CASE 9357 Published on 20.09.2011

Giant cell reparative granuloma of the jaw

Section

Head & neck imaging

Case Type

Clinical Cases

Authors

Cabral P1, Fonseca I2, Rosa Santos J3, Vinhais S4

1) Department of Radiology of Hospital Prof. Dr. Fernando Fonseca, Amadora
2) Department of Pathology of Instituto Português de Oncologia Francisco Gentil, Lisboa
3) Department of Head and Neck Surgery of Instituto Português de Oncologia Francisco Gentil, Lisboa
4) Department of Radiology of Instituto Português de Oncologia Francisco Gentil, Lisboa

Patient

57 years, female

Categories
Area of Interest Head and neck ; Technique Ultrasound, CT
Clinical History
A 57-year-old woman was referred to our hospital with a mandibular mass of chronic evolution (more than two years), lately associated with pain, purulent discharge and bleeding.
Imaging Findings
The X-ray showed a lytic lesion on the right side of the body of the mandible (Fig. 1).
Neck ultrasound was also performed depicting the lesion’s soft component as a hypoechoic solid mass of well defined lobulated contours, and internal heterogeneity due to bone involvement (Fig. 2).
Contrast enhanced CT better demonstrated the extension of the lesion and its characteristics. Located from the incisor to the right molar region, it was in continuity with an enhancing soft tissue component, which included a small calcification (Fig. 3). The maximum diameter of the lesion was 30 mm. The adjacent cortex was thin and focal disruption could be observed (Fig. 4a).
A second lytic lesion of smaller size (17mm) was visible in the right maxilla with an intact cortex surrounding it (Fig. 4b).
Discussion
The bone lesions in the jaw and maxilla were biopsied and both corresponded to giant cell reparative granulomas. Complete surgical excision of the jaw mass was then undertaken successfully and the diagnosis was confirmed (Fig. 5).

Giant cell reparative granuloma (GCRG) was first described by Jaffe [8] in 1953 but its aetiology remains unknown, with some controversy as to whether this lesion represents a neoplastic or most probably a reactive process.
Other designations like giant cell granuloma, osteoclastoma, giant cell epulis and myeloid epulis derive from the numerous osteoclast-like multinucleated giant cells admixed throughout the stroma. Immunohistochemistry studies have shown giant cells to be only slightly different from true osteoclasts but their origin is still unknown.

GCRG involving the mandible can be either central (bone origin) or peripheral (gingival soft tissues) and accounts for 1%-7% of all benign oral lesions [3].
Jaw lesions have female predominance (2:1) with a wide age range (20-60 years) being more common in patients younger than 30 (75%) [1]. In 70% of cases occurs in the anterior segment of the jaw, like the premolar, canine and incisor regions. Lesions are usually less than 2 cm, but sometimes may grow as large as 5 cm, and rarely undergo sarcomatous transformation [1, 2].
Multiple lesions such as seen in our case are rare.

The radiologic features of GCRG are nonspecific. Gnathic lesions demonstrate bone expansion and remodelling and have multilocular appearance. The cortex is usually thinned but intact, although more aggressive behaviour has been described. The radiographic appearance is indistinguishable from that of odontogenic cysts, aneurismal bone cysts, ameloblastoma, odontogenic myxoma, odontogenic fibroma and giant cell tumour (GCT).
Though radiologically similar, GCRG and GCT can be distinguished clinically as GCRG mostly affects the mandible, axilla, hands or feet. Histologically, osteoid production along haemorrhagic foci, an unusual feature in GCT, is frequently seen in GCRG whereas cystic degeneration and aneurismal bone cysts components are uncommon. Unlike GCT, mineralisation in GCRG is limited [3].

Two other lesions of the gingiva, pyogenic granuloma and peripheral ossifying fibroma, are clinically identical to the peripheral subtype of giant cell granuloma, with the histological analysis mandatory to establish the diagnosis [5, 6].

The treatment of choice is surgical, with a recurrence rate of 22-50% after a complete excision. In case of recurrence a second complete excision is curative [3].
Differential Diagnosis List
Giant cell reparative granuloma of the mandible
Odontogenic cysts and tumours
Central giant cell tumour
Bone metastasis
Pyogenic granuloma
Peripheral ossifying fibroma
Final Diagnosis
Giant cell reparative granuloma of the mandible
Case information
URL: https://www.eurorad.org/case/9357
DOI: 10.1594/EURORAD/CASE.9357
ISSN: 1563-4086