1988radiologic features including those seen with ct of central gial cell granuloma.pdf
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Radiologic features, including those seen
with computed tomography, of central
giant cell granuloma of the jaws
Mark A. Cohen, BSc., M.Dent., F.F.D.(S.A.),* and Yancu Hertzanu, M.D.,**
Johannesburg, South Africa
UNIVERSITY OF THE WITWATERSRAND
The radiologic features of 16 cases of central giant cell granuloma of the jaws were studied. Three cases,
two involving the maxilla and one involving an extensive lesion in the mand ible, were further investigated
with the use of computed tomography. In the mandib le, the radiolog ic features varied from ill-defined
destructive lesions to a well-defined, multilocular appearance. One of the most consistent features found
was splaying of the roots of teeth adjacen t to the lesion . The features as seen with computed tomography
are reported in detail and are of benefit in the surgic al managem ent of maxillary lesio ns and large
mandibular lesions.
(CAL SURC
ORAL MED ORAL
PATHOL
1988;65:255-61)
T he central giant cell granuloma (CGCG) of the
jaws is a relatively uncommon pathologic process,
accounting for less than 7 of all benign jaw lesions.’
The lesion was considered by Jaffe2 to be a local
reparative reaction of bone, possibly to intramedulla-
ry hemorrhage or trauma. Hence, the term
repara-
tive giant cell granuloma was at one time widely
accepted. The word reparative has subsequently been
deleted since the lesion represents essentially a
destructive process.
Clinically, the CGCG usually occurs in patients
under the age of 30 years, occurs more often in
females than in males, and is more common in the
mandible than in the maxilla. In most series, the
lesion has been reported as being confined to the
tooth-bearing areas of the jaws.3s4
The radiologic appearance of the CGCG is vari-
able (Figs. 1,2, and 3). Usually the lesion appears as
a unilocular or multilocular radiolucency; it may be
well defined or ill defined and shows variable expan-
sion and destruction of the cortical plates. The
radiologic appearance of the lesion is not pathogno-
*Formerly, Division of Maxillofacial and Oral Surgery, Depart-
ment of Surgery, and Department of Oral Pathology, University
of the Witwatersrand. Presently, Division of Oral and Maxillofa-
cial Surgery, College of Dentistry, University of Saskatchewan,
Saskatoon, Saskatchewan, Canada.
**Formerly Department of Diagnostic Radiology, University of
the Witwatersrand; presently, Department of Diagnostic Radiolo-
gy, Soroka Medical Centre, Beersheba, Israel.
Fig. 1.
Central giant cell granulomawith multiloculated
“soap bubble” appearance.
manic and may be confused with that of many other
lesions of jaws.5*6 Because of the well-documented
varying radiologic appearance of the lesion, an
attempt was made in a series of 16 cases to charac-
terize any of the distinctive radiologic features of the
CGCG. In addition, three CGCGs in the series were
examined with computed tomography (CT), and the
value of this modality in diagnosis and treatment is
discussed.
PATIENTS AND METHODS
The radiographs and clinical details of 16 cases of
CGCG of the jaws were obtained from the files of the
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256
Cohen and Hertzanu
Oral Surg
February 1988
Fig. 2. Radiographof central giant cell granulomawith
unilocular adiolucentappearance ndsplayingof rootsof
adjacent eeth.
Fig. 3. Occlusal radiograph of ill-defined mandibular
lesionwith buccal expansion nd loculation.
Departments of Oral Pathology and Maxillofacial
and Oral Surgery at the University of the Witwaters-
rand. CT had been used with three of the patients.
The clinical features noted were age, gender, race,
site and extent of the lesion. Features noted on the
radiographs included the definition of the radiolu-
cency, whether the margin was corticated, and the
effect of the lesion on the roots of the teeth, i.e.,
displacement and resorption. Unilocularity and mul-
tilocularity of the lesions were also noted.
RESULTS
The ages of the patients ranged from 7 to 63 years,
with the majority of patients (seven) in the second
decade. There were seven male and nine female
patients with a white-to-black ratio of 9:7. The size
Fig.
4. Site distribution and extent of 16cases f central
giant cell granulomas f jaws.
of the lesions varied from those of less than 1 cm to
large lesions occupying an entire hemimandible.
Only three lesions were present in the maxilla. The
site distribution and the extent of lesions are shown
in Fig. 4.
RA434OL004C FEATURES
All cases of CGCG appeared as radiolucencies,
50 of which were multilocular. The remaining
cases had a unilocular appearance. The majority of
lesions (nine) were well defined, while seven
appeared as ill-defined radiolucencies. Eleven lesions
showed cortication of bone at the periphery of the
lesion, while eight lesions (50 ) had scalloped mar-
gins. Displacement and divergence of the apices of
the roots were present in ten cases, and root resorp-
tion was seen in three cases. In two of the cases, the
patients were edentulous. The radiologic features are
summarized in Table I. The features of the lesions as
seen on CT are described in the individual case
reports.
CASE REPORTS
CASE 1
A 13-year-old white boy was referred becauseof a
slow-growing, amlessmassn the left maxilla. It was irst
noticed by his parents 1 year previously and had been
steadily increasing n size. On examination, the patient
exhibited a facial asymmetry that included fifling out of
the left nasolabialold with lifting of the ala of the nose n
that side. The skin wasof normal color and texture, and
motor andsensory erve functionswere ntact. Intraorally,
the lesion had causedmarked palatal expansion,which
extendedacross he midlineand posteriorly to the level of
the molar teeth. There was also mild expansion nto the
buccal sulcusover the left incisor and canine teeth, The
masswas irm and rubbery, with no evidenceof fluctua-
tion. The mucosa verlying the lesionwasnormal.
A panoramic adiograph Fig. 5) showed n ill-defined
radiolucent lesion of the right maxilla. A degree of
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Radiolog’c features of CGCG of jaws
257
Table
I. Radiologic features of 16 cases of central
giant cell granuloma of the jaws
Fe&we No. of cases
Multilocularity
8 50
Unilocularity 8
50
Scalloped margin
8 50
Smooth margin
8 50
Well defined
9 56
Poorly defined I 44
Divergence of roots 10 71
Root resorption
3 21
splaying of the roots of the lateral incisorand canine eeth
wasvisible.A tomogram Fig. 6) showed massnvolving
the left maxilla and extending nto the nasal ossa. xial
and coronalCT Fig. 7) showed well-definedmasswith a
corticated margin. Calcified trabeculae were present
throughout the lesion.The massoccupied he horizontal
plate of the palatine bonewith someexpansion nto the
maxillary sinus and the nasal fossa. The differential
diagnosisncludedbenign ibro-osseousesionand CGCG.
Biochemicalanalysisncludedserumalkalinephosphatase
and serum calcium levels, both of which were within
normal imits. An incisionalbiopsy wasperformed,and a
histopathologicdiagnosisof CGCG was returned. With
the patient undergeneralanesthesia,he lesionwasenucle-
ated. Recoverywasuneventful, with no signof recurrence
after 4 yearsof follow-up.
CASE 2
A 62-year-oldblack womanwas eferred for the nvesti-
gation and management f a large tumor of the right side
of the mandible. The patient had a 4-year history of a
slow-growing,nontender massof the right side of her
face.
Her main reason or seeking elpwas hat the masswas
interfering with mastication.On examination,an obvious
swellingof the right sideof the mandibleextending rom
just below he zygomatic arch to the inferior borderof the
mandible was present.The skin over the lesion was of
normal color and texture, and motor and sensorynerve
functionswere ntact. The patient experiencedmild limita-
tion of mandibular opening. Intraoral examination
revealed a large mass,which occupied the entire right
mandibular buccal sulcusand which extended over the
mandibularalveolus o the lingual side.The masswas irm
and nontender and exhibited areasof ulceration on its
surface.All mandibular eeth posterior o the right canine
had beenpreviouslyextracted.
A panoramic radiograph Fig. 8) showeda relatively
ill-defined,destructive esionof the right mandible,which
extended rom the area of the right canine o the neck of
the mandibularcondyle. An incisionalbiospyof the mass
returned a diagnosisof CGCG of the jaw. Biochemical
investigation excluded hyperparathyroidism. Computed
axial and coronal tomograms Fig. 9) showeda large,
Fig. 5. Panoramic radiograph showing an ill-defined
radiolucencyof the left maxilla arrows).
Fig. 6. Case1. Tomographiccut demonstrating alatal
expansion nd extensionof the massnto the nasal ossa.
soft-tissuemasson the buccal and lingual sidesof the
mandible. Extension of the mass nto the floor of the
mouth and displacement f the tonguewere clearly seen.
Destructionof the buccaland ingual cortical platesof the
mandibleby the masswas evident. The condylar process
wasessentially ninvolvedby the lesion.With the patient
undergeneralanesthesia,he lesionwas esectedrom the
midline of the mandible to the condylar process.The
mandibular ragmentswere splintedby means f a previ-
ously constructedwire splint. The patient’s recovery was
uneventful,andshewasdischarged ith an appointment o
return 4 weeks ater for bonegrafting. She failed to return
and hassincebeen ost to follow-up.
CASE 3
A
lo-year-old black girl was referred becauseof a
painless, ony hard swellingof the right maxilla. It was
first noticed by her parents4 monthsbefore he consulta-
tion and since then had slowly increased n size. The
swellingextended rom just below the right infraorbital
margin o the nasolabialold area,which was illed out and
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258 Cohen and Hertzanu
Oral Surg
February 1988
Fig. 7. Case1. Coronal top) and axial (bottom) CT scans. he lesion s well corticated with extensionnto
the palatine boneand nasal ossa.Bony trabeculaeare clearly seenwithin the lesion.
Fig.
8. Case 2. Panoramic radiograph showing a
destructive esionof the left sideof the mandiblewith a
large soft tissueshadow.
obliteratedby the mass. light lifting of the right ala of the
nosewas evident. The overlying skin was mobile and of
normal color and texture. All motor and sensorynerve
functionswere ntact. There wasno extensionof the mass
into the nasalvestibule.
Intraoral examination revealed a relatively healthy
mouth with teeth in the mixed-deniition phase. t was
noteworthy that the right maxillary first premolar had
eruptedadjacent o the lateral incisor ooth. There wasno
signof the cuspid ooth in the mouth. This was n contrast
to the left side, where the deciduouscuspid was still
present.A well-defined,bony hard mass xtendedbuccally
from the midline o the right maxillary first molarareaand
obliterated the buccal sulcus.The mucosaoverlying the
masswasof normalcolor and texture. Palatal swellingwas
not evident. The panoramic radiograph showedan ill-
defined radiolucencyof the right maxilla extending from
the lateral ncisor o the second eciduousmolar ooth. The
unerupted uspid ooth on that sidewasdisplacedmedially
toward the midline. An intraoral occlusal radiograph
showed n ll-defined esionof the right maxilla adjacent o
an uneruptedcuspid ooth Fig. 10). Definite splayingof
the rootsof the lateral incisor ooth and first premolarwas
evident. An incisionalbiopsyspecimen howed he typical
histologic featuresof CGCG. Biochemical nvestigations
were all within normal imits. Axial and coronal CT was
carried out Fig. 10). This showeda trabeculated esion,
which extended rom the right maxillary alveolus nto the
maxillary sinus.There wasno associated oft-tissuemass,
although expansion of the buccal cortical plate was
marked.
With the patient under general anesthesia,he lesion
enucleatedeasily with the useof a buccal approach.The
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Radiologic features of CGCG of jaws
259
Fig. 9.
Case
bucally and in
tissue mass
Fig. 10. Case3. Intraoral occlusal adiograph top right) showingan ill-defined oculated esionof the
maxilla with splayingof the roots of the second uspidand first premolar eeth. CoronalCT scan top left)
showsextensionof the lesion from the alveolus nto the maxillary sinus.The axial CT scansbottom)
demonstraterabeculation of the lesion,buccal expansion, nd extension nto the nasal ossa.
impactedcuspid tooth was removed.A nasalantrostomy
Half of the lesions studied had a multilocular
wasperformed,and healingwasuneventful. After 2 years
of follow-up, there has beenno sign of recurrence.
appearance, while half were unilocular. Further-
more, this feature did not depend on the site or extent
DISCUSSION
From the study of 16 cases of CGCG, it is clear
that the radiologic features of the lesion are variable.
of the lesion. One of the most consistent features
found was significant divergence of the roots of teeth
adjacent to the lesion. This occurred in 10 of 14
lesions (two lesions were in edentulous mandibles).
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260 Cohen and Hertzanu
Root resorption however, was, an uncommon feature
(three cases). It has been suggested that two distinct
radiologic appearances of CGCG of the jaws exist.6
One variety appears as a unilocular radiolucency,
while the other type is multilocular with fine trabec-
ulae coursing through the radiolucency. The present
study supports these findings.
The site distributions of the lesions in this series
varied markedly from that of Waldron and Shafer.l
All of their cases occurred in the tooth-bearing areas
of the jaws, and, in fact, fe w were situated in the
molar regions. In the present series, five lesions
(31 ) extended into the ascending ramus of the
mandible, with two lesions involving the condylar
process. This feature has been reported previously
but appears to be rare.‘aE
Four of the lesions in this
report were extensive lesions that involved virtually
an entire hemimandible.
The literature appears to be confused with respect
to the terminology and exact nature of the central
giant cell lesion of the jaws. Although the term
granuloma is still widely used to describe the lesion,
others have recognized its neoplastic potential and
refer to the lesion as giant cell “tumor.“9 Indeed, it
has been extensively shown that the lesion is destruc-
tive, rather than reparative. Confusion arises as the
term tumor equates the lesion in the jaws with the
giant cell tumor of long bones. The long bone lesion
has a propensity for recurrence after conservative
management and often displays malignant behavior
with metastasis. However, metastasis from jaw
lesions is extremely rare,” although recurrence after
curettage has been reported.8, ‘I* I2 Attempts to distin-
guish the jaw lesion from the long bone lesion
histologically have met with some success. Signifi-
cant differences in the size and the number of the
nuclei of the giant cells between jaw lesions and long
bone lesions have been described.13 With the use of
stereologic techniques, differences in nuclear numer-
ical density and absolute cell volumes have also been
reported. I4 These features, however, remain incon-
clusive for the prediction of behavior. Shklar and
Meyer9 have presented a series of cases with the
features of a neoplasm and suggest that these lesions
be referred to as giant cell tumors. Their observa-
tions are based on radiologic and histologic criteria,
as well as the clinical behavior of the lesion. On this
basis, the authors dispute earlier2 theories that the
giant cell tumor is extremely rare in the jaws, but
they conclude that until larger series of lesions have
been studied, the distinction between tumor and
granuloma remains unclear.
CT is now a well-established technique used for
examining lesions of the head and neck, particularly
Oral Surg
February 1988
malignant tumors. Only recently, however, have the
advantages of CT over conventional radiography
been demonstrated in the diagnosis of benign lesions
of the jaws.15.17
CT is superior to conventional
radiography in that it clearly demonstrates the
soft-tissue mass of a lesion, extension into adjacent
structures, and bony destruction. This is clearly
shown by cases 1 and 3 in this article. In case 1, the
lesion was poorly defined on conventional radio-
graphs; however, extension of the lesion to the
palatine bone and into the nasal fossa was clearly
seen on CT. Furthermore, trabeculations running
through the lesion were visualized. Similarly, in case
3, extension of the mass into the maxillary sinus and
expansion of the buccal cortical plate of the maxilla
were superiorly visualized in both the axial and
coronal planes. Case 2 is an example of an extensive,
destructive tumor, the extent of which was poorly
visualized on plane mandibular radiographs. CT
clearly demonstrated the soft-tissue mass with exten-
sion into the floor of the mouth and buccal areas.
Furthermore, preservation of the condylar process is
evident on the coronal scan, an important feature in
surgical management. Two fairly recent publica-
tions’8.‘9 have mentioned the CT features of several
giant cell lesions of the maxilla; however, the present
article probably constitutes the first detailed descrip-
tion in the literature of the CT features of CGCG of
the jaws.
Although simple curettage is effective treatment
for the majority of CGCGs of the jaws, extensive
lesions such as that demonstrated in case 2 must be
treated by resection. In these cases, as well as in
maxillary lesions in which the tumor mass may lie
adjacent to several important structures, CT is
invaluable to surgical planning and management.
Weare grateful to Dr H. Kola for permission to use case
2 in this article.
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Hertzanu Y, Cohen M, Mendelsohn DB. Nasopalatine duct
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Reprint requests to:
Dr Mark A. Cohen
College of Dentis try
University of Saskatchewan
Saskatoon
Sask
S7N OWO
Canada