|Year : 2013 | Volume
| Issue : 1 | Page : 41-43
Dilemma in the management of central giant cell granuloma of maxilla
Rajendra B Metgudmath1, Anjali R Metgudmath2, Sunita Y Patil3, Mohit Sinha1
1 Department of Otorhinolaryngology, Head and Neck Surgery, Jawaharlal Nehru Medical College, KLE University, Belgaum, Karnataka, India
2 Department of General Medicine, Jawaharlal Nehru Medical College, KLE University, Belgaum, Karnataka, India
3 Department of Pathology, Jawaharlal Nehru Medical College, KLE University, Belgaum, Karnataka, India
|Date of Web Publication||28-Mar-2013|
Rajendra B Metgudmath
95/c, Anugraha, Shanti-Nagar, M.G.Road, Tilakwadi, Belgaum - 590 006, Karnataka
Source of Support: None, Conflict of Interest: None
Central giant cell granuloma is a rare benign lesion occasionally causing severe local destruction. Surgical excision is the main stay of treatment. As this lesion is unusual in clinical practice and is associated with dilemma in the treatment, we present here a case report with review of the literature concerning management.
Keywords: Central giant cell granuloma, salmon calcitonin, triamcinolone acetonide
|How to cite this article:|
Metgudmath RB, Metgudmath AR, Patil SY, Sinha M. Dilemma in the management of central giant cell granuloma of maxilla. J Sci Soc 2013;40:41-3
| Introduction|| |
Central giant cell granuloma (CGCG) is a benign tumor rarely affecting maxilla. Jaffe in 1953 was the first to report CGCG of the jaw.  The widely accepted therapy for CGCG is surgical excision or curettage. Jacoway et al., in 1988 have suggested administering corticosteroids intralesionally. , Harris in 1993 first reported the use of calcitonin injections in the treatment of CGCG. Use of interferon and intranasal spray of calcitonin in the treatment of CGCG has also been reported. , We report a rare case of CGCG of maxilla who was managed with surgical curettage and intranasal calcitonin spray.
| Case Report|| |
A 16-year-old female presented to outpatient department of surgical oncology with the complaints of right cheek swelling since last 4 months. She also had right nasal obstruction and loosing of right upper canine tooth since last 1 month. Prior to visiting us, the patient had undergone biopsy elsewhere and was diagnosed as CGCG of right maxilla. She had received four doses of intralesional injection of Triamcinolone 40 mg, once a month for 4 months. However, as there was progressive increase in the size of swelling the patient presented to us.
On examination, fullness was seen over right maxillary area. Right nasal cavity was filled with mass pushing the septum towards other side. Oral cavity examination revealed swelling over the right half of hard palate and on palpation, there were areas of varying consistency from soft to hard were found. Eye ball movements were within normal limits.
The patient was subjected for computed tomography scan of nose and paranasal sinus, which showed a large multi-loculated soft-tissue density mass measuring 4.8 cm × 4.0 cm involving the right maxillary sinus. The lesion was also involving the right nasal cavity causing deviation of nasal septum to left side and blocking the right osteo-meatal complex. Furthermore, there was destruction of anterior and medial walls of right maxilla and inferiorly the lesion was causing destruction of alveolar ridge, pushing the hard palate inferiorly [Figure 1]. The tissue diagnosis was reconfirmed. Along with routine blood, and urine investigation, the levels of serum calcium, phosphorus, and parathormone were assessed and were found to be within normal limits.
|Figure 1: Computed tomography scan paranasal sinus plain - coronal section with bone algorithm showing mass occupying right maxillary sinus with its extension|
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The patient was advised to undergo right maxillectomy. However, the patient and her parents refused to undergo any surgical procedure, which would cause facial or palatal deformity. Hence, to keep the palate intact an extended sublabial incision was given and the tumor mass was accessed [Figure 2]. The anterior and medial walls of right maxilla along with inferior and middle turbinates were excised. Part of the septum where tumor was adherent was also excised, whereas mass over the floor of right maxillary sinus and right nasal cavity was curetted. Loose right canine tooth was removed. Histopathology of the excised tumor showed numerous osteoclast such as giant cells, stromal cells, congested blood vessels, and focal areas of osteoid tissue confirming the diagnosis [Figure 3] and [Figure 4].
|Figure 2: Intra-operative picture showing right maxillary sinus and nasal cavity after excision of the tumor mass|
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|Figure 3: Microphotograph (H and E, ×100). Black arrow - numerous osteoclast like giant cells, white arrow - focal areas of osteoid tissue, #stromal cells, and *congested blood vessels|
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|Figure 4: Microphotograph, (H and E, ×400). Black arrow - numerous multinucleated osteoclast like giant cells, #stromal cells, and *congested capillaries|
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Post-surgery, the patient received calcitonin nasal spray, once daily for 11 months. During this post-operative follow-up period, except for the floor of the right maxilla, and right nasal cavity, all other walls were free from the lesion, i.e., the areas, which were curetted showed recurrence. The patient was subjected for repeated curettage of these areas and at the end of 1 year the patient was lost for follow-up.
| Discussion|| |
CGCG are a benign lesion affecting the facial bones mainly the mandible and less frequently the maxilla. The lesion is usually seen in women more than men and occurs usually below 30 years of age. This lesion usually presents as a painless and progressively growing swelling. The conventional management of CGCG is surgery. The recurrence rate in CGCG can widely vary between 11% and 49% depending upon the management.  As these lesions are not malignant, the wide spectrums of surgical procedures have been mentioned ranging from just curettage or enucleation to the extensive resection. The curettage is associated with high rate of recurrence, as in our case, whereas the extensive resection is associated with disfigurement of face, which poses a serious problem especially in young individuals.  To avoid the morbidities of surgical therapy various non-surgical therapies have been reported in the successful management of CGCG. Irradiation is avoided as it may incite malignant transformation of CGCG. 
Intra lesional injection of corticosteroid, that is a mixture of triamcinolone acetonide and lignocaine weekly for 6 weeks has been reported with promising results.  Lange J de et al. mention the use of intra lesional injection of methyl prednisolone with 6 weeks interval though the results of which were not satisfactory. 
The literature also mentions the use of calcitonin in the management of CGCG. Two types of calcitonin are used for the treatment of CGCG, namely salmon calcitonin and human calcitonin. , It has been reported that in humans the effect of salmon calcitonin is better than that of human. Calcitonin can be administered either in the form of daily subcutaneous injection with a dose of 50-100 IU for the period of up to 15 months or in the form of nasal spray with higher dose of 200 IU.  Intranasal spray avoids the daily injections and has better patient compliance. Though, the results of the use of calcitonin are mixed, some reports show calcitonin as a promising alternative in the management of CGCG. The side effects are nausea, dizziness, flushes, headaches, and diarrhea. 
| Conclusion|| |
CGCG are a benign lesion affecting the facial bones and even though this clinical entity has been described more than half a century ago, there still exists a dilemma regarding its management. Radical surgery should be the main stay of treatment, as the area which received extensive clearance was free from the lesion, whereas the area which received curettage showed recurrence in our case. As the extensive resection is associated with disfigurement of face, alternative non-surgical therapies can be tried before going for radical surgery.
| References|| |
|1.||De Lange J, Rosenberg AJ, van den Akker HP, Koole R, Wirds JJ, van den Berg H. Treatment of central giant cell granuloma of the jaw with calcitonin. Int J Oral Maxillofac Surg 1999;28:372-6. |
|2.||Kermer C, Millesi W, Watzke IM. Local injection of corticosteroids for central giant cell granuloma. A case report. Int J Oral Maxillofac Surg 1994;23:366-8. |
|3.||Rajeevan NS, Soumithran CS. Intralesional corticosteroid injection for central giant cell granuloma. A case report. Int J Oral Maxillofac Surg 1998;27:303-4. |
|4.||De Lange J, van den Akker HP, van den Berg H, Richel DJ, Gortzak RA. Limited regression of central giant cell granuloma by interferon alpha after failed calcitonin therapy: A report of 2 cases. Int J Oral Maxillofac Surg 2006;35:865-9. |
|5.||Abdo EN, Alves LC, Rodrigues AS, Mesquita RA, Gomez RS. Treatment of a central giant cell granuloma with intralesional corticosteroid. Br J Oral Maxillofac Surg 2005;43:74-6. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]