Central Giant Cell Granuloma of Maxilla: A Case Report

Abstract

Central giant cell granuloma formerly called giant cell reparative granuloma is a non neoplastic proliferative lesion of an unknown aetiology. It occurs most commonly in mandible, but can also occur in maxilla. The case described here involved maxilla which was treated with surgical excision.

Introduction

Central giant cell granuloma (CGCG) is a non- neoplastic lesion of unknown etiology. In 1953, Jaffe described it as reparative granuloma of jaw bones [1]. However, the term reparative is obsolete, as CGCG causes the destruction of involved bones [1]. CGCG account for 7% of all benign tumours affecting the mandible [2]. There is a slight female predilection, with a peak age incidence range between 10 and 25 years [3]. The etiopathogenesis of the CGCG is controversial and has been a reactive, an inflammatory, an infective or a neoplastic process occurring secondary to previous trauma [4].

Here with we describe a case of CGCG affecting the maxilla when a 23 year old female patient presented to us with swelling over the left cheek.

Case History

A 23-year-old woman presented to our ENT OPD with complaints of swelling in the left side of the cheek since one month. History revealed that the swelling was insidious in onset and gradually progressed to present size, not associated with pain. There was no history of loosening of teeth, nasal obstruction, difficulty in chewing, fever, preceding trauma. Past history, medical and family history were noncontributory.

External examination: revealed a solitary swelling on the left side of the face causing obliteration of nasolabial fold resulting in facial asymmetry (Fig. 1) A swelling of size 4 × 4 cm located in the left side of the cheek which is of soft to firm in consistency, non-tender, non fluctuant, with no discharge, or overlying skin change. There was no associated lymphadenopathy.

Fig. 1.

Upon initial examination, the patient had a mass in the left nasolabial area with associated facial asymmetry

Intraoral examination appeared normal with no extension of swelling.

Routine investigation, biochemical studies for serum calcium, phosphate, alkaline phosphatase were within the normal limits.

CT PNS suggested an expansile lytic lesion arising from the alveolus involving maxilla on the left side with large exophytic soft to cystic component. The lesion all together measuring 37 × 34 × 32 mm with minimal exophytic extension into left maxillary sinus with dense peripheral wall calcification which suggested a benign cystic lesion of maxilla possibly odontogenic keratocyst. Rest of paranasal sinuses and sinus walls appeared normal (Fig. 2).

Fig. 2.

CT (axial section) shows an expansile lytic lesion arising from the alveolus involving maxilla on the left side

Differential diagnosis of aneurismal bone cyst (ABC), odontogenic keratocyst, calcifying epithelial odontogenic cyst, nasolabial cyst, radicular cyst, giant cell tumour, brown tumour of hypoparathyroidism, central giant cell granuloma were considered.

The case was planned for surgery under general anesthesia. Through intraoral approach the lesion was exposed sublabially. Enucleaion with extensive curettage was done Fig. 3. Maxillary sinus was extensively curetted taking care not to injure the greater palatine vessels and inferior alveolar nerve. Hemostasis was achieved. The entire mass was excised and the wound closed by using catgut 3-0. The patient tolerated the procedure well.

Fig. 3.

intraoral approach to excise the lesion through a sublabial incision in the upper buccal sulcus

The excised biopsy was subjected to an histopathological examination (Fig. 4a).

Fig. 4.

a Gross specimen b histopathology slide showing multinucleated giant cells scattered in a highly cellular and vascular stroma (red arrow-giant cell, blue arrow-RBC’s, star mark-stromal cells)

Histopathological examination revealed multinuecleated giant cells scattered in a highly cellular and vascular stroma filled with rbc’s. The stromal cells did not show any mitosis or cellular atypia (Fig. 4b). A diagnosis of CGCG was made.

Outcome and Follow-Up

The prognosis of present case was fair. In the last one year’s follow up, there has not been any recurrence and the facial profile became almost normal (Fig. 5).

Fig. 5.

Two months postoperatively, there is no facial edema and no signs of recurrence

Discussion and Conclusion

Giant cell granuloma is a rare bony lesion in the head and neck region. According to World Health Organization 1992 classification, CGCG is defined as an intraosseous lesion consisting of fibrous tissue containing multiple foci of hemorrhage, aggregates of multinucleated giant cells and trabeculae of woven bone [2]. It is a non-odontogenic tumor never seen in any other bone of the skeleton [5].

The clinical behavior of CGCG ranges from a slow growing asymptomatic swelling discovered on X ray to a rapidly expanding aggressive variety characterized by pain and facial swelling. The fast growing lesion have a high rate of recurrence when the lesion perforates the cortical plates to involve the surrounding soft tissue [6].

The radiological appearance of CGCG is variable. CGCG of the jaw is usually unifocal. Multifocal lesions should alert the clinician to the possibility of hyperparathyroidism. If bilateral cherubism should be considered [7].

CGCG should also be distinguished from giant cell tumor. The giant cell tumour involves long bones and is more aggressive in nature with frequent recurrence after curettage. Microscopically, the giant cells are osteoclastic and almost uniformly distributed, whereas in giant cell granuloma, foreign body type giant cells with irregular distribution and vacuolation are seen [7, 8].

The final diagnosis of CGCG eventually rests on histopathology because the clinical and radiological features are not specific.

Surgical excision is the best way to manage and showed better results. The extent of tissue removal varies from a simple curettage to extensive resection based on the nature of lesion. Cryosurgey and peripheral osteotomy are the other options [9].

Non surgical methods like radiotherapy, systemic calcitonin and intralesional injection with corticosteroids have shown effective results in some studies [5, 9, 10]. Aggressive CGCG can be managed by interferon-alpha due to its anti-angiogenic effects [9].

The incidence of recurrence of CGCG after surgery is 4–20%. Prompt diagnosis and management can greatly improve morbidity and long term outcomes.