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Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 677-678
Giant cell reparative granuloma of the jaw: A case report


Department of Radiodiagnosis & Imaging, B. J. Medical College, Civil Hospital, Ahmedabad, India

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Date of Submission11-Jul-2006
Date of Acceptance10-Oct-2006
 

Keywords: Giant cell reparative granuloma, Jaw, Lytic, Expansile

How to cite this article:
Shah U A, Shah A K, Kumar S. Giant cell reparative granuloma of the jaw: A case report. Indian J Radiol Imaging 2006;16:677-8

How to cite this URL:
Shah U A, Shah A K, Kumar S. Giant cell reparative granuloma of the jaw: A case report. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Feb 18];16:677-8. Available from: http://www.ijri.org/text.asp?2006/16/4/677/32297
Giant Cell Reparative Granuloma (GCRG) was introduced by Jaffe in 1953 [1] to describe an apparently reactive intraosseous lesion of the mandible and maxilla following trauma induced intraosseous hemorrhage and containing prominent giant cells. It is a disease of the young presenting as a painless swelling in the anterior jaw and radiographically appearing as a lytic expansile lesion with a characteristic tendency of resorbing the root tips of adjacent unerupted teeth [2]. It is also known as Central Giant Cell Granuloma [2].


   Case history Top


A 6 yr old female child presented with painless swelling affecting on right side of jaw insidiously growing over the period of last 6-7 months. On examination, the lesion was firm and nontender. She did not have any systemic complains and routine laboratory investigations were normal.

Orthopantomogram [Figure - 1] and plain oblique radiograph of mandible [Figure - 2] revealed a well defined, lytic, expansile lesion in right paramedian aspect of the body of mandible with resorption of root of adjacent teeth. There was no e/o sclerosis or internal calcification and matrix appeared clear. On histopathological examination connective tissue stroma composed of proliferating plump fibroblasts with small capillaries was seen. Osteoclasts like cells were seen amidst the stroma with haemosiderin laden macrophages and areas of hemorrhage and small foci of osteoid, thus diagnosing a giant cell reparative granuloma.


   Discussion Top


GCRG is a rare, benign, non-neoplastic lesion with a granulomatous appearance peculiarly affecting mandible and maxilla [1]. They generally occur in patients in the 2nd and 3rd decades of life. Although reported age ranges from infancy to 7th decade, 74% of patients are under 30 years of age at presentation [3].

Cases have been reported in other parts of body including small bones of hands and feet, sinuses, temporal bone, skull, spine, clavicle, tibia, humerus, ribs, and femur [4]. Commonest site is anterior part of mandible (2/3 rd of cases) between the 2nd premolar and 2nd molar with extension across the midline [5]. Small bones of hands and feet are the 2nd most common site for involvement. In gnathic lesions, females are affected more frequently (2:1 ratio) than males [3]. Marked growth of the lesion associated with pregnancy has been described, presumably related to hormonal stimulation [6]. Outside the jaw no sex predilection is noted [4]. Two forms of GCRG are described [4], central arising from bone and peripheral arising from the soft tissue of maxilla and mandible, involving gingiva and alveolar mucosa. Peripheral type is four times common than central type and rarely involves the underlying bone and is seen in middle aged and elderly patients.

Multiple lesions are rare but have been reported [4]. GCRG has also been described in association with enchondromatosis, Goltz syndrome, fibrous dysplasia, and Paget disease [4].

It is said that GCRG occurs in the period when the deciduous teeth are being shed. One theory suggested that it is an exaggeration of the normal resorption process that occurs around deciduous teeth. Pathogenesis includes theories of hyperplasic reparative reaction to intraosseous hemorrhage induced by trauma as well as infections and developmental causes.

Radiologically, GCRG appears as non specific lytic, expansile multiloculated lesions which due to slow growth cause thinning and scalloping of the cortex which however is rarely breached [1],[2],[3],[4],[5]. Periosteal reaction is not usually seen. Sometimes aggressive lesions may present with bone destruction. It has a tendency of resorbing the root tips of adjacent unerupted teeth [2]. Sometimes unilocular lesions without trabeculations may occur [5]. Some lesions especially those in the antral region may show ground glass appearance also [5].

Long bone GCRG [4] appear as 2 -2.5 cm diameter, lytic expansile, trabeculated lesions which are metaphyseal with or without diaphyseal extension. No extension into the unfused epiphysis has been recorded.

CT is excellent for demonstration of bony thinning or destruction. The lesion attenuation is similar to muscle [4].

MRI is the best modality of evaluating extent of the lesion as well as evaluating adjacent soft tissue. It has low to intermediate intensity signals on both T1W & T2W images [4] similar to GCT. Mild post contrast enhancement is evident both on CT & MRI.

Brown tumor of Hyperparathyroidism, Chondroblastoma, Fibrous Dysplasia, Odontogenic cyst, Aneurysmal bone cyst, Ameloblastoma, Odontogenic myxoma, and Odontogenic fibroma [4].

Amongst all, Giant cell tumor is most difficult to differentiate from GCRG without clinical and histological aids. GCRG generally occurs at younger age than Giant cell tumor. Histologically, GCRG has a hemorrhagic background with presence of plump bland fibroblast, haemosiderin and fewer giant cells with smaller number of nuclei which are less uniformly distributed [4]. While in case of GCT giant cells are uniformly scattered with larger number of nuclei and absence of fibroblasts and hemorrhage [4]. Diffuse sheets of large giant cells and polygonal mononuclear cells seen in GCT are lacking in GCRG. Deposition of osteoid is observed in GCRG sometimes which is lacking in GCT [4]. Cystic areas (the ABC component) are lesser as compared to GCT [4]. Differential diagnosis from Brown tumor is based mainly on clinical and laboratory data as well as age of onset and multiplicity of lesions [4].

Treatment consists of curettage or local excision. Recurrence rate of 22%-50% is reported, although lesion eradication typically does not require more than two excisions [4]. Chemical cautery, electrocautery, cryotherapy have all been used and newer therapies like Calcitonin, Interferon alpha and intralesional steroids are being used for more aggressive and recurrent lesions [5].

 
   References Top

1.Jaffe HL. Giant-cell reparative granuloma, traumatic bone cyst, and fibrous (fibroosseous) dysplasia of the jaw bones. Oral Surg 1953; 6:159-175.  Back to cited text no. 1    
2.Angelo M DelBalso. An approach to the diagnostic imaging of jaw lesions, dental implants, and the temporomandibular joint. RCNA. 1998; Vol 36 (5):865.  Back to cited text no. 2    
3.Waldron CA, Shafer WG. The central giant cell reparative granuloma of the jaws. Am J Clin Pathol 1966; 45:437-447.  Back to cited text no. 3    
4.Mark D. Murphey, George C. Nomikos, Donald J. Flemming et al. Imaging of Giant Cell Tumor and Giant Cell Reparative Granuloma of Bone: Radiologic-Pathologic Correlation. Radiographics. 2001; 21:1283-1309.   Back to cited text no. 4    
5.Peter M Som, Hugh D Curtin. Jaw: Cysts, Tumours and Nontumourous lesions. In: Peter M Som, Hugh D Curtin. Head & Neck Imaging, Vol -I, 4th edition, Mosby, 2003: 961-962.  Back to cited text no. 5    
6.Fechner RE, Fitz-Hugh GS, Pope TL, Jr. Extraordinary growth of giant cell reparative granuloma during pregnancy. Arch Otolaryngol 1984; 110:116-119.  Back to cited text no. 6    

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Correspondence Address:
U A Shah
#3, Calindi Bungalows, Near Gulab Tower, Near Sola Overbridge, Thaltej, Ahmedabad -380054
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32297

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