Document Detail

Peripheral giant cell granuloma.
Jump to Full Text
MedLine Citation:
PMID:  22629051     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Peripheral giant cell granuloma or the so-called "giant cell epulis" is the most common oral giant cell lesion. It normally presents as a soft tissue purplish-red nodule consisting of multinucleated giant cells in a background of mononuclear stromal cells and extravasated red blood cells. This lesion probably does not represent a true neoplasm, but rather may be reactive in nature, believed to be stimulated by local irritation or trauma, but the cause is not certainly known. This article reports a case of peripheral giant cell granuloma arising at the maxillary anterior region in a 22-year-old female patient. The lesion was completely excised to the periosteum level and there is no residual or recurrent swelling or bony defect apparent in the area of biopsy after a follow-up period of 6 months.
Authors:
Padam Narayan Tandon; S K Gupta; Durga Shanker Gupta; Sunit Kumar Jurel; Abhishek Saraswat
Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Contemporary clinical dentistry     Volume:  3     ISSN:  0976-2361     ISO Abbreviation:  Contemp Clin Dent     Publication Date:  2012 Apr 
Date Detail:
Created Date:  2012-05-25     Completed Date:  2012-10-02     Revised Date:  2013-05-29    
Medline Journal Info:
Nlm Unique ID:  101552967     Medline TA:  Contemp Clin Dent     Country:  India    
Other Details:
Languages:  eng     Pagination:  S118-21     Citation Subset:  -    
Affiliation:
Department of Oral and Maxillofacial Surgery, Teerthanker Mahaveer Dental College and Research Centre, Delhi Road, Moradabad, India.
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Descriptor/Qualifier:
Comments/Corrections

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Contemp Clin Dent
Journal ID (iso-abbrev): Contemp Clin Dent
Journal ID (publisher-id): CCD
ISSN: 0976-237X
ISSN: 0976-2361
Publisher: Medknow Publications & Media Pvt Ltd, India
Article Information
Copyright: © Contemporary Clinical Dentistry
open-access:
Print publication date: Month: 4 Year: 2012
Volume: 3 Issue: Suppl1
First Page: S118 Last Page: S121
ID: 3354806
PubMed Id: 22629051
Publisher Id: CCD-3-118
DOI: 10.4103/0976-237X.95121

Peripheral giant cell granuloma
Padam Narayan Tandonaff1
S. K. Gupta1
Durga Shanker Guptaaff1
Sunit Kumar Jurel2
Abhishek Saraswataff1
Department of Oral and Maxillofacial Surgery, Teerthanker Mahaveer Dental College and Research Centre, Delhi Road, Moradabad, India
1Department of Oral and Maxillofacial Surgery, Rama Dental College and Research Centre, Kanpur, Uttar Pradesh, India
2Department of Prosthodontics, Faculty of Dental Sciences, Upgraded KGMC, Lucknow, India
Correspondence: Correspondence: Dr. P. N. Tandon, Department of Oral and Maxillofacial Surgery, No. 1 Madhubani Duplex Kaanth Road, Moradabad, Uttar Pradesh, India. E-mail: drpntandon@gmail.com

Introduction

Peripheral giant cell granuloma (PGCG) is the most common oral giant cell lesion appearing as a soft tissue extra-osseous purplish-red nodule consisting of multinucleated giant cells in a background of mononuclear stromal cells and extravasated red blood cells.

This lesion is probably not present as a true neoplasm, but rather may be reactive in nature. The initiating stimulus has been believed to be due to local irritation or trauma, but the cause is not certainly known. It has been termed a peripheral giant cell “reparative” granuloma, but whether it is in fact reparative has not been established and its osteoclastic activity nature appears doubtful. Its membrane receptors for calcitonin demonstrated by immunohistochemistry and its osteoclastic activity when cultured in vitro are evidences that the lesions are osteoclasts,[15] whereas other authors have suggested that the lesion is formed by cells of the mononuclear phagocyte system.[6] The PGCG bears a close microscopic resemblance to the central giant cell granuloma, and some pathologists believe that it may represent a soft tissue counterpart of the central bony lesion.[7]


Case Report

A 22-year-old female patient reported to the Department of Oral and Maxillofacial Surgery with the complaint of swelling in the left upper jaw since 1 year. History revealed that the swelling started as a small one and progressively increased to the present size over a period of 1 year. It was associated with intermittent pain. There was no history of trauma, neurological deficit, fever, loss of appetite, loss of weight. There was no similar swelling present in any other part of the body. The patient was systemically healthy.

On extraoral examination, a single, diffuse swelling was seen on the left side of the face in the region of anterior maxilla. The swelling measured about 2 × 1.5 cm. The surface of the swelling was lobulated and present in relation to 11 21 22. The swelling was firm in consistency and bluish in color, and the overlying mucus membrane was intact [Figure 1]. Orthopantomogram, intraoral periapical radiographs, and maxillary occlusal radiograph showed no bone resorption. The fine needle aspiration cytology (FNAC) features showed numerous giant cells in a hemorrhagic background. Spindle cells/inflammatory cells were not seen.

Surgery (excisional biopsy) was planned under local anesthesia (LA). The overlying mucosa was incised and undermined. Lesion was separated from the adjacent tissue by blunt dissection and removed in one piece [Figure 2]. Primary closure was done with 3-0 silk suture [Figure 3]. The specimen was sent for histopathologic examination. Sutures were removed after 1 week. There was no evidence of recurrence till 5 months of follow-up [Figure 4].

Histopathology

Histopathologic examination of biopsied specimen revealed it to be whitish in color, oval in shape, firm in consistency and measuring about 2 × 1 cm in dimension [Figure 5]. The connective tissue stroma was highly cellular, consisting of proliferating plump fibroblasts. Numerous giant cells of various shapes and sizes, containing 8–15 nuclei, were seen with proliferating and dilated endothelial lined blood capillaries with extravasated red blood cells (RBCs). Few giant cells were also seen inside the vascular spaces. Numerous ossifications were also seen in the stroma [Figure 6].


Discussion

The etiology and nature of PGCG (giant cell epulides) still remains undecided. In the past, several hypotheses had been proposed to explain the nature of multinucleated giant cells, including the explanation that they were osteoclasts left from physiological resorption of teeth or reaction to injury to periosteum. There is strong evidence that these cells are osteoclasts as they have been shown to possess receptors for calcitonin and were able to excavate bone in vitro.

The PGCG occurs throughout life, with peaks in incidence during the mixed dentitional years[8] and in the age group of 30–40 years.[7, 9] It is more common among females (60%).[7, 9] The mandible is affected slightly more often than the maxilla.[7, 9] Lesions can become large, some attaining 2 cm in size. The clinical appearance is similar to that of the more common pyogenic granuloma, although the PGCG often is more bluish-purple compared with the bright red color of a typical pyogenic granuloma. Recently, the PGCG associated with dental implants has also been reported.[10]

Although the PGCG develops within soft tissue, “cupping” superficial resorption of the underlying alveolar bony crest is sometimes seen. At times, it may be difficult to determine whether the mass is a peripheral lesion or a central giant cell granuloma eroding through the cortical plate into the gingival soft tissues.[11, 12, 13]

The extra-osseous lesions of cherubism involving the gingiva appear very similar to giant cell epulides. However, the other distinctive clinical and radiographic features of cherubism will indicate the correct diagnosis.[14]

Histologically, PGCG is composed of nodules of multinucleated giant cells in a background of plump ovoid and spindle-shaped mesenchymal cells and extravasated RBCs. The giant cells may contain only a few nuclei or up to several dozen of them. Some of them are large, vesicular nuclei; others demonstrate small, pyknotic nuclei. The origin of the giant cell is unknown. Ultrastructural and immunological studies[26] have shown that the giant cells are derived from osteoclasts.[15]

There is also a growing body of opinion that giant cells may simply represent a reactionary component of the lesion and are derived via blood stream from bone marrow mononuclear cells and may be present only in response to an as yet unknown stimulus from the stroma. This concept is based on the results of some more recent studies using cell culture and transplantation,[16, 17] in which the giant cells have been found to be short lived and to disappear early in culture in contrast to the active proliferation of the stromal cells.

A study by Willing et al.[18] revealed that the stromal cells secrete a variety of cytokines and differentiation factors, including monocyte chemoattractant protein-1 (MCP1), osteoclast differentiation factor (ODF), and macrophage-colony stimulating factor (M-CSF). These molecules are monocyte chemoattractants and are essential for osteoclast differentiation, suggesting that the stromal cell stimulates blood monocyte immigration into tumor tissue and enhances their fusion into osteoclast-like, multinucleated giant cells. Furthermore, the recently identified membrane-bound protein family, a disintegrin and metalloprotease (ADAM), is considered to play a role in the multinucleation of osteoclasts and macrophage-derived giant cells from mononuclear precursor cells.[19]

In the most recent study by Bo Liu et al.,[5] in situ hybridization was carried out to detect the mRNA expression of the newly identified receptor activator of nuclear factor (NF)-kappaB ligand (RANKL) that is shown to be essential in the osteoclastogenesis, its receptor, receptor activator of NF-kappaB (RANK), and its decoy receptor, osteoprotegerin (OPG). They concluded that RANKL, OPG and RANK expressed in these lesions may play important roles in the formation of multinucleated giant cells.


Notes

Source of Support: Nil.

Conflict of Interest: None declared.

References
1. Bonetti F,Pelosi G,Martignoni G,Mombello A,Zamboni G,Pea M,et al. Peripheral giant cell granuloma: evidence for osteoclastic differentiationOral Surg Oral Med Oral PatholYear: 19907047152216383
2. Lim L,Gibbins JR. Immunohistochemical and structural evidence of a modified microvasculature in the giant cell granuloma of the jawsOral Surg Oral Med Oral PatholYear: 1995791908
3. Mighell AJ,Robinson PA,Hume WJ. PCNA and Ki-67 immunoreactivity in multinucleated cells of giant cell fibroma and peripheral giant cell granulomaJ Oral Pathol MedYear: 19962519398835814
4. Souza PE,Mesquita RA,Gomez RS. Evaluation of p53, PCNA, Ki-67, MDM2 and AgNOR in oral peripheral and central giant cell lesionsOral DisYear: 2000635910673786
5. Bo Liu,Shi-Feng Yu,Tie-Jun Li. Multinucleated giant cells in various forms of giant cell containing lesions of the jaws express features of osteoclastsJ Oral Pathol MedYear: 20033236712787044
6. Carvalho YR,Loyola AM,Gomez RS,Araujo VC. Peripheral giant cell granuloma. An immuno-histochemical and ultrastructural studyOral DisYear: 199512057553376
7. Katsikeris N,Kakarantza-Angelopoulou E,Angelopoulos AP. Peripheral giant cell granuloma. Clinicopathologic study of 224 new cases and review of 956 reported casesInt J Oral Maxillofac SurgYear: 1988179493133432
8. Chadwick BL,Crawford PJ,Aldred MJ. Massive giant cell epulis in a child with familial cyclic neutropeniaBr Dent JYear: 1989167279812590585
9. Giansanti JS,Waldron CA. Peripheral giant cell granuloma: review of 720 casesJ Oral SurgYear: 196927787915258991
10. Hirshberg A,Kozlovsky A,Schwartz-Arad D,Mardinger O,Kaplan I. Peripheral giant cell granuloma associated with dental implantsJ periodontolYear: 2003741381414584874
11. Dayan D,Buchner A,Spirer S. Bone formation in peripheral giant cell granulomaJ PeriodontolYear: 19906144462117655
12. Smith BR,Fowler CB,Svane TJ. Primary hyperparathyroidism presenting as a “peripheral” giant cell granulomaJ Oral Maxillofac SurgYear: 1988466593276854
13. Burkes EJ,White RP. A peripheral giant-cell granuloma manifestation of primary hyperparathyroidism: report of caseJ Am Dent AssocYear: 19891186242913105
14. Odell EW,Morgan PR. Biopsy Pathology of the Oral TissuesYear: 1998LondonChapman Hall Medical111
15. Flanagan AM,Tinkler SMB,Horton MA,Williams MD,Chambers DJ. The multinucleated giant cell granulomas of the jaws are osteoclastsCancerYear: 1988621139452457425
16. El-Mofty SK,Osdoby P. Growth behaviour and lineage of isolated and cultured cells derived from giant cell granuloma of the mandibleJ Oral PatholYear: 198514539523928848
17. Cohen MA,Grossman ES,Thompson SH. Features of central giant cell granuloma of the jaws xenografted in nude miceOral Surg Oral Med Oral PatholYear: 1988662093174055
18. Willing M,Engels C,Jesse N,Werner M,Delling G,Kaiser E. The nature of giant cell tumor of boneJ Cancer Res Clin OncolYear: 20011274677411501745
19. Abe E,Mocharla H,Yamate T,Taguchi Y. Monolages SC.Meltrinalpha, a fusion protein involved in multinucleated giant cell and osteoclast formationCalcif TissueYear: 19996450815

Figures

[Figure ID: F1]
Figure 1 

Preoperative intraoral presentation of lesion



[Figure ID: F2]
Figure 2 

Excision of mass



[Figure ID: F3]
Figure 3 

Immediate postoperative view



[Figure ID: F4]
Figure 4 

Postoperative view after 1 month



[Figure ID: F5]
Figure 5 

Measurement of excised mass



[Figure ID: F6]
Figure 6 

Histopathologic view ×10 magnification



Article Categories:
  • Case Report

Keywords: Peripheral giant cell granuloma/giant cell epulis, Jaw, reactive.

Previous Document:  Ectrodactyly, ectodermal dysplasia, and cleft lip/palate syndrome: A case report of "Incomplete synd...
Next Document:  Adolescent rampant caries.