1988radiologic features including those seen with ct of central gial cell granuloma.pdf

8/18/2019 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

255


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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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Volume 65

Number 2

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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Volume 65

Number 2

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.

REFERENCES

1.

2.

3.

4.

5.

6.

I.

8.

Austin Jr LT. Dahlin DC, Royer RQ. Giant cell reparative

granuloma and related conditions affect ing the jawbones.

ORAL SURGORAL MED ORAL PATHOL 1959;12:1285-95.

Jaffe HL. Giant cell reparative granuloma, traumatic bone

cyst, and fibrous (fibro-osseus) dysplasia of the jawbones.

ORAL SURGORAL MED ORAL PATHOL 1953;6:159-75.

Waldron CA, Shafer WC. The central giant cell reparative

granuloma of the jaws. Am J Clin Path01 1966;45:437-47.

Lucas RB. Pathology of tumors of the oral tissues. 4th ed.

London: Churchill Livingstone, 1984:262.

Shafer WC. Hine MK. Lev v BM. A textbook of oral

pathology. 4th ed. Philadelphja: WB Saunders Company,

1983:146.

Stafne EC, Gibilisco JA. Oral roentgenographic diagnosis.

4th ed. Philadelphia: W.B. Saunders Company, 1975:200.

Shensa DR, Nasseri S. Central giant cell granuloma of the

mandibular condyle. J Oral Surg 1978;36:642-3.

Tasanen A, Konow L, Nordling S. Central giant-cell lesion in


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the mandibular condyle. Report of a case. ORAL SURC ORAL

MED ORAL PATHOL 1978;45:532-9.

9. Sbklar G, Meyer I. Giant-cell tumors of the mandible and

maxilla. ORAL SURC ORAL MED ORAL PATHOL 1961;14:809-

21.

10. Mintz GA, Abrams AM, Carlsen CD, Melrose RJ, Fister

HW. Primarv malignant giant cell tumor of mandible.

ORAL

SURG ORAL T&D ORAL P~HOL 1981;51:164-71.

11. Guralinick WC, Donoff RB. Central giant cell granuloma. Br

J Oral Surg 1972;9:200-7.

12. Davis GB, Tideman H. Multiple recurrent central giant cell

granulomas of the jaws. Case report. J Maxillofac Surg

1977;5:12?-9.

13. Abrams B, Shear M. A histological comparison of the giant

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giant cell tumor of long bone. J Oral Path01 1974;3:217-23.

14. Franklin CD, Craig GT, Smith CJ. Quantitative analysis of

histologic parameters in giant cell lesions of the jaws and long

bones. Histopathology 1979;3:51 l-22.

15. Mendelsohn DB, Hertzanu Y, Cohen M, Lello G. Computed

tomography of craniofacial fibrous dysplasia. J CAT 1984;

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Hertzanu Y, Cohen M, Mendelsohn DB. Nasopalatine duct

cyst. Clin Radio1 1985;36:153-8.

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Reprint requests to:

Dr Mark A. Cohen

College of Dentis try

University of Saskatchewan

Saskatoon

Sask

S7N OWO

Canada

1988radiologic features including those seen with ct of central gial cell granuloma.pdf

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