Central giant cell granulomaJournal club Presenter: Dr. Shilpa Kokate

Surgical treatment and reconstruction for central giant cell granuloma of thejaws: A review of 18 cases

•P.Tosco , G. Tanteri, C. Iaquinta, M. Fasolis, F. Roccia, S. Berrone, P.Garzino-Demo

•Journal of Cranio-Maxillofacial Surgery (2009) 37, 380- 387

INTRODUCTION

•WHO - CGCG as an intraosseous lesion consisting of cellular fibrous tissue that contains multiple foci of haemorrhage, aggregations of multinucleated giant cells and occasional trabeculae of woven bone

•predominantly in children or young adults ( 75%)

•Females : males = 2:1•Maxilla - anterior region•Mandible - equally distributed anteriorly and

posteriorly•Clinical behavior of CGCG - aggressive or non-

aggressive (Chuong et al., 1986)6 criteria : pain,rate of growthswelling,tooth root resorption cortical perforation recurrences

•Non-surgical treatments - alpha interferon [α-IFN], calcitonin, corticosteroids

•Surgery - traditional treatment and it is still the most accepted one

Aim of this study

•To evaluate recurrences in patients treated with surgery alone

•To compare these preliminary results with those found in the literature regarding medical therapy

MATERIALS AND METHODS• Between 1998 and 2004 - 18 cases of CGCG

were surgically treated under general anaesthesia, at the Department of Oral and Maxillofacial Surgery, University of Turin Hospital, Italy

•Patients who had previously undergone medical therapy & elevated serum calcium, phosphorus and alkaline phosphatase (hyperparathyroidism ) were excluded from the study

•Patients’ data were analysed in terms of age, gender, anatomic location, clinical and radiographic features, type of surgery, reconstruction and follow-up period

RESULTS• Patients- 3 males and 15 females. ages - 7 to 80 years• Location- 12 mandibular lesion, 6 in maxillary lesions No patient had multiple lesions.

• Clinical features- expansion of the buccal plate in both the maxilla and mandible

• partial obliteration of the buccal vestibule

• 4 pt. - pain, tooth mobility, and a rapidly enlarging facial swelling.• 3 pt - Paraesthesia• 3 pt - painful swelling• 1 pt. - perforation of the cortical plate both vestibularly and buccally,

a painful swelling of the face, anaesthesia of the alveolar nerve, tooth mobility, partial obliteration of the buccal vestibule and perforation of the overlying mucosa

Radiographic features

•5 pt.- CGCG in edentulous areas,•13 pt. - teeth involved with the lesions

•Chuong’s criteria- 11 aggressive & 7 non-aggressive cases

Type of treatment• All patients were operated under general anaesthesia• Mandible- 8 pt - through an intraoral approach and en bloc resection

with at least a 5 mm margin• mandibular continuity was conserved• 1 pt.- submental approach and an en bloc resection of the CGCG - at the

mental symphysis. • involved teeth were preserved• 2 pts.- total resection of the bone

• inferior alveolar nerve was preserved.• periosteum was minimally sacrificed.• Immediate reconstruction was carried out for all the above cases with

iliac crest bone graft

• 1 pt - subtotal mandibulectomy• reconstruction with a fibula free flap

•Maxilla – 5 cases – resection beyond 5 mm from the lesion

•reconstruction of the bony gap an autogenous iliac crest bone graft

•1 case - reconstruction was performed with a temporal myofascial flap (TMF).

•Average hospitalization time was 8 days

Follow-up

•followed annually with clinical and radiographic examinations for periods ranging from 2 to 10 years (mean 65 months).

•No recurrences •No pathological fractures occurred.•After 4 months- prosthetic rehabilitation

DISCUSSION• Jaffe - ‘‘giant cell reparative granuloma’’• Shafer et al., 1983; Neville et al., 1995 - destructive rather than

reparative

• Jaffe, 1953; Austin et al., 1959; Chuong et al., 1986 - an inflammatory lesion, a reactive lesion, a true tumour, or an endocrine lesion

• Collins, 2000; Kaban et al., 2002 - mesenchymal proliferative vascular primary jaw lesions

• Vered et al., 2006 - low mean microvascular volume (MVV) of Vascular Endothelial Growth Factor (VEGF)- and Basic Fibroblast Growth Factor (bFGF)-positive blood vessels implies little angiogenic activity, which contradicts the description of CGCG as a true proliferative vascular lesion

Different therapeutical options for CGCG treatment.•Jacoway et al. (1988) were the first to

report on treatment with corticosteroids•MOA - Extracellular production of bone-

resorption-mediating lysosomal proteases by giant cells is inhibited by steroids which also induce apoptosis of the osteoclast-like cells.

•complete resolution in 3 out of 4 patients,

First author No. Administration and dose Effect Follow-up

Terry (1994) 4

Triamcinolone 10 mg/ml and marcain

0.5%, 1:1, 2 ml per 2 cm of the lesion,

once a week for 6 weeks

Complete remission in all patients16— 36

months

Rajeevan (1998) 1

Triamcinolone 10 mg/ml and lidocaine

0.5%, 1:1, 2 ml per 2 cm of the lesion,

once a week for 6 weeks

Complete remission 10 months

Khafif (2000) 1Triamcinolone 40 mg/ml and marcain

0.5%, 1:1, once a week for 6 weeksComplete calcification of the lesion 24 months

Kurtz (2001) 1

Triamcinolone 10 mg/ml and

marcain 0.5%, 1:1, 2 ml per 2 cm

of the lesion, once a week for 6 weeks

Complete remission after two

treatment sessions18 months

Carlos (2002) 4

Triamcinolone 10 mg/ml and

marcain 0.5% , 1:1, 6 ml variable

number of injections (3—20). Additional

surgery in 2 patients

Variable from considerable

regression to complete remission2—7 years

calcitonin therapy

•Immunohistochemical study demonstrated that giant cells in CGCGs- osteoclasts through osteoclast-specific monoclonal antibodies staining

•giant cells in CGCG express calcitonin receptors

•directly inhibit giant cells

First author No.Human

/salmonAdministration and dose Duration Effect Follow-up

Harris (1993) 4 h/sInjection, 100 IU/day/nasal

spray 200 IU/day12—14 months

Complete remission

with additional surgery

in 2 patients

14—72

months

de Lange

(1999)4 h

Injection, 50—100

IU/day/nasal

spray 200 IU/day

12—15 months Complete remission 7—36 months

O'Regan (2001) 1 h Injection, 100 IU/day 15 months Partial remission 30 months

Pogrel (2003) 9 s Injection, 100 IU/day19 — 27

monthsComplete remission

26—50

months

Dominguez 3 s Nasal spray, 100 IU/day12 — 19

monthsComplete remission 12 months

Cuadrado

(2004)

Beck-

Mannagetta1 s Nasal spray, 100 IU/day 13 months Complete remission 62 months

(2004)with additional

surgery

de Lange

(2006)14 s Nasal spray, 200 IU/day 12—15 months

No response-partial

remission6 months

Vered (2007) 5 sNasal spray 200—400

IU/day

13 — 14

months

Partial response with

additional surgery

10—24

months

Borges (2008) 4 sSubcutaneous 100 IU/day

and nasal spray 200 IU/day6— 28 months Partial remission ?

α-IFN

• angiogenic potential and as a mediator in differentiation from mesenchymal cells to osteoblasts thus leading to an increase in bone apposition

First author No. Administration and dose Duration Effect Follow-up

Collins

(2000)1 Injection 1 x 106 IU/day 9 months Complete remission > 3 months

Kaban (2002) 8Injection 2.3 x 106—3.106

IU/day6—8.4 months

Complete remission

with curettage

12— 72

months

Busaidy

(2002)5 ? 2 months Partial remission —

Goldman

(2005)1

Injection 1.51 x 106—9.106

IU/day8 months Partial remission with 4 months

Injection 3 x 106—9.106

IU/day

curettage

de Lange

(2006)2

10—14

monthsPartial remission > 6 months

Kaban (2006) 16 Injection 3 x 106 IU/day >6 months

Partial-complete

remission with

curettage

> 3 months

de Lange

(2008)1 Injection 180 |µg weekly 9 months Partial remission —

Surgery

•traditional treatment•range from large (en bloc resection) to

more conservative approaches (curettage )

First author No.

Aggressive

/non-

aggressive

Treatment Follow-up

Overall

recurrence

rate

Chuong (1986) 17 8/9 Curettage, radiation 24—380 months 41.0%

therapy in 4

patients

Eisenbud (1988) 37 ?Curettage and

resection2—16 years 11.0%

Whitaker (1993) 47 26/21 Curettage Mean 48 months 49.0%

Bataineh (2002) 18 18/18 Resection 1 — 9 years 5.6%

de Lange (2005) 80 16/64 Curettage 0—10 years 26.3%

Kruse-Losler

(2006)26 10/16

Curettage and

resection

9 months to 12

years11.5%

Tosco (2008) 18 11/7 Resection (> 5 mm) Mean 68 months 0%

CONCLUSIONS

•En bloc resection - greatest certainty of a cure

•soft tissues and periosteum are preserved, and only the bony component is excised, then it is possible to reconstruct the surgical defect with autogenous bone grafts.

•prosthetic rehabilitation via implants can be safely performed.

Review of literature

Clinical and radiological features of central giant-cell lesions of the jaw

•J. Lange, and H. P. Akker

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:464-70

•Aim - to evaluate the clinical and radiological features of central giant-cell lesions that were diagnosed in The Netherlands between January 1, 1990, and January 1, 1995.

•Results - 83 patients (89 lesions).•16 – Aggressive , 3 - Multiple lesions •recurrence rate - 26.3%•Conclusion - Surgical curettage is not an

effective therapy for CGCGs in young people who show aggressive signs and symptoms. Calcitonin therapy could prove to be a good presurgical treatment modality.

GIANT CELL GRANULOMA OF THE MAXILLA - CASE REPORT

•U. H. Uzbek, I. Mushtaq

•J Ayub Med Coll Abbottabad 2007; 19(3): 93- 95

The mass involving anteriorpart of maxilla and alveolar ridge

Swelling of the left cheek

multinucleated giant cells and spindle cells which have oval and fusiform nuclei.

Partial maxillectomy-gingival sulcus approach. Entire tumoral mass wasremoved along with portions of invaded bone and corresponding teeth.

The Surgical Treatment of Central Giant Cell Granuloma of the Mandible

•A. B. Bataineh, T. Al-Khateeb, M. A.Rawashdeh

• J Oral Maxillofac Surg 60:756-761, 2002

•Methods – 18 pts. treated between 1991 and 2000, in the Oral and Maxillofacial Surgery Unit at Jordan University of Science and Technology.

• lower border of the mandible and/or posterior border of the ascending ramus, together with the nutrient periosteum attached to it, was preserved.

•All soft tissues in contact with or overlying the lesion and a margin of cancellous bone related to the lesion were excised.

•Results – 18 pts - 9 males and 9 females•5 - incisor-canine region, 2 - premolar

region, 4 - premolar-molar region, 7 - molar-ramus

regionAll pts . Aggressive CGCG lesion - 2.7 to 10 cmRecurrence – 1 pts

•Conclusion: resection without a continuity defect and peripheral osteoctomy is a satisfactory method in the treatment of central giant cell granuloma of the mandible

Recurrent central giant cell granuloma in the mandible: Surgical treatment and dental implant restoration •P. I. Cossío , R. M. Fuentes , A. C.

Carranza, D. T. Lagares , J. L. Pérez

•Med Oral Patol Oral Cir Bucal 2007;12:E229-32.

uniloculated appearance and poorly defined borders of the lesion adjacent to the image of extraction of the left second molar tooth.

curettage of the lesion followed by removal of the peripheral bony margins through a retromolar approach

osteolysis of the mandible with loss of bone in medial cortex.

•lesion was removed en bloc with a bony security margin of 0.5 cm

•autogenous particulated bone harvested from the mandibular ramus of the left side +bioactive glass + 50 cc of venous blood was processed using double centrifugation technique

two years later showing a well-healed and diseased-free mandible.

•Restoration - with a composite bone graft that consisted of autogenous bone, xenograft, and autologous platelet-rich plasma (PRP)

• restoration - implant-supported prosthesis.

Advanced giant cell reparative granuloma of the mandible: radiological featuresand surgical treatment

•E. DE CORSO, M. POLITI , M.R. MARCHESE, T. PIRRONTI, R. RICCI, G. PALUDETTI

•ACTA OTORHINOLARYNGOL ITAL 26, 168-172, 2006

Conclusion

•Considering the high rate of recurrences after

•curettage, En bloc resection provides the greatest certainty of a cure although morbidity is undoubtedly high

Thank you