Immunohistochemical and ultrastructural evidence of a modified microvasculature in the giant cell granuloma of the jaws

Infantile anterior maxillary swelling: A diagnostician's dilemma

Anterior maxillary swellings are commonly encountered in the adolescents and adults and they represent lesions ranging from cysts to tumors which can be both benign as well as malignant. However the anterior maxillary swellings are a rare phenomenon in the infants and toddlers and they generally are indicative of an aggressive lesion. We hereby present a case of a rapidly growing infantile swelling which was histopathologically diagnosed as Peripheral Giant Cell Granuloma.

Immunohistochemical comparison of p53, Ki-67, CD68, vimentin, α-smooth muscle actin and alpha-1-antichymotry-psin in oral peripheral and central giant cell granuloma

INTRODUCTION

Giant cell lesions are characterised histologically by multinucleated giant cells in a background of ovoid to spindle-shaped mesenchymal cells. There is a major debate whether these lesions are separate entities or variants of the same disease. Our aim was to study the nature of multinucleated and mononuclear cells from peripheral giant cell granuloma (PGCG), and central giant cell granuloma (CGCG) and giant cell tumor (GCT) of long bones using immunohistochemistry evaluation and to determine whether there is a correlation between recurrence and the markers used.

MATERIALS AND METHODS

Ki-67, p53, Vimentin, smooth muscle specific actin, CD68 and alpha-1-antichymotrypsin were used to study 60 giant cell lesions. These included 26 CGCG, 28 PGCG, and 6 GCT cases using an avidin-biotin-complex immunohistochemistry standard method.

RESULTS

All studied cases showed the same results except the percentage of Ki-67 positive mononuclear cells in PGCG was significantly higher than that of both CGCG and GCT (p<0.05). Interestingly, no statistical correlation between recurrence and the markers used was found.

CONCLUSION

Our results may suggest that these lesions have the same histogenesis. The mononuclear stromal cells, both histiocytic and myofibroblastic, are thought to be responsible for the behavior of these lesions whereas the multinucleated cells are considered as reactive. This might support the argument that PGCG, CGCG and GCT are different variants for the same disease. Further studies using molecular techniques are required to elucidate why some of these lesions behave aggressively than others.

CTCFL (BORIS) mRNA Expression in a Peripheral Giant Cell Granuloma of the Oral Cavity

Peripheral giant cell granuloma (PGCG) is a relatively common benign reactive lesion of the oral cavity which can occur at any age. CTCFL/BORIS (CTCF like/Brother of the Regulator of Imprinted Sites) and CTCF (CCCTC-binding factor) are paralogous genes with an important role in the regulation of gene expression, genomic imprinting, and nuclear chromatin insulators regulation. BORIS expression promotes cell immortalization and growth while CTCF has tumor suppressor activity; the expression pattern may reflect the reverse transcription silencing of BORIS. The aim of this work was to describe a histopathological and molecular approach of an 8-year-old pediatric male patient with PGCG diagnosis. It was observed that the PGCG under study expressed CTCF as well as BORIS mRNAs alongside with the housekeeping gene GAPDH, which may be related to possible genetic and epigenetic changes in normal cells of oral cavity.

Immunohistochemical expression of Src protein in peripheral and central giant cell granulomas of the jaws

Aim and Objective:

The aim of this study was to investigate the expression of Src protein (an osteoclastic factor) in peripheral and central giant cell granulomas (PGCG and CGCGs) of the jaws and the relationship between the expression of this protein and the clinical behavior of these two lesions.

Materials and Methods:

Thirty cases of PGCG and 30 cases of CGCG were immunohistochemically stained with Src. A staining-intensity-distribution (SID) score (proportion of stained cells × staining intensity) was used to evaluate immunoreactivity of the protein. Data were analyzed using statistical package for social sciences (SPSS) 17.0.

Results:

There were no significant differences in the Src expression and the SID score between PGCG and CGCG. Furthermore, Spearman's rank correlation coefficient showed that there was a significant correlation between Src expression and SID score within both PGCG and CGCG (P < 0.001; r = 0.87 and 0.75, respectively).

Conclusion:

The findings of this study suggest that the multinucleated giant cells share some similarities with osteoclasts and Src protein can be used as a new therapeutic target to inhibit osteoclastic activity. In addition, differences in immunoreactivity of this osteoclastic protein do not reflect different clinical behaviors of PGCG and CGCG.

Peripheral giant cell granuloma

Peripheral giant cell granuloma or the so-called “giant cell epulis” is the most common oral giant cell lesion. It normally presents as a soft tissue purplish-red nodule consisting of multinucleated giant cells in a background of mononuclear stromal cells and extravasated red blood cells. This lesion probably does not represent a true neoplasm, but rather may be reactive in nature, believed to be stimulated by local irritation or trauma, but the cause is not certainly known. This article reports a case of peripheral giant cell granuloma arising at the maxillary anterior region in a 22-year-old female patient. The lesion was completely excised to the periosteum level and there is no residual or recurrent swelling or bony defect apparent in the area of biopsy after a follow-up period of 6 months.

Immunohistochemical evaluation of giant cell tumors of the jaws using CD34 density analysis

PURPOSE

To compare CD34 expression in both aggressive and nonaggressive giant cell lesions of the jaws and identify any associations between tumor vascular density and biologic behavior.

MATERIALS AND METHODS

This was a retrospective study of subjects treated for giant cell lesions of the jaws at Massachusetts General Hospital from 1992 to 2006. The primary predictor variable was tumor classification (aggressive or nonaggressive); tumors were considered aggressive if they were greater than 5 cm in size, recurred after treatment, or exhibited 3 of the following: presence of root resorption, tooth displacement, or cortical bone thinning or perforation. Secondary predictor variables, recorded for each patient, were demographic, anatomic, and clinical measures. The outcome variable was the average CD34 staining density of histologic specimens quantified in 2 different areas. Descriptive and bivariate statistics were computed to identify predictors associated with vascular density.

RESULTS

The study sample was composed of 32 subjects with a mean age of 24.4 +/- 19.77 years (range: 2-83); 23 subjects (71.8%) were female. Of the tumors included, 11 (34.4%) were located in the maxilla, 21 (65.6%) in the mandible. Twenty-six tumors (81.2%) were classified as aggressive; the remainder (18.8%) were nonaggressive. There were no statistically significant differences between subjects with aggressive versus nonaggressive tumors with regard to age, gender, or location. Subjects with aggressive tumors had a significantly higher CD34 staining density (P = .02). None of the secondary predictors was associated with vascular density.

CONCLUSION

Vascular density of giant cell tumors of the jaws is significantly increased in aggressive tumors.

Giant cell granuloma of the jawbones ? a proliferative vascular lesion? Immunohistochemical study with vascular endothelial growth factor and basic fibroblast growth factor

AIM

To estimate the angiogenic activity in central giant cell granuloma (CGCG) by immunohistochemical stains for vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF). VEGF and bFGF immunoreactivity of the lesional mononuclear (MC) and giant (GC) cells was also investigated.

METHOD

The study consisted of 41 cases of CGCG. Vascularity was quantified by microvascular volume (MVV) as determined by point counting. In five cases of CGCG, regions at the surrounding border, which demonstrated reactive vascular-rich inflammatory areas, served as control. Immunoreactivity of the MC and GC was assessed as the percentage of VEGF- and bFGF-positive cells from the total number of the respective cell type.

RESULTS

Within CGCG lesions the extent of angiogenesis was low; MVV did not exceed 5% for either VEGF (88% of lesions) or bFGF (78% of lesions). The mean MVV of VEGF- and bFGF-positive blood vessels was 2.9% +/- 2.4% and 3.46% +/- 2.35%, respectively, significantly lower than in the control areas (27.5% +/- 7.3% and 28.08% +/- 5.5%, respectively) (P = 0.043). VEGF-positive and bFGF-positive MC and GC were found in nearly all lesions and in less than half of the lesions, respectively.

CONCLUSION

The low mean MVV of VEGF- and bFGF-positive blood vessels implies low angiogenic activity, which does not support the designation of CGCG as a true proliferative vascular lesion. MC and GC immunoreactivity for the angiogenic factors is assumed to play an important role in the osteoclastogenesis process, thus contributing to additional growth of the CGCG lesions.

Multinucleated giant cells in various forms of giant cell containing lesions of the jaws express features of osteoclasts

BACKGROUND

The nature and the mechanism involved in the formation of the multinucleated giant cells (MGCs) in various giant cell-containing lesions of the jaws are not fully understood. The aim of this study is to clarify the osteoclastic features of the MGCs in central giant cell granuloma (CGCG), peripheral giant cell granuloma (PGCG), cherubism, and aneurysmal bone cyst (ABC), and the mechanism underlying the interrelations between cellular components in the formation of the MGCs.

METHODS

Immunohistochemical study with a panel of antibodies including vacuolar H+-ATPase (V-ATPase), carbonic anhydrase II (CA II), Cathepsin K, matrix metalloproteinases-9 (MMP-9), CD68, and proliferating cell nuclear antigen (PCNA), and enzyme histochemical staining for tartarate-resistant acid phosphatase (TRAP) were applied on a total number of 53 cases of giant cell-containing lesions including CGCG (n = 34), PGCG (n = 6), cherubism (n = 7), and ABC (n = 6). In situ hybridization was also carried out to detect the mRNA expression of the receptor activator of NF-kappaB ligand (RANKL), a newly identified cytokine that is shown to be essential in the osteoclastogenesis, its receptor RANK (receptor activator of NF-kappaB ligand), and its decoy receptor OPG (osteoprotegerin) in these four types of lesions.

RESULTS

Immunohistochemical and enzyme histochemical studies showed that both the MGCs and a fraction of mononuclear cells in these lesions were strongly positive for TRAP, V-ATPase, CA II, Cathepsin K, MMP-9, and CD68, while the spindle-shaped mononuclear cells were positive for PCNA. The results with in situ hybridization indicated that RANKL mRNA was mainly expressed in the spindle mononuclear cells while OPG was extensively distributed in both the MGCs and the mononuclear cells. RANK mRNA was expressed in the MGCs and some round mononuclear cells.

CONCLUSIONS

These results suggest that MGCs in the four types of giant cell-containing lesions of the jaws show characteristics of the osteoclast phenotype. The mononuclear stromal cells, which show TRAP positively, may be the precursors of the MGCs. RANKL, OPG, and RANK expressed in these lesions may play important roles in the formation of the MGCs. The similar characteristics and mechanisms in the differentiation of MGCs in these lesions also suggest that there might be a similar kind of pathogenesis involved in the formation of the MGCs in these lesions

Calcitonin therapy for central giant cell granuloma

PURPOSE

A number of alternative nonsurgical therapies have been advocated in recent years for the management of the central giant cell granuloma (CGCG). These include calcitonin injections, intralesional steroid injections and subcutaneous alpha-interferon injections. This report provides the results of calcitonin therapy.

MATERIALS AND METHODS

Ten patients received calcitonin therapy, 9 via subcutaneous injection and 1 via nasal spray, for the management of a CGCG. Patients were reviewed retrospectively

RESULTS

In 8 cases, the lesions resolved completely after 19 to 21 months of subcutaneous calcitonin treatment. In the ninth case, the lesion resolved on calcitonin treatment only to reappear 26 months later. The recurrence was treated with both repeated calcitonin and local enucleation. The tenth case with calcitonin (intranasal) treatment was abandoned due to poor patient compliance, and the patient ultimately underwent surgical treatment.

CONCLUSION

Calcitonin treatment appears to be a viable option for the treatment of CGCGs but, because of the length of treatment time, should probably be reserved for multiple lesions, recurrent lesions, or particularly aggressive lesions. The exact mechanism of action of both calcitonin and other treatment modalities remains to be fully elucidated. The reported success of all such treatments raises questions about the natural history of this lesion.

Odontogenic cysts, odontogenic tumors, fibroosseous, and giant cell lesions of the jaws

Odontogenic cysts that can be problematic because of recurrence and/or aggressive growth include odontogenic keratocyst (OKC), calcifying odontogenic cyst, and the recently described glandular odontogenic cyst. The OKC has significant growth capacity and recurrence potential and is occasionally indicative of the nevoid basal cell carcinoma syndrome. There is also an orthokeratinized variant, the orthokeratinized odontogenic cyst, which is less aggressive and is not syndrome associated. Ghost cell keratinization, which typifies the calcifying odontogenic cyst, can be seen in solid lesions that have now been designated odontogenic ghost cell tumor. The glandular odontogenic cyst contains mucous cells and ductlike structures that may mimic central mucoepidermoid carcinoma. Several odontogenic tumors may provide diagnostic challenges, particularly the cystic ameloblastoma. Identification of this frequently underdiagnosed cystic tumor often comes after one or more recurrences and a destructive course. Other difficult lesions include malignant ameloblastomas, calcifying epithelial odontogenic tumor, squamous odontogenic tumor, and clear-cell odontogenic tumor. Histologic identification of myxofibrous lesions of the jaws (odontogenic myxoma, odontogenic fibroma, desmoplastic fibroma) is necessary to avoid the diagnostic pitfall of overdiagnosis of similar-appearing follicular sacs and dental pulps. Fibroosseous lesions of the jaws show considerable microscopic overlap and include fibrous dysplasia, ossifying fibroma, periapical cementoosseous dysplasia, and low-grade chronic osteomyelitis. The term fibrous dysplasia is probably overused in general practice and should be reserved for the rare lesion that presents as a large, expansile, diffuse opacity of children and young adults. The need to use clinicopathologic correlation in assessing these lesions is of particular importance. Central giant cell granuloma is a relatively common jaw lesion of young adults that has an unpredictable behavior. Microscopic diagnosis is relatively straightforward; however, this lesion continues to be somewhat controversial because of its disputed classification (reactive versus neoplastic) and because of its management (surgical versus. medical). Its relationship to giant cell tumor of long bone remains undetermined.

3D-CT vascular setting protocol using computer graphics for the evaluation of maxillofacial lesions

In this paper we present the aspect of a mandibular giant cell granuloma in spiral computed tomography-based three-dimensional (3D-CT) reconstructed images using computer graphics, and demonstrate the importance of the vascular protocol in permitting better diagnosis, visualization and determination of the dimensions of the lesion. We analyzed 21 patients with maxillofacial lesions of neoplastic and proliferative origins. Two oral and maxillofacial radiologists analyzed the images. The usefulness of interactive 3D images reconstructed by means of computer graphics, especially using a vascular setting protocol for qualitative and quantitative analyses for the diagnosis, determination of the extent of lesions, treatment planning and follow-up, was demonstrated. The technique is an important adjunct to the evaluation of lesions in relation to axial CT slices and 3D-CT bone images.

Markers for macrophage and osteoclast lineages in giant cell lesions of the oral cavity

PURPOSE

Giant cell lesions of the oral cavity are a well recognized entity. However, the histogenesis of these lesions is still the subject of controversy, with support for both histiocyte/macrophage and osteoclast origins being found in the literature. This study evaluated a set of peripheral giant cell lesions (PGCLs) and central giant cell lesions (CGCLs) for characteristics of both cell types to address this dilemma.

MATERIALS AND METHODS

Detection of histiocyte/macrophage characteristics was accomplished immunohistochemically by evaluating for markers specific for this cell type, namely alpha-1 -antichymotrypsin (1 -ACT) and factor XIIIa antibodies. Detection of osteoclast characteristics made use of the fact that osteoclasts possess a unique enzyme, tartrate-resistant acid phosphatase, which can be appreciated by histochemical procedures.

RESULTS

A large percentage of the multinucleated cells stained with the 1-ACT (38.08% in PGCLs and 15.84% in CGCLs), while only isolated cells stained for factor XIIIa (1.20% PGCLs, 0.99% CGCLs). Isolated stromal cells also were stained. Virtually all multinucleated cells reacted with the tartrate-resistant acid phosphatase stain (99.26% PGCLs, 98.34% CGCLs), as did a number of the mononuclear stromal cells.

CONCLUSIONS

This study supports the contention that GCLs of the oral cavity may arise from precursor cells related to the granulocyte/macrophage line, and may originate from mononuclear cells that express markers for both macrophages and osteoclasts.

The spectrum of giant cells in tumours of the salivary glands: an analysis of 11 cases

In view of the different terminology for salivary gland tumours with giant cells, eleven cases were analysed by histopathology and immunocytochemistry. Four cases (three pleomorphic adenomas, one carcinosarcoma in a pleomorphic adenoma) were classified as having a foreign-body giant cell reaction, and five cases (two mucoepidermoid carcinomas, one acinic cell carcinoma, two carcinomas in pleomorphic adenomas) as having a sarcomatoid osteoclast-like giant cell reaction. In two further cases a giant cell tumour and a giant cell granuloma were associated with carcinomas in pleomorphic adenomas. All giant cells showed characteristic expression of CD68 as a typical marker for histiocytes and macrophages with their origin in mononuclear haematopoetic stem cells. There was no evidence for an epithelial origin of the giant cells because all those examined had a negative reaction to cytokeratin. Foreign-body cells were characterized by cytoplasmic vacuoles and irregularly dispersed nuclei. They showed a focally circumscribed reaction mostly outside the connective tissue pseudocapsule of the tumours. The sarcomatoid osteoclast-like giant cell reactions in carcinomas were distinctly intermingled with the carcinomatous patterns. In contrast, the associated osteoclast-like giant cell tumour was distinctly separate from the salivary gland tumour tissue and was composed of numerous larger osteoclast-like giant cells with a greater number of nuclei (more than 20); these giant cells were uniformly distributed throughout the tumour tissue. The giant cell granuloma was also separate from the carcinoma and was composed of nests of smaller, more irregularly distributed giant cells.

Recurrent peripheral giant cell granuloma associated with cervical resorption

A case of recurrent peripheral giant cell granuloma in a 38-year-old man is reported. The lesion was localized on the attached gingiva of the lower left second premolar (tooth #35). The surgical excision of the lesion revealed a superficial resorption of the cervical region of the involved tooth. The resorption was smoothed out, and there was no sign of recurrence or further resorption after 14 months. Root resorption, although extremely rare, may be associated with peripheral giant cell granuloma.

Central giant cell granulomas of the jaws: phenotype and proliferation-associated markers

Central giant cell granulomas (CGCGs) are jaw tumors of unknown origin that often exhibit an aggressive, though unpredictable, clinical course. The purpose of this study was to determine the immunoprofile of the mononuclear cells that seem to be responsible for the biologic behavior of these tumors. Numbers of cells in cell cycle were also determined and compared in clinically aggressive and non-aggressive CGCGs. Sixteen aggressive and 12 non-aggressive CGCGs were immunohistochemically stained with antibodies to CD34, CD68, factor XIIIa, alpha-smooth muscle actin, prolyl 4-hydroxylase, Ki-67, and p53 protein. Cell populations and numbers of cells in cell cycle were determined through microscopic quantitative assessment. CD34-positive cells were limited to support vessels. CD68-positive mononuclear cells constituted a small population of cells in all tumors. With two exceptions, factor XIIIa-positive cells were rarely seen. Alpha-smooth muscle actin staining was present in approximately half the tumors, and occasionally large numbers of positive cells were seen. Most mononuclear cells were positive for fibroblast-associated antigen. No phenotypic differences were detected between aggressive and non-aggressive tumors. P53 protein did not appear to be overexpressed in CGCGs. Ki-67 staining showed that only mononuclear cells were in cell cycle, and that there were no differences between aggressive and non-aggressive tumors. We conclude that CGCGs are primarily fibroblastic (and myofibroblastic) tumors in which macrophages appear to play a secondary role. Tumor cells show no differentiation toward endothelial cells or macrophage-related dendrocytes (factor XIIIa). Cellular phenotypes and numbers of cells in cell cycle are similar in both aggressive and non-aggressive tumors.