidence of tumour recurrence or metastasis.

Giant cell tumours in mandible and spine: a rare complication of Paget's disease of bone

The case of a man who was diagnosed as having polyostotic Paget's disease at the age of 52 years is described. He developed a rare neoplastic complication of Paget's disease--a giant cell tumour in his mandible, which was excised. Nine years after the diagnosis of this tumour he developed a new giant cell tumour arising from the L3 vertebral body. He was born in Avellino in Italy, from where five other cases of giant cell tumours arising from Pagetic bone disease have been reported. No family relationship between our patient and the other cases was established. His Paget's disease was particularly aggressive and resistant to treatment with two single high dose infusions of pamidronate almost two years apart.

Benign fibro-osseous lesions in Paget's disease of the jaws

A clinicopathologic study of five patients with Paget's disease of the jaws is reported. All patients had well-documented cases of osteitis deformans with polyostotic involvement. Histologic studies of facial bones could be performed because surgery was necessary for either cosmetic or functional reasons. Three specimens consisted of maxillary bone, and two were mandibular. Microscopically, all cases showed multiple and irregular fibroproliferative lesions containing mineralized structures intermingled with bone characteristic of Paget's disease. The purpose of this article is to present these fibro-osseous lesions in relation to Paget's disease of the jaws and to emphasize their close resemblance to other benign fibro-osseous lesions of the jaws, especially cementifying and ossifying fibroma, and florid osseous dysplasia.

Rhinological manifestations of Paget's disease of bone (Osteitis deformans)

Two cases of Paget's disease of bone are presented in which nasal symptoms were prominent. The clinical and radiographic features of Paget's disease of the maxilla and ethmoids are described. Medical and surgical treatment is discussed with the recommendation that surgery is kept to a minimum and covered by prophylactic antibiotics to prevent osteomyelitis. Sudden enlargement of the involved bones should raise the suspicion of malignancy.

Giant cell tumour of the sphenoid bone with coincidental galactorrhoea--a case report

A case of the rare giant cell tumour involving the sphenoid bone is reported. The usual presentation of these tumours is headache and cranial nerve deficits. This 25-year-old lady presented with oligomenorrhoea and galactorrhoea. Investigations demonstrated an asymptomatic erosive mass lesion in the sphenoid with suprasellar extension and extension into the nasopharynx. The tumour was partially resected via the transphenoidal route. The differential diagnosis and treatment of these lesions are discussed.

Giant cell tumour of the temporosphenoidal region

A case of giant cell tumour of the temporo-sphenoidal region and superior part of infratemporal fossa is presented along with a brief review of the literature. The tumour mass was removed by curettage using a Weber-Fergusson incision with transection of the zygoma. There was no recurrence at three-year follow up.

Giant cell tumor of the infratemporal fossa: report of case

A rare case of giant cell tumor occupying the infratemporal fossa is reported. The site of origin was obscure, although the tumor had obviously eroded a portion of the zygomatic arch and involved the outer cortex of the temporal bone. Aggressive surgical ablation is suggested as the primary treatment of choice for giant cell tumors in any location. Long-term follow-up evaluation is also necessary.

Giant-cell tumor of the sphenoid bone. Review of 10 cases

Giant-cell tumor rarely affects the sphenoid bone. Ten cases of this tumor seen at the Mayo Clinic are reviewed, bringing the number of cases in the world literature to 31. These tumors, which present in the second and third decades of life and are slightly more frequent in women than in men, may present with various symptoms, including headache, visual field defects, blindness, and diplopia. The symptom complex and roentgenographic findings are seldom, if ever, sufficiently characteristic to allow preoperative diagnosis. The microscopic differential diagnosis of giant-cell tumor of the sphenoid region includes giant-cell reparative granuloma, aneurysmal bone cyst, fibrous dysplasia, and "brown tumor" of hyperparathyroidism. Interesting features of this series include the presence of multifocal giant-cell tumor in one case, and the absence of Paget's disease of bone in every case. Complete follow-up review in these cases allowed a discussion of therapy and prognosis; it appears that subtotal excision with postoperative radiation therapy is the treatment of choice. While the histological appearance of giant-cell tumor is characteristic, caution must be exercised in interpreting small samples, and various reparative and metabolic disorders must be considered in the differential diagnosis.

Comparison of the ultrastructure of a malignant tumor of the mandible containing giant cells with Paget's disease of bone

Distinction between lesions of the jaws containing giant cells can be difficult. This study reports the results of the study of the ultrastructure of 30 patients with Paget's disease in comparison with a patient diagnosed as having malignant giant cell tumor of the mandible. The ultrastructure of the malignant giant cell tumor of the mandible was found to contain nuclear inclusions morphologically identical with the 12-15 nm tubules characteristic of the nuclei of osteoclasts in Paget's disease of bone. No clinical or laboratory signs of Paget's disease was found in this patient. A search of the literature failed to produce reports of identical nuclear inclusions in soft tissue giant cell tumors, osteosarcomas, reparative granulomas containing giant cells or in osteitis fibrosa cystica. Such nuclear inclusions have been reported in benign giant cell tumors of bone, one another in malignant giant cell tumor and cases of polymyositis. These observations raise the question of a possible virus associated with the tumor since there are recent reports of immunological evidence for the presence of a virus in Paget's disease, and viruses have been suspected in polymyositis.

Giant cell tumor in Paget's disease of bone: familial and geographic clustering

Four patients with benign giant cell tumor and one patient with probable benign giant cell tumor associated with Paget's disease of bone are reported. The familial and geographic clustering of these cases is unique in that three patients were related and all patients traced ancestral roots to the same area of southern Italy. Tumors arose from the cranial or facial bones in three patients and from vertebral bodies in two patients. All caused symptoms by local compression, and treatment by curettage or radiotherapy was successful in all patients. Three separate tumors in one patient shrank dramatically in response to treatment with high doses of dexamethasone, and one patient whose tumor caused spinal cord compression showed marked improvement in neurologic function on therapy with dexamathasone.

Central giant-cell granuloma of the jaw - a hormonal influence

A case is reported of the recurrence of a central giant-cell granuloma during pregnancy, six years after removal. It is suggested in view of possible hormonal reactivation, that careful follow-up is necessary for women of child-bearing age presenting with this type of lesion.