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Intra-Lesional Steroid Treatment of Central Giant Cell granuloma of The Mandible, A case report Dr. Mohammed Al-Bodbaij BDS (KSU), MSc, OMFS (Eng. ), MFD RCSI (Ireland)

Central Giant Cell Granuloma WHO definition: An intra-osseous lesion consisting of cellular fibrous tissue that contains multiple foci of hemorrhage, aggregations of multinucleated giant cells and occasionally trabecule of woven bone. First described by Jaffe in 1953 as a giant-cell reparative granuloma of the jaw bones.

Incidence of CGCG • It accounts for less than 7% of all benign lesions of the jaws. (Austin LT, etl, 1959) • Occurs mainly in children and young adults with more than 60% of all cases occurring before the age of 30 years and female to male ratio of 2: 1 (Jaffe 1953). The peak of incidence: • M : 10 - 14 years of age. • F : 15 - 19 years of age. • Mandible : maxilla » 2 : 1 de Lange J, van den Akker HP, Klip H. 2004.

CGCG, aetiology and classification Etiology: - Obscure - Trauma ? ? !!. Classifications: - Genetic ? ? !!. Depending on the clinical signs and symptoms and radiological features, CGCGs are classified into: • Non-aggressive (indolent) : characterized by slow growth that doesn't cause cortical bone perforation or root resorption. It has low tendency to recur. • Aggressive: characterized by pain, rapid growth, expansion and/or perforation of cortical bone, root resorption and high recurrence tendency.

Clinical features Slow growing. Swelling of the jaw. Rarely, Pain and sensory disturbances. Intra-orally : a swelling with sometimes a bluish-brown aspect. • Displacement of teeth » malocclusion. • •

Radiological findings CGCGs present as an expansile radiolucency, either unilocular or multilocular with defined, poorly defined or diffused borders, with displacement of teeth and tooth germs, root resorption, and cortical perforation. • Whitaker and Waldron 1993: 142 cases: - 43%: root resorption. - 36%: displacement of tooth germs. - 60%: multilocular.

Histological features • Highly cellular, fibroblastic stroma. • Plump, spindle-shaped cells with a high mitotic rate. • High vascular density. • Prominent multinucleated giant cells. • Dystrophic calcification & metaplastic ossification.

Treatment modalities • Surgical excision either by curettage (most frequent therapy) or en bloc resection. Recurrence rates ranging from 11% - 49% • Corticosteroid injections. • Calcitonin. • Interferon.

Surgical curettage: • In 1986, Chuong, reported a recurrence rate (RR) of 72% in aggressive lesions. • CGCGs in the Dutch population (2005): - Overall recurrence rate: 26. 3% after surgical curettage. - R. R. in aggressive type: 37. 5%, - R. R. in indolent lesions: 23. 4%. - Higher incidence of recurrence in younger patients, especially in young males.

Corticosteroid The mode of action is not fully understood. Hypothesis: • Inhibition of the extracelluar production of lysosomal proteases. • Steroidal apoptotic action on osteoclast-like cells.

Corticosteroid • In 1988, Jacoway et al: first reported on the treatment of CGCG with corticosteroids. • In 1994, Terry and Jacoway presented 4 patients treated with steroids. • A weekly intra-lesional injection of steroids of 6 weeks period resulted in a complete resolution in 3 patients, while 1 patient needed additional surgery.

Calcitonin • It causes an increased influx of calcium into the bones and thus functions antagonistically to parathyroid hormone. • It has been demonstrated that giant cells express calcitonin receptors which are also detected on giant cells in GCTs. • It is assumed that giant cells are directly inhibited in their function by calcitonin.

Calcitonin (cont. ) • Harris was the first to report on the use of synthetic human calcitonin as a therapy for CGCG. • In a study on 4 patients, He administered 0. 5 mg (100 iu) human calcitonin sc for about 12 months with total remission of the lesions. • Calcitonin nasal spray is used with less effective than subcutaneous injections for the management of CGCG lesions. (Marilena Vered, etl. 2007) • At present only salmon calcitonin is commercially available.

Interferon • Interferon (IFN) is an antiviral and anti-angiogenic agent that is used in a variety of conditions. • Few case reports on the use of IFN combined with conservative surgical debulking as a treatment for aggressive CGCGs. • A report of rapidly expanding CGCG in the mandible was treated with IFN without additional surgery, resulting in resolution of the lesion beginning after 3 months and complete bony regeneration after 8 months. (Collins A. , 2000)

Case report Personal Data: • 14 years old, Saudi, Female. • Student in intermediate school.

Chief complaint: Gradually enlarged swelling of the left side of the lower jaw. History of chief complaint: In December 2014 Patient was referred for management of giant cell granuloma of the mandible. Medical History: Unremarkable.

Clinical examination Extra- oral exam. : • Non-tender enlarged left side of the mandible. • No regional lymphadenopathy

Clinical examination Intra-oral exam. : • Non-tender hard swelling of canine – premolars region of left mandibular side. • Linear scar of overlying mucosa. • Buccal expansion with slight buccal sulcus obliteration. • Slight mobility of teeth No. 43 & 44.

Investigations: Radiograph (plain & CT scan: • Destructed alveolar and basilar bones of anterior region of the mandible extending from tooth #35 to #43

C. T. Scan.

C. T. Scan. (cont)

Investigations (cont. ) Incisional biopsy: Central Giant Cell Granuloma (CGCG). Biochemistry: Serum calcium, parathyroid hormone and phosphate levels were normal.

Histological findings Osteoclast-like giant cells are scattered within a fibroblastic matrix. (H & E, X 100).

Diagnosis Central Giant Cell Granuloma of the mandible. (CGCG)

Treatment • Intra-lesional injections of 4 cm³ of a mixture of triamcinolone acetonide 10 mg/ml and lidocaine hydrochloride with adrenaline 1: 80, 000 in 1: 1 ratio was administered on weekly bases for six weeks.