Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 10 (2017) xxx–xxx

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Interdisciplinary Neurosurgery: Advanced Techniques andCase Management

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Case Report

A new case of Giant Cell ‘Reparative’ Granuloma of the temporal bonerelated to trauma

Adinda De Pauw a,⁎, Sophie Lunskens a, Bob D'haen e, An Vonck b, Romaric Croes c,Kevin Wetzels c, Bart Vanzieleghem d

a Department of Neurology, AZ Sint Blasius, Dendermonde, Belgiumb Department of Internal Medicine, AZ Sint Blasius, Dendermonde, Belgiumc Department of Anatomopathology, AZ Sint Blasius, Dendermonde, Belgiumd Department of Radiology, AZ Sint Blasius, Dendermonde, Belgiume Department of Neurosurgery, AZ Sint Blasius, Dendermonde, Belgium

⁎ Corresponding author.E-mail address: adinda.depauw@azsintblasius.be (A. D

Please cite this article as: A. De Pauw, et al., Aplinary Neurosurgery: Advanced Techniques

http://dx.doi.org/10.1016/j.inat.2017.07.0062214-7519/© 2017 The Authors. Published by Elsevier B.V

a b s t r a c t

a r t i c l e i n f o

Article history:Received 14 February 2017Revised 28 June 2017Accepted 9 July 2017Available online xxxx

Giant Cell Reparative Granuloma (GCRG) is an uncommon benign non-neoplastic lesion that most commonlyaffects the mandible and maxilla.Only sporadic cases involving the skull base have been reported.The etiology of GCRG is uncertain but may be related to trauma.The origin of ‘reparative’ in the name comes from these lesions appearing after bone trauma.We present a new case of GCRG in the temporal bone of possible posttraumatic origin.To distinguish this type of lesions from true giant cell tumours of bone, from brown tumours, from inflammatorylesions or metastatic lesions, histologic examination is required.The true giant cell tumours of bone are themost important to diagnose as these are generally considered to havea prognosis that is worse than GCRG and require adjunctive radiotherapy in addition to surgical excision.© 2017 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords:GCRGGiant Cell Reparative GranulomaTraumaTrue giant cell tumour of boneHistology

1. Introduction

Jaffe describedGiant Cell Reparative Granuloma (GCRG)first in 1953[1].

The first case of GCRG in the temporal bonewas reported in 1974 byHirschl and Katz [2].

Although GCRG is considered a benign lesion of bone, it is locallyaggressive and requires surgical excision. If resection of GCRG isincomplete, post-operative radiotherapy can be given.

Our case represents a new finding of a GCRG of posttraumatic origin.

2. Case report

In 2010, a 26-year-old man was hospitalised with a craniocerebraltrauma due to impact on the right side of his skull.

This resulted in a commotio cerebri and a fracture of the zygomaticarch (Fig. 1).

No therapy for the zygoma fracture was needed.In 2013, he returned because of a painless swelling in the right

preauricular region and fullness in that ear.

e Pauw). Fig. 1. 2010: zygomatic arch fracture.

new case of Giant Cell ‘Reparative’ Granuloma of the temporal bone related to trauma, Interdisci-and Case Management (2017), http://dx.doi.org/10.1016/j.inat.2017.07.006

. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Fig. 2. In 2013 axial and coronal reconstructed contrast enhanced CT scan (A, B), 3D volume rendering (C) and axial unenhanced (D) and contrast enhanced T1-weighted MR images (E)revealed a lobulated contrast enhancing mass in the temporal fossa with bony destruction of the temporal bone, anterior petrous bone and the roof of the mandibular fossa. Axial T2-weighted image (F) shows a heterogeneous hypo-intense mass penetrating the temporal bone. The hypo-intense signals on T2 may reflect the iron load of the lesion. Iron causes fieldmagnetic field inhomogeneities with signal loss (T2*decay).

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Visual inspection of the right eardrum was impossible because theswelling blocked his right meatus.

2.1. Radiologic findings (Fig. 2)

CT showed an enhancingmass in the right temporal fossa, with lyticaspect of the temporal bone, intracranial extensions and erosion of theanterior part of the os petrosum.

Magnetic Resonance Imaging (MRI) demonstrated an anterior tem-poral fossa extradural mass that was encapsulated and multilobularwith hypo-intense signal on T2-weighted imaging. No cystic changes

Please cite this article as: A. De Pauw, et al., A new case of Giant Cell ‘Repaplinary Neurosurgery: Advanced Techniques and Case Management (201

were present. On T1-weighted imaging the lesion is hypo-intense,with homogenous enhancement, and expansion in the adjacent softtissue.

The mass was completely resected with preserved hearing. Noadjuvant treatment was given.

Follow-up MRI in 2016 showed no signs of relapse.

2.2. Pathological findings (Fig. 3)

Histology revealed a nodular cellular lesion composed of numerousgiant cells mixed up with non-atypical spindle shaped mononuclear

rative’ Granuloma of the temporal bone related to trauma, Interdisci-7), http://dx.doi.org/10.1016/j.inat.2017.07.006

Fig. 3. (A) H&E staining, ×16 shows the lesion on the right side, well delineated from fibrous stroma and striated muscle on the left. The tumour contains abundant brown pigment. (B)H&E staining, ×50 shows a cellular lesion. Scattered multinucleated giant cells can be appreciated. (C) H&E staining, ×200: numerous giant cell with variable size are seen. (D) H&Estaining, ×400 demonstrates the cellular detail and presence of iron pigment in the tumour cells. (For interpretation of the references to colour in this figure legend, the reader isreferred to the web version of this article.)

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cells and numerous iron-loaded macrophages (siderophages). Therewere no mitotic figures and no nuclear atypia.

The cells revealed diffuse and strong immunoreactivity for CD68 andp16, confirming monocytic–histocytic origin differentiation.

The differential diagnosis with a true giant cell tumourwas retained.The absence of any tendency to regular distribution of the giant cells ofuniformity among stromal cells are arguments that favour pro a giantcell reparative granuloma. In giant cell reparative granulomas, the stro-mal-cell nuclei also tend to be more elongated with tapered ends thanin true giant cell tumours [3].

The complete morphologic and immunohistochemical findings andthe clinical presentation favoured pro the histiologic diagnosis of a reac-tive, reparative process than pro a true osseous neoplasm as a giant celltumour is.

3. Discussion

The GCRGswere described by Jaffe [1] as benign processes limited tothemandible of maxilla andmay be related to trauma and intraosseoushaemorrhage.

The GCRGs have since been reported to occur in other bones [4,5].The pathogenesis of GCRG is controversial.Since the first GCRG of the temporal bone was published in 1974,

several others have been mentioned.No other cases of GCRG in the temporal bone have been reported in

Belgium since.In most cases, the patients are less than 35 years old. The most com-

mon presenting symptoms are hearing loss, amass, pain, facial paralysisand tinnitus. These symptoms were also present in our patient.

Differential diagnosis of GCRGs includes other giant cell lesions, suchas true giant cell tumours of bone, brown tumours of hyperparathyroid-ism, enchondromas or chronic inflammatory processes.

Please cite this article as: A. De Pauw, et al., A new case of Giant Cell ‘Repaplinary Neurosurgery: Advanced Techniques and Case Management (201

Because of their more aggressive behaviour, the most important le-sions to distinguish from GCRGs are true giant cell tumours of bone.Compared to giant cell tumours GCRGs more often have foci of osteoid,haemorrhage, hemosiderin or fibrosis.

The trauma in 2010, with zygomatic arch fracture and histologicexamination with numerous iron-overloaded macrophages supportthe reparative character of the lesion.

The absence of relapse after resection only supports the benignorigin of this tumour.

4. Conclusion

This case illustrates again that GCRGs can have a posttraumaticorigin.

GCRG is an important diagnosis to consider in patients with a post-traumatic bone lesion especially in unusual areas.

Conflicts of interest

There are no conflicts of interest.

References

[1] H.L. Jaffe, Giant-cell reparative granuloma, traumatic bone cyst, and fibrous (fibro-os-seous) dysplasia of the jawbones, Oral Surg. 6 (1953) 159–175.

[2] S. Hirschl, A. Katz, Giant cell reparative granuloma outside the jaw bone, Hum. Pathol.5 (1974) 171–181.

[3] M. Wich, M. Mc Dermott, P. Swanson, Proliferative, reparative, and reactive benignbone lesionds that may be confused diagnostically with true osseous neoplasms,Semin. Diagn. Pathol. 31 (2014) 66–88.

[4] G.S. Govett, R.G. Amedee, Giant cell reparative granuloma presenting as a midlinenasal mass, Ear Nose Throat J. 70 (1991) 137–139.

[5] G.V. Mercado, C.L. Shields, K. Gunduz, J.A. Shields, R.C. Eagle, Giant cell reparativegranuloma of the orbit, Am. J. Ophthalmol. 127 (1999) 485–487.

rative’ Granuloma of the temporal bone related to trauma, Interdisci-7), http://dx.doi.org/10.1016/j.inat.2017.07.006