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Central Giant Cell granuloma from Diagnosis to Management

Central Giant Cell granuloma and its differential diagnosis from the clinical and surgical point of view.

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Central Giant Cell granuloma from Diagnosis to Management

  1. 1. Facing the Giant Central Giant Cell Granuloma Dr Saikat Saha MDS (OMFS) Oral & Maxillofacial Surgeon Center for Jaw Face Neck Oral Surgery Head and Neck Reconstructive and Onco Surgery
  2. 2. “If you do not tame the cub today, be prepared to face the Giant Lion Tomorrow”
  3. 3. “If you do not tame the cub today, be prepared to face the Giant Lion Tomorrow”
  4. 4. Let Us Now See The Giants in Play
  5. 5. THE CASE MALE – 32 Swelling on the left side of the lower jaw since 8 months that gradually grew in size. The left lip and the chin area subsequently felt numb. There was no associated pain. Family History: Not relevant Past Medical History: He was treated elsewhere one month back.
  6. 6. CLINICAL PRESENTATION ON EXTRAORAL EXAMINATION: A Brawny hard swelling of the left body of the mandible was noted. The swelling was non-fluctuant. ON INTRAORAL EXAMINATION: A Brawny hard swelling was felt over the left buccal cortical plate with respect to teeth region #32, #33, #34, #35, #36 and #37. The left lower buccal vestibule was obliterated.
  7. 7. RADIOGRAPHIC INTERPRETATION Well defined radiolucent osteolytic lesion present at the left body of the mandible with some fine wispy trabeculae. There are multiple root resorption of the teeth on the left lower jaw. The lesion appears cystic and expansile with medullary hollowing out, thinning of the cortical plates and approaching the lower border of the mandible.
  8. 8. No significant Blood Picture Serum Calcium and Phosphate ------- NAD
  9. 9. PROVISIONAL DIAGNOSIS • AMELOBLASTOMA (UNICYSTIC)
  10. 10. CT - FACE & NECK IMPRESSION Lobulated , expansile lesion involving the  left half of symphysis menti and body of mandible with almost deficiency of the wall of the lesion on  left antero-lateral aspect involving the gingivo - buccal sulcus and left mandibular canal.
  11. 11. PRE OP CT
  12. 12. FNAC was done. Few giant cells were found in a matrix of RBCs
  13. 13. DIFFERENTIAL DIAGNOSIS - Based on Clinical and Radiographic features AMELOBLASTOMA BROWN TUMOR OF HYPERPARATHYROIDISM ANEURYSMAL BONE CYST TRAUMATIC BONE CYST CHERUBISM ODONTOGENIC MYXOMA
  14. 14. • It is uncommon in a younger age range, which is most susceptible to giant cell granuloma. • Seen in posterior mandible in contrast to giant cell granuloma which occurs anterior to the first molar. • Ameloblastoma demonstrates internal, hard curved arch like septa whereas giant cell granuloma has lighter wispy septa. • Ameloblastoma is usually multiloculated AMELOBLASTOMA
  15. 15. Ameloblastoma is a true neoplasm of enamel organ type. Unicentric, nonfunctional, intermittent in growth, It is the second most common odontogenic neoplasm. Mandible > Maxilla (molar-ramus area region.) AMELOBLASTOMA
  16. 16. Clinical Slow growing Painless expansion Thinning of cortical plates. In Advanced Stages -- • Root resorption, • Tooth mobility • Paresthesia AMELOBLASTOMA
  17. 17. Histological subtypes: 1. Follicular, 2. Plexiform 3. Acanthomatous 4. Granular 5. Desmoplastic 6. Basilar. AMELOBLASTOMA
  18. 18. Image Courtesy: Journal of Pathology and Translational Medicine https://www.jpatholtm.org/journal/Figure.php?xn=kjpathol-47-191.xml&id= Follicular type Plexiform type Acanthomatous type Desmoplastic type AMELOBLASTOMA
  19. 19. Radiographically : •Unicystic, •Multicystic •Solid •Peripheral type Multicystic or solid type is prevalent in 86% of cases. Unicystic ameloblastoma is of three subtypes: 1. Luminal, 2. Intraluminal 3. Mural AMELOBLASTOMA
  20. 20. AMELOBLASTOMA Image Reference : https://radiopaedia.org/articles/ameloblastoma
  21. 21. AMELOBLASTOMA Image Reference : https://radiopaedia.org/articles/ameloblastoma
  22. 22. AMELOBLASTOMA Tatapudi R, Samad SA, Reddy RS, Boddu NK. Prevalence of ameloblastoma: A three-year retrospective study . J Indian Acad Oral Med Radiol [serial online] 2014 [cited 2020 Jul 11];26:145-51. Available from: http://www.jiaomr.in/text.asp?2014/26/2/145/143687 Unicystic type Spider-web type Soap-bubble type Honeycomb type
  23. 23. BROWN TUMOR OF HYPERPARATHYROIDISM ECF [Ca 2+] ECF [Ca 2+] & [Phosphate] PTH Vitamin D
  24. 24. • Parathyroid hormone (PTH) is released in response to decreased serum Ca  PTH increase Ca by: causing an efflux of Ca from the bony skeleton increased reabsorption by the kidneys. PTH also leads to increased release of vitamin D from the kidneys, which in turn causes increased Ca absorption from GIT. • Conversely, PTH leads to decreased P levels due to increased excretion by the kidneys. BROWN TUMOR OF HYPERPARATHYROIDISM
  25. 25. • Primary HPT  one or more parathyroid glands secrete an excessive amount of PTH, eg. parathyroid adenoma; • Secondary HPT  increased secretion of PTH is a response to lowered ionized calcium, typically as a result of renal disease. • In Tertiary HPT  secretion of PTH occurs as a result of long-standing chronic renal disease eventually leading to overactive parathyroid glands that become independent of the underlying disease. Hence, tertiary HPT is not corrected when patients receive a renal transplant that corrects the underlying renal etiology BROWN TUMOR OF HYPERPARATHYROIDISM
  26. 26. • Uncontrolled HPT  BTHPT. • Presents late in untreated disease • Extensive bone resorption, which is replaced by fibrovascular tissue and giant cells with abundant deposits hemorrhage and hemosiderin. BROWN TUMOR OF HYPERPARATHYROIDISM
  27. 27. • Histology – Similar to central reparative giant cell granulomas. histologically  abnormal calcium homeostasis in HPT. BROWN TUMOR OF HYPERPARATHYROIDISM
  28. 28. Image Courtesy: Shetty, Akshay D., J Namitha and Leena James. “Brown Tumor of Mandible in Association with Primary Hyperparathyroidism: A Case Report.” Journal of International Oral Health : JIOH 7 (2015): 50 - 52.
  29. 29. • Treatment: Manage underlying HPT • Surgical treatment may be required in  [refractory cases] / [symptomatic lesions.] BROWN TUMOR OF HYPERPARATHYROIDISM
  30. 30. • In this current case serum calcium levels were not elevated. Is it a Brown tumor?  Yes  No BROWN TUMOR OF HYPERPARATHYROIDISM
  31. 31. Calcium is maintained within a fairly narrow range from 8.5 to 10.5 mg/dl (4.3 to 5.3 mEq/L or 2.2 to 2.7 mmol/L). The Normal Serum calcium levels ? A) 8.5 to 10.5 mg/dl B) 4.3 to 5.3 mg/dl C) 2.2 to 2.7 mg/dl D) 15 to 20 mg/dl
  32. 32. • ABC is a giant cell lesion within a fibroconnective tissue stroma with blood caverns or sinusoids and no epithelial lining. • A reactive lesion of bone rather than a cyst or true neoplasm, • it occurs in posterior segment of mandible, posterior to molar region. • Aspiration produces blood ANEURYSMAL BONEC CYST
  33. 33. • The radiographic features are not pathognomonic and are sometimes confusing. • Can mimic a Neoplasm • An associated periosteal reaction with reactive new bone forming a peripheral sclerotic border (difficult to differentiate from a subperiosteal hematoma) ANEURYSMAL BONEC CYST
  34. 34. ANEURYSMAL BONEC CYST Cause : Exaggerated, localized, proliferative response of vascular tissue in bone. Diagnosis: Blood aspirate obtained and the histopathologic findings
  35. 35. ANEURYSMAL BONEC CYST Image Courtesy; Sharma GH, Dabir AV, Das DA, Talreja-Kanchan PP. Bilateral aneurysmal bone cyst of the mandible: A case report. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2020 Jul 11];27:479-83. Available from: http://www.jiaomr.in/text.asp?2015/27/3/479/170471
  36. 36. TRAUMATIC BONE CYST •Rare , asymptomatic • Intraosseous lesion •Pseudocyst of jaws and long bones . •It is otherwise regarded as solitary bone cyst, hemorrhagic bone cyst, simple bone cyst, extravasation cyst or progressive bone cyst. • Young males in 2nd decade of life. Long Bones (90-95% in long bones)  Symphysis and body of mandible > (75%) > humerus (65%),> femur (25%) rare involvement of maxilla and condyle (1%). •Cortical plate expansion are rarely noticed
  37. 37. • No expansion of overlying bone cortex (rare). • No bodily movement of teeth is present. • Aspiration is negative mostly or sometimes a little straw colored liquid. TRAUMATIC BONE CYST
  38. 38. TRAUMATIC BONE CYST Radiograph features Well-defined, unilocular radiolucency +/- sclerotic margins extending between the roots of the tooth in the affected region, providing a characteristic scalloping feature.
  39. 39. TRAUMATIC BONE CYST Reference Image: Titsinides S, Kalyvas D. Traumatic bone cyst of the jaw: a case report and review of previous studies. J Dent Health Oral Disord Ther. 2016;5(5):318‒325. DOI: 10.15406/jdhodt.2016.05.00167
  40. 40. TRAUMATIC BONE CYST Reference ImageKarthik KP, Balamurugan R, SahanaPushpa T (2019) Traumatic bone cyst of anterior mandible: A surgical approach. Dent Oral Maxillofac Res 5: DOI: 10.15761/DOMR.1000306
  41. 41. TRAUMATIC BONE CYST Reference Image: https://www.rdhmag.com/patient-care/radiology/article/16407975/traumatic-bone-cyst
  42. 42. Histological findings: Fibrous connective tissue + chronic inflammatory cell infiltrate No epithelial lining. Treatment: Surgical excision followed by curettage of cystic cavity. Surgical exploration  bleeding which forms  blood clot within the cavity  resolution and regeneration of new bone. TRAUMATIC BONE CYST
  43. 43. 3rd most common odontogenic tumor after ameloblastoma and odontomas. The tumor is almost always located intraosseously, Peripheral types have been described. Odontogenic Myxoma
  44. 44. Clinical features Benign, slow growing but locally aggressive tumor. 2nd to 4th decades. Common site: Molar and ramus regions of the mandible. Maxillary lesions also tend to present in the posterior quadrant. Odontogenic Myxoma
  45. 45. Radiographic features •Well circumscribed / diffuse lesions •+/- Root displacement / resorption • •Missing or impacted tooth is usually a finding. Odontogenic Myxoma
  46. 46. • Small lesions may have a unilocular appearance. • Most lesions are multilocular radiolucencies with internal bony septa. • These septa gives the following radiologic appearances a) Tennis- racket b) Honey comb c) Soap bubble d) Step Ladder ODONTOGENIC MYXOMA Radiographic features
  47. 47. Image Reference: Manne, Rakesh Kumar, Venkata suneel Kumar, P. Venkata Sarath, Lavanya Anumula, Sridhar Mundlapudi, and Rambabu Tanikonda. “Odontogenic Myxoma of the Mandible.” Case Reports in Dentistry. Hindawi, July 9, 2012. https://www.hindawi.com/journals/crid/2012/214704/. ODONTOGENIC MYXOMA
  48. 48. Image Reference : Manne, Rakesh Kumar, Venkata suneel Kumar, P. Venkata Sarath, Lavanya Anumula, Sridhar Mundlapudi, and Rambabu Tanikonda. “Odontogenic Myxoma of the Mandible.” Case Reports in Dentistry. Hindawi, July 9, 2012. https://www.hindawi.com/journals/crid/2012/214704/. ODONTOGENIC MYXOMA
  49. 49. Image Reference: Wright, John M, and Merva Soluk Tekkesin. “Odontogenic Tumors: Where Are We in 2017 ?” Journal of Istanbul University Faculty of Dentistry. Istanbul University Faculty of Dentisty, December 2, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750825/. ODONTOGENIC MYXOMA
  50. 50. Image Reference: Jawaid, Moazzam, Sunil R. Panat, Ashish Aggarwal, Nitin Upadhayay, Nupur Aggarwal, Astha Durgvanshi and G. N. Sowmya. “Odontogenic Myxoma of the Mandible : A Rare Case Report.” (2016). ODONTOGENIC MYXOMA
  51. 51. • Histopathology • Fine delicate stellate, fusiform and round cells in a bland myxoid stroma • Appear like ~~ Dental papilla. • If more collagen Odontogenic Myxoma  Odontogenic Myxofibroma
  52. 52. Treatment and prognosis •Resection with free margins. •Small lesions can be treated by conservative surgery. •Recurrence = 25% (long-term follow-up is required) Odontogenic Myxoma
  53. 53. Odontogenic Myxoma is a _________________ common odontogenic tumor after ameloblastoma? A) 2nd Most B) 3rd Most C) 4th Most D) 5th Most
  54. 54. Peripheral varieties of Odontogenic Myxoma are also seen. 1) True 2) False
  55. 55. Odontogenic Myxoma is a very fast growing tumor?. 1) True 2) False In Odontogenic Myxoma which radiological appearance is common?. 1) Step Ladder 2) Tennis Racket 3) Honey Comb
  56. 56. CHERUBISM • Inherited • Characterized by bone degradation and replacement by fibrous tissue at maxilla and mandible during childhood. • This disease tends to show variable degree of remission or spontaneous involution after puberty;  facial deformity.
  57. 57. • It is bilateral in the posterior part of mandible and there is history of familial involvement. • It does not cross the midline. • Frequent in first decade especially in 2-5 years. Females>males, 2:1. CHERUBISM
  58. 58. CHERUBISM Reference Image : Fernandes Gomes M, Ferraz de Brito Penna Forte L, Hiraoka CM, Augusto Claro F, Costa Armond M. Clinical and surgical management of an aggressive cherubism treated with autogenous bone graft and calcitonin. ISRN Dentistry. 2011 ;2011:340960. DOI: 10.5402/2011/340960.
  59. 59. CHERUBISM Reference Image : Fernandes Gomes M, Ferraz de Brito Penna Forte L, Hiraoka CM, Augusto Claro F, Costa Armond M. Clinical and surgical management of an aggressive cherubism treated with autogenous bone graft and calcitonin. ISRN Dentistry. 2011 ;2011:340960. DOI: 10.5402/2011/340960.
  60. 60. CHERUBISM Treatment • Calcitonin + Autogenous Bone Grafting Calcitonin  inhibits bone resorption  Osteoclastic cells ( inhibited) Osteo-inductive implant material chemotactic, mitogenic and osteogenic potential. Autogenous bone & marrow grafts
  61. 61. Back to our today’s case
  62. 62. What are Giant Cell Granulomas?
  63. 63. Bone Marrow Chemokines IL, Interferon etc. Differentiate Irritation site in the body. Inflamation
  64. 64. Benign Intraosseous Jaw Lesion CGCG Non Odontogenic
  65. 65. Still Unknown How? Reactive Hamartomatous Neoplastic
  66. 66. Fibroblasts and Multinucleated Giant Cells in a densely packed stroma
  67. 67. Clinical Presentation
  68. 68. Most in children and young adults. Age= 1st 3 decades 2:1 Female:Male CGCG = 10% of all the Benign lesions of the jaw CGCG is less common than the giant cell granulomas of the extremities
  69. 69. Mostly confined to the tooth bearing areas of the jaw Mandible> Maxilla More common in the anterior mandible, Often crossing the midline and causing painless swellings Rarely posterior jaw (ramus and the condyle)
  70. 70. Asymptomatic, Painless Expansion Thinning of the cortical plates with plate perforation Early Signs = Swelling & Premature deciduous Loose tooth Jaw/Facial Asymmetry
  71. 71. Two Biologic Forms Reactive Neoplastic Non - Aggresive Aggressive
  72. 72. Giant Cells are the most prominent feature But The mononuclear spindle cell is the proliferating cell (in cell cycle) Spindle Cell Originate from the mesenchyme of the marrow. Expression of the cell cycle protein Ki-67 in CGCGs. indicated by
  73. 73. Etiopathogenesis
  74. 74. Spindle Cells (Fibroblast or Fibroblast Like) A Belief !!!!!! Monocytes Cytokines Osteoclastic Epigenitic Event
  75. 75. Radiographic Features Central giant cell lesions present as radiolucent defects. Which may be unilocular or multilocolar. The lesion may vary from a 5×5mm incidental radiographic findings to a destructive lesion greater than 10cm in size. The radiographic findings are not specifically diagnostic. Small unilocular lesion may be confused with periapical granuloma or cysts. Multilocular giant cell lesions cannot be radiographically distinguished from ameloblastomas or other multilocular lesion.
  76. 76. Ameloblastoma ????
  77. 77. Grossing  Brownish to reddish friable tissue of various size. Specimen is usually coated with fresh or coagulated blood.
  78. 78. Central Giant Cell lesions of the jaws are usually treated by curettage Studies indicate a recurrence rate of about 15-20%. Long term prognosis is good & no metastasis reported Surgical resection in more aggressive malignant cases. Treatment
  79. 79. Differential Diagnosis Ameloblastoma Brown tumor Aneurysmal bone cyst  Cherubism  Myxoma  Intra bony hemangioma
  80. 80. TREATMENT Surgical Resection of the left partial-mandible followed by Reconstruction using Rib Graft under Hypotensive General Anesthesia. The sample was sent for histopathological analysis.
  81. 81. Midline lip-split incision
  82. 82. After left Hemi-Mandibulectomy
  83. 83. Harvesting the 5th Rib graft from the Right side
  84. 84. Reconstruction of the Left Hemi-mandible with Rib graft and titanium mandible recon plate
  85. 85. Closure of the flap
  86. 86. POST OP CT
  87. 87. PRE OP CHEST X-RAY
  88. 88. POST OP CHEST X-RAY
  89. 89. POST OP 1 WEEK LATER
  90. 90. POST OP 3 MONTHS LATER
  91. 91. Recap
  92. 92. AMELOBLASTOMA
  93. 93. TRAUMATIC BONE CYST NO ROOT RESORPTION NO BODILY MOVEMENT OF TEETH
  94. 94. ODONTOGENIC MYXOMA TENNIS RACKET APPEARANCE
  95. 95. ANEURYSMALBONE CYST
  96. 96. CHERUBISM Bilateral involvement, but does not cross the midline
  97. 97. BROWN TUMOR OF THE MANDIBLE PEPPER POT APPEARANCE OF THE SKULL
  98. 98. Controversy in the Treatment of Central Giant Cell Granuloma Calcitonin Calcitonin and Interferon , Calcitonin/Interferon/Imatinib/Corticosteroids, Calcitonin/Interferon/Alendronate/Sorafenib Calcitonin/Interferon/Coritcosteroids in order to correct facial contours or to remove a remaining lesion after stabilization with extensive pharmacological treatment. None of these lesions recurred in the follow-up period Ref : Schreuder, W. & Berg, Henk & Lange, J.. (2011). Controversy in the Treatment of Central Giant Cell Granuloma: In Search of Evidence-Based Treatment. Journal of Oral and Maxillofacial Surgery - J ORAL MAXILLOFAC SURG. 69. 10.1016/j.joms.2011.06.231.
  99. 99. Thank You

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