Giant cell lesions of the maxilla and paranasal sinuses

Maxillofacial challenge: Rare presentation of central giant cell tumor involving both maxilla and mandible

INTRODUCTION AND IMPORTANCE

Central giant cell tumor (CGCT) of bone is an uncommon yet locally aggressive neoplasm originating from undifferentiated mesenchymal cells in bone marrow. This case report explores a rare presentation in the maxilla extending to the mandible, emphasizing the complexity of CGCT management and the need for a multidisciplinary approach.

CASE PRESENTATION

A 35-year-old female presented with a progressively enlarging non-tender, firm swelling on the left maxilla and a similar mandibular swelling. Paraesthesia of the left lower lip and chin accompanied the mandibular swelling. CT scans and 3D reconstructions revealed expansive osteolytic defects affecting the maxilla and mandible. Biochemical tests supported a central giant cell tumor diagnosis. Histopathology confirmed spindle cell proliferation and multinucleated giant cells in both lesions. Surgical intervention involved excision and reconstruction. A five-month follow-up showed no recurrence, affirming the treatment's success.

CLINICAL DISCUSSION

Central giant cell tumors (CGCTs) of bone are primarily benign, arising from undifferentiated mesenchymal cells. While mostly benign, they carry a rare potential for malignancy. Diagnosis involves imaging (CT, MRI, bone scintigraphy) and confirmation through biopsy. Surgical resection is the standard treatment, with radiotherapy considered in challenging cases. Recurrence rates vary with the extent of surgical intervention. Alternative treatments like cryotherapy and chemotherapy show varying success.

CONCLUSION

This case emphasizes the necessity of precise histopathological diagnosis for CGCT management. The intricate nature of maxillary involvement, coupled with mandibular association, mandates a multidisciplinary approach. Surgery, while the primary treatment, should be judiciously determined based on tumor characteristics and recurrence.

Central giant cell granuloma of the head & neck: A case report and systematic review

PURPOSE

The purpose of this paper is to describe a recent case of central giant cell granuloma (CGCG) that rapidly progressed post corticosteroid treatment while also providing a review of the existing literature on CGCG of the head and neck (HNCGCG), with particular emphasis on extra-mandibular and maxillary cases.

MATERIALS AND METHODS

The investigators designed and implemented a 32-year review of literature, using the online databases: PubMed, Google Scholar, Medline, and Proquest. The total number of cases analyzed was 55 (42 case reports; 3 case series; 8 comparative studies; 1 retrospective cohort).

CASE PRESENTATION

We present a case of a CGCG in a 10-year old male. The lesion originated in the right anterior mandibular body and progressed after corticosteroid treatment. Diagnosis was made using a combination of imaging and histology. A timely debulking procedure of the hemi-mandible was performed and there was no recurrence of the lesion at follow up.

RESULTS

The average age at the time of diagnosis of CGCG was 27.5 years. HNCGCG was most commonly detected in the jaw (43.1%), but was also found in the temporal bone (33.3%). The most frequently employed treatment modality was complete surgical excision (76.9%). 93.2% of patients were alive with no evidence of disease at follow-up, while 6.8% of patients exhibited recurrence at follow-up. The median follow up was 13 months.

CONCLUSION

It is important for clinicians to recognize that CGCGs are capable of manifesting outside of the jaw. CGCG should be considered in the differential diagnosis of non-odontogenic radiolucent lesions, especially in young patients. CGCGs also need to be distinguished from brown tumor of hyperparathyroidism (BTH) and giant cell tumors, which are histologically similar.

Multiple versus solitary giant cell lesions of the jaw: Similar or distinct entities?

The majority of giant cell lesions of the jaw present as a solitary focus of disease in bones of the maxillofacial skeleton. Less frequently they occur as multifocal lesions. This raises the clinical dilemma if these should be considered distinct entities and therefore each need a specific therapeutic approach. Solitary giant cell lesions of the jaw present with a great diversity of symptoms. Recent molecular analysis revealed that these are associated with somatic gain-of-function mutations in KRAS, FGFR1 or TRPV4 in a large component of the mononuclear stromal cells which all act on the RAS/MAPK pathway. For multifocal lesions, a small group of neoplastic multifocal giant cell lesions of the jaw remain after ruling out hyperparathyroidism. Strikingly, most of these patients are diagnosed with jaw lesions before the age of 20 years, thus before the completion of dental and jaw development. These multifocal lesions are often accompanied by a diagnosis or strong clinical suspicion of a syndrome. Many of the frequently reported syndromes belong to the so-called RASopathies, with germline or mosaic mutations leading to downstream upregulation of the RAS/MAPK pathway. The other frequently reported syndrome is cherubism, with gain-of-function mutations in the SH3BP2 gene leading through assumed and unknown signaling to an autoinflammatory bone disorder with hyperactive osteoclasts and defective osteoblastogenesis. Based on this extensive literature review, a RAS/MAPK pathway activation is hypothesized in all giant cell lesions of the jaw. The different interaction between and contribution of deregulated signaling in individual cell lineages and crosstalk with other pathways among the different germline- and non-germline-based alterations causing giant cell lesions of the jaw can be explanatory for the characteristic clinical features. As such, this might also aid in the understanding of the age-dependent symptomatology of syndrome associated giant cell lesions of the jaw; hopefully guiding ideal timing when installing treatment strategies in the future.

Peripheral and Central Giant Cell Lesions in Children: Institutional Experience at Subharti Dental College and Hospital

Introduction:

Giant cell lesions (GCG) are a group of varied lesions that contain a multitude of multinucleated, osteoclast like giant cells within connective tissue stroma. These include giant cell granulomas which may be central (CGCG), if they lie within the jaw bone, or, peripheral (PGCG) if they lie within the soft tissue. Giant cell granulomas comprised 9.29% of all oral lesions. This case series comprises of 5 giant cell lesions in children between the ages of 4 to 12 years.

Materials and Methods:

A retrospective analysis was conducted of all patients who were diagnosed with giant cell lesions and treated over a period of 10 years (from August 2004 to August 2014) at Subharti Dental College and Hospital, Meerut, India.

Results:

A total of 5 giant cell lesions were identified in this case series, of which 2 cases were diagnosed as PGCG and 3 cases as CGCG. Surgical excision and curettage was performed for 2 peripheral lesions under local anesthesia while 1 central lesion was excised under general anesthesia. Two central lesions were treated with a non-surgical approach using intralesional corticosteroid.

Conclusion:

Our experience suggests that a correct diagnosis and complete surgical excision with curettage is effective in complete management of oral giant cell lesions in the pediatric age group.

Pharmacological and surgical therapy for the central giant cell granuloma: A long-term retrospective cohort study

PURPOSE

This is a retrospective cohort study of patients with a central giant cell granuloma (CGCG) treated at a single center to assess and compare the different surgical and non-surgical approaches.

MATERIAL AND METHODS

A cohort with a single histologically proven non-syndrome-related CGCG was selected and reviewed. Patients were allocated to group I (surgery), group II (pharmacotherapy), and group III (pharmacotherapy and surgery). The primary outcome was long-term radiologic response using computed tomography. Secondary outcomes were intermediate radiologic responses and occurrence and severity of side effects.

RESULTS

Thirty-three subjects were included in the study. The surgical group (n = 4) included 1 patient with progression during follow-up and a relatively high post-surgical morbidity. Twenty-nine patients started on various pharmacological treatment regimens (groups II and III). Fourteen patients could be managed without additional surgery. One of these lesions showed progression during follow-up. The other 15 lesions underwent additional surgery, and none showed progression during follow-up. Interferon treatment was associated with the most side effects.

CONCLUSION

Pharmacological agents have a role in the treatment of aggressive and non-aggressive CGCGs by limiting the renewed progression during long-term follow up and the extent and morbidity of surgical treatment.

Recurrent case of central giant cell granuloma with multiple soft tissue involvement

Central giant cell granuloma is a fairly common lesion in the jaws aetiology of which is still completely unknown but thought to be of a reactive process to some unknown stimuli. It usually arises either peripherally in periodontal ligament, mucoperiosteum, or centrally in the bone. The histological hallmark for both peripheral and central giant cell granuloma (CGCG) is the presence of distinctive multinucleated giant cells (MGCs) in a prominent fibrous stroma. Central giant cell granuloma is an uncommon benign proliferative lesion that almost exclusively occurs within the jaw. Eventually, it may become aggressive leading to the expansion and perforation of cortex resulting into mobility and displacement of teeth with root resorption. The present case focuses on the dilemma and perplexity in diagnosing aggressive CGCGs, due to its close proximity with respect to pathology, behavior and prognosis from giant cell tumors (GCT). Central giant cell granuloma persuaded extensive destruction to the hard and soft tissues with high rate of recurrence encourage us the need of exploring the possibilities of giant cell tumors having a definitive presence in the jaws.

Bone Lesions of the Head and Neck

This article describes the clinical, radiographic, and pathologic features of tumors and tumorlike lesions affecting the bones of the head and neck region. Emphasis is placed on common bone lesions affecting the craniofacial skeleton, particularly those that occur with more frequency or those that are unique to this part of the skeleton. Several of these lesions pose a diagnostic challenge to the pathologist. To ensure that a correct diagnosis is rendered, it is of utmost importance that accurate and detailed clinical and radiographic information is available.

A case of recurrent multifocal central giant cell granulomas

One case of recurrent multifocal central giant cell granulomas (CGCG) is presented. Initially, the lesions presented concurrently in the maxilla and mandible with subsequent recurrence in the mandible. Now, two recurrences are seen in the maxillary sinus and ethmoid region. The literature regarding multifocal CGCG is reviewed.

[Orbital aneurysmal bone cyst in a 2-year-old child]

An aneurysmal bone cyst is a rare tumor-like lesion which can affect any part of the skeleton. It is a disease of childhood and adolescence. Reports of its occurrence on the skull base in children are rare. A 22-month-old male patient was admitted to our ENT department with a sudden protrusion of the right eyeball. Radiologically, a cystic, well-defined and contrast enhanced mass on the medial-cranial orbital wall with beginning destruction of the frontal skull base was detected. Histological assessment of a biopsy, which was taken by medial orbitotomy, showed giant-cellular and fibrohistiocytic changes. Definitive histological diagnosis after removal showed an aneurysmal bone cyst. If there is evidence for aggressive, expansive growth, an aneurysmal bone cyst should be included into the ENT-differential diagnosis of orbital tumors. It is not possible to confirm diagnosis from clinical or radiological data. Early biopsy is essential for a reliable diagnosis even if histological assessment is challenging.

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.

Central giant cell granuloma of the jaws: A clinical, radiologic, and histopathologic study of 26 cases

The clinical behavior of central giant cell granuloma (CGCG) of the jaws is variable and difficult to predict. Clinical data and follow-up information of 26 patients with CGCG were analyzed. Histologic features were correlated with the clinical course of the disease. In 16 patients the CGCGs were asymptomatic; 10 lesions presented with aggressive growth, pain, massive swelling, root resorption, cortical perforation, and/or recurrence. These patients were younger and the lesions were larger than in the nonaggressive group. The histomorphometric analysis proved a significant increase in large giant cells, fractional surface area, and mitotic activity in aggressive CGCG lesions. Immunohistologic investigation (Ki-67 and p53 stain) revealed no significant differences. After surgical treatment, 3 patients with aggressive lesions developed a recurrence. The data show that clinical and histomorphometric features may be reliable indicators for the differentiation between aggressive and nonaggressive CGCG. This should be accounted for to improve the individual planning of the treatment and follow-up.

Long-term clinical and radiological outcomes of surgical management of central giant cell granuloma of the maxilla

The aim of this study was to report the results of long-term clinical and radiological follow up of the surgical management of central giant cell granuloma of the maxilla. A retrospective analysis was conducted on 12 patients--5 male and 7 female whose ages ranged from 9 to 41 years, with central giant cell granuloma of the maxilla treated between 1991 and 2000. The anterior maxilla was involved in five cases, seven cases were in the posterior region, and none crossed the midline. Four patients were asymptomatic and eight patients presented with pain, mobility of teeth, and rapidly enlarging facial swelling. Radiographically, all lesions were radiolucent; 58.3% were unilocular, and the borders were well-defined in 33.3%. Roots were commonly displaced by the lesion, but no root resorption was observed. Cortical perforation was seen clinically and on CT scan in four patients. All cases were treated with thorough curettage until healthy bone was encountered. In cases with cortical perforation the affected buccal and/or palatal mucosa was excised. When the maxillary sinus was affected or the lesion was bulging into the nose, the nasal mucosa was also removed. All patients were reviewed annually for a follow-up period of 2-9 years; the condition recurred in two patients. It is concluded that thorough curettage is a satisfactory method for the treatment of non-aggressive and aggressive central giant cell granuloma of the maxilla, with a low recurrence rate and favorable postoperative outcome.

Riesenzellgranulom und Osteitis fibrosa cystica bei Hyperparathyreoidismus

BACKGROUND

Giant cell lesions of the bone present similar histological features. The differential diagnosis comprises central giant cell granuloma, giant cell tumor of bone, and osteitis fibrosa cystica (brown tumor) in combination with hyperparathyroidism. Since these lesions may mimic metastatic bone disease in patients with a history of cancer, a malignant process has to be considered. Since the treatment and prognosis of these entities-benign versus malignant osteolytic bone processes-differ greatly, definitive differential diagnosis is of utmost importance.

CASE REPORT

Two patients presenting with osteolytic lesions of the maxilla are reported here. In both cases a history of cancer (breast and prostate) suggested bone spreading of these malignant tumors. The clinical and histological findings were similar in both patients. One lesion was diagnosed as central giant cell granuloma, the other was found to be brown tumour in osteitis fibrosa cystica as an initial manifestation of hyperparathyroidism.

DISCUSSION

The presented cases demonstrate the difficulties in establishing the correct diagnosis of patients found to have osteolytic lesions of the jawbones which is critical for the appropriate management of these patients. The article discusses the different entities of osteolytic lesions of the jawbones and the necessary diagnostic and therapeutic approach.

Two unusual lesions in the nasal cavity of infants--a nasal chondromesenchymal hamartoma and an aneurysmal bone cyst like lesion. More closely related than we think?

Benign reparative lesions in the head and neck region in infants are rare and often difficult to classify on histology. Discussed herein are two rare lesions in infants occurring at identical locations in the nasal cavity with striking histologic similarity but different histologic labels. One was a case of nasal chondromesenchymal hamartoma (NCMH) occurring in a 1-year-old child and the other an aneurysmal bone cyst (ABC) like lesion affecting a 4-month infant. Both these lesions were locally destructive and had nearly similar clinical presentation. Both on immunohistochemistry showed myofibroblastic nature and had similar histology except that the ABC like lesion lacked the cartilage component of the former. In view of great similarity in the two lesions, it was thought that the second lesion might also represent a reparative, non-cartilage-containing counterpart of the former.

An endosseous, implant-retained obturator for the rehabilitation of a recurrent central giant cell granuloma: a clinical report

The prosthodontic rehabilitation of a patient with a recurrent maxillary CGCG has been described. The patient's immense defect originally was rehabilitated with a scapular microvascular free flap, endosseous dental implants, and an ISP that became obsolete by virtue of the resection of recurrent disease and the subsequent need for velopharyngeal obturation. The patient was provided with a surgical obturator at the time of the resection of the recurrent CGCG. The surgical obturator thereafter was modified into an interim obturator to provide velopharyngeal competence while the soft tissues around the palatal defect healed. Finally, the construction of a bar-retained definitive obturator markedly improved the patient's speech, mastication, and deglutition.

Giant cell tumor of the larynx

Giant cell tumors are benign tumors generally found in the long bones. Very rarely, they can occur in the larynx and may present with dysphonia, dysphagia, or dyspnea. A case of giant cell tumor of the larynx was recently identified and successfully treated by a partial laryngectomy. A literature review has revealed 18 case reports of giant cell tumor of the larynx. All cases occurred in men. These 19 cases are reviewed, and follow-up data presented where available. There have been no reports of recurrence regardless of treatment, and an excellent prognosis can be expected when one encounters this unusual laryngeal neoplasm.

Sinonasal imaging: malignant disease

The clinical presentation of sinonasal malignancy overlaps that of more common benign inflammatory disease. For this reason, unsuspected malignant lesions are often first recognized on the screening CT exam. We will focus on the initial CT appearance of various malignancies and discuss the goals of imaging including the use of MR.

Giant cell tumors of the jugular foramen

PURPOSE

To review the diagnosis and treatment of giant cell tumors of the jugular foramen.

MATERIALS AND METHODS

A typical case is reported. Symptoms, signs, and diagnostic studies are reviewed. Photomicrographs and angiographic studies showing the differences between these and glomus jugulare tumors are provided. A coherent approach to their management is presented.

RESULTS

These hypervascular, traditionally radioresistant tumors may cause pulsatile tinnitus, conductive hearing loss, and lower cranial nerve paresis. Angiographic studies showed a hypervascular lesion supplied by numerous small branches of the external carotid artery, making embolization difficult. Complete resection was achieved by an infratemporal fossa approach with preoperative embolization.

CONCLUSION

Giant cell tumors of the temporal bone may mimic glomus jugulare tumors with respect to anatomic location, cranial nerve deficits, and vascularity.

Radiographic features of central giant cell granuloma of the jaws in children

The radiographic features of ten pediatric cases of central giant cell granuloma of the jaws were studied, using plain film radiography (PFR), computed tomography (CT), and a dental CT software program (DS). The radiologic features varied from ill-defined destructive lesions to a well-defined, multilocular appearance. Teeth or root displacement was found as the most consistent feature. Root resorption was rare. The features seen on CT were clearer than those seen on PFR. DS, by its visualization of the jaw in three plans - axial, panoramic, and buccolingual - provided useful information for determining the topography of the lesion in its structure (uni- or multilocular) and proximity to adjacent anatomic structures, such as teeth, nerves, or maxillary sinus. CT and, ideally, CT with DS should be used for diagnosis and surgical management of central giant cell granuloma of the jaws in children.