Figure 1
Mandible X-ray
Giant cell reparative granuloma of the jaw
SectionHead & neck imaging
Case TypeClinical 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
Connected authors
57 years, female
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).
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].
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
References
[1] Scholl RJ, Kellett HM, Neumann DP, Lurie AG (1999) Cysts and cystic lesions of the mandible: clinical and radiologic-histopathologic review. Radiographics 19:1107-1124 (PMID: 10489168)
[2] Dunfee BL, Sakai O, Pistey R, Gohel A (2006) Radiologic and pathologic characteristics of benign and malignant lesions of the mandible. Radiographics 26: 1751-1768 (PMID: 17102048)
[3] Murphey MD, Nomikos GC, Flemming DJ, Gannon FH, Temple HT, Kransdorf MJ (2001) Imaging of giant cell tumor and giant cell reparative granuloma of bone: radiologic-pathologic correlation. Radiographics 21: 1283-1309 (PMID: 11553835)
[4] Guimaraes AL, Marques-Silva L, Gomes CC, Castro WH, Mesquita RA, Gomez RS (2006) Peripheral brown tumour of hyperparathyroidism in the oral cavity. Oral Oncology 42:91-93
[5] Flaitz CM (2000) Peripheral giant cell granuloma: a potentially agressive lesion in children. Pediatric dentistry 22:232-233
[6] Ozcan C, Apaydin FD, Gorur K, Apa DD (2005) Peripheral giant cell granuloma of the mandibular condyle presenting as a preauricular mass. Eur Arch Otorhinolaryngology 262:178-81 (PMID: 15133683)
[7] Bayar MA, Erdem Y, Gokcek C, Koktekir E, Kilic C, Yasitli U, Tekiner A (2009) Giant cell reparative granuloma of the axis. Turkish Neurosurgery 19:423-7 (PMID: 19847766)
[8] Jaffe HL (1953) Giant-cell reparative granuloma, traumatic bone cyst and fibrous dysplasia of the jawbones. Oral Surg Oral Med Oral Pathol 6:159–75 (PMID: 13026160)
Case information
| URL: | https://www.eurorad.org/case/9357 |
| DOI: | 10.1594/EURORAD/CASE.9357 |
| ISSN: | 1563-4086 |
Figure 2
Ultrasound
Heterogeneous soft-tissue lesion, with some calcifications and well defined lobulated contour.
Figure 4
CE-CT (soft-tissue window)
Axial view of the soft tissue mass.
It is a rather homogeneously enhancing mass with well defined limits, growing outside the bone.
Axial image 20 mm above Fig 4a where the mass reaches its maximum length. Notice the way it displaces the tongue but does not invade any of the nearby structures suggesting a benign behaviour.
Figure 5
Histologic samples
Ultrasound
Heterogeneous soft-tissue lesion, with some calcifications and well defined lobulated contour.
CE-CT (soft-tissue window)
Axial view of the soft tissue mass.
It is a rather homogeneously enhancing mass with well defined limits, growing outside the bone.
Axial image 20 mm above Fig 4a where the mass reaches its maximum length. Notice the way it displaces the tongue but does not invade any of the nearby structures suggesting a benign behaviour.
