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Pseudo giant cell tumor (reparative granuloma) of the jaw
Operative PSEUDO GIANT
Oral
Surgery
CELL TUMOR (REPARATIVE THE JAW
GRANULOMA)
OF
the the the
Of
tee ma
Fig.
l.--Case 1. Intraoral surfaces of the teeth. Fig. Z.-Case 1. Occlusal corticcs. mamdibular
actAusal
1 il.\\
showing
roentwmograph
elevatiun showing
uf ftovr bony
of nwuth expansion
to tlw nnrl
Iwel thinning
of tllr.
of
Fig Fig. %--Case locular uwearance Fig. 4.-Case wir of defect.
4.
1. Lateral oblique roentgenogranl of Ivft side of manrliblc showing: nlultiand normal and displaced tooth buds. 1. Occlusal roentgenogmm six montlls postolwr‘nti~~~ly showing: hrmy re-
Pathologic
Examination.--
1’SI’:l’liO
(;I.\.\;‘i’
(‘i<:I,I,
‘l’I’~I(~Ii
il:I~:1’.\1:.\‘1.i\‘I,:
c:1~.\sl~I.o.\I.\
01,’ .I \\\’
11;
Itaft IIl:txillary premolars had to be esfracted with a~lministration of 1,500 C.C. of whole blood. The WV~II weeks postoperatively the patient was prosthesis. The contour of the alveolar portion matc!ly normal ant1 was firm and noncompressible. of early osseous repair of the defect.
the ;* tumor. ‘I 1310011loss necessitated 111~: postoperative course was uneventful, and asymptomati( arili reai1y for temporary of the masilla Ilad returned to approxiI~:~~lia~ral~hi~~~ll~, there was evidences
Discussion ‘J’he~
is
clinical
convincing
and pathologic: evitlcnce to support the
Iwlirf that giant cell tumors of the maxilla anti Illalldible are rare nucl th:tt nlost giant cell lesions in these bones are not true giant cell tumors. It apl~ars very likely that many of the lesions mistaken for giwt ccl1 tumors are giant cell reparative granulomas. The clinical, and l)nthologic differences lwtwwn these two lesions are presented iu Table I. Much of the present confusion SLIT*wunding t.hc reported incidence, clinical behavior. illlil treatment OP giant Cell tlinlors n~ay he attributed to the failure to separate giant cell WpilELt,iY(a granulonla ant1 other pseudo-giant ccl1 tumors fr0~11 the t we giant wll tumor.
Cl:\NT
I
CRLT, TI:MOR
I Gidmcc:
IL:1 rc!
Age of patients lktory of trauma
lisually ahove 21 years Orr,asional A2gjiressivc!
Uilliwl
Therapy
lx41:trior
response
Ikws not sul,sidc spoiitanc~tnisi~ I~~~(~rlrsfroquentl) O(,casionally metastasizes lielxtivcly uniform appearance throughout Nuclear preponderance of stroma1 cells Giant cells numerous Giant cells uniformly distributed FIcmorrhages frequently prcscnt No collagen, ostcoid, or bone formation Recurs if incomplctelv re~lorcrl or inadequateIy irradiated
Vi’:. 13
Vi x. I 4
Fig’. 13.-.\ true giant cell tumor of bone (tibia). In contras:;05(i:le giant cell granuloma, the giant cells are uniformly distributed and more abundant. Fig. 14.---Iligher power of same section. Compare the appear&e of the stromal cells with those of the piant cell gr:~nilloms~ They are more clowly packed and haw a neoplastic :\ppenmnce. (X3.50.)
~lorlulcs widely scparatcd by dcnscr stromal clrmcnts which arc largcl~- devoid oC giant cells. These nodules arc characterixcd h,v more edematous or loosely giant cells, ervthrucytcs, or hrmosiderin pigment &lTi~IlgC?d St,rOIIl:Ll elements, anti small numbers of nonspecific chronic inflammatory cells. The stromal cells of giant cell reparative granulomn ma?- resemble those of giant cell tumor but usually thtyv are more spindle-shaped and fibrillar with less hyperchromatic
Itiwlci
a,rlil
I)rominent i’orrnation
are
selclon~
is not
‘Fliere
are
oCten otllcr
es
and
/ sllelr
as
l’oam”Tmay
R m;~~*kcvl boll)-
I’w~~IIY’,
Iwions
ohtaincd
il
which
i re
hilt Ii!.
t)rl
drill
is
j)ig:.lhcllt,
while
is c,llc’ollnl(,l.c’cI mlisl.
with it
irtrti
;111(1
its
frcqncklti
c7)lisitlc~rcct
~II~Y;I~~
possible
IJiopq-)
may
all
sliw~~
is
1111’ tlift’eIY~~lti;ll
IJe lilt
le clifficdt!,
cosinophilic iilRCll’(~lllllo onI?.
iolk ostcwitl
I>iti
christic
1 Ililt
~I~~posil
Iwlic~ iIll(l
There should
~~~lIlUlOlllit.
uior~tr
IllaclQpllagc‘s. be
~i’illllllOlll~i.
rc~~miativc~
diagnosis or giant ccl 1 t’epat3, ill excluding eosinophdic !/rw)r q-t
1 lc~mc~ri~l~i~~~~
as c~l~~sc~l~- pacli~d.
in giant, wll
liort
lc~uko-
spwi1ric~i io:ls
oi’
the
cwino~~liilie granuloma wit Ii fibrosis and giant ~11s and witho~lt. lii(~ 01~1~1, clitwacteristic findings. In fibrous t~,tJSp~kSick thew is n~orc collagen. osleoitl or ttonc formation, and fewer giant cells or hemorrhag’c. Sane 01’ the maligriaikl ;lw SW11 in gianl veil wlwxtivc~ ~t~i~ll~~lOlll~l. i’cwhws of ostc-ogctzic sc17-w)tw More difficult or occasionallp impossible to diffcrcntiate is tllc, hrvcr~ t~tw~r 0J’ Ilyperptrrn thyt-oidism. I rlasmuch as the pathogenesis of both lwions is I)rot)ably closely related, it is not swprising that it may not be possihlc to tliff’ercntiatv ti;cm Iii.;tologically. Thrwl’ore. it is important, that in c>ac:h itwtallcc~ of II histologic lesion of this kind, blood calcium, phosphorus, and ;Ilkalinc l)hosphatase determinations be pc~rformed. The possibility of hyperparat hyroidism ?:hollltl bc CV(fll lnoI’(: stro11plp snspcct,ed when rcc*~~l’rellces arc cw~ollt~twxl ( iood rwults have lwn obtained in patient,s with giant cell I(Gons ol’ thv In view crf th heriigli ,jaws I))- cm’cttagc, rescct,ionz or small doses of rildiat~iurl. tlatare ot’ this lesion, it wo111(1seem that simple currt,tagr is tllc trvatnro~lt 01 ctioiw.
Summary and Conclusions 1. True giant cell tumor 01’ the tjaw is a rt1I.e lesion while giant cell reparative granuloma, with \vhivh it, is Irequenlly conl’used, is not uncom~~~on. Two typical cases of giant cell reparative granulonia Of the ,jii\VS IlaIr? l,fV1ll clcwribed ancl the differential tliagnosis, especially as it wlntrs to giant wll I llmor, briefly discussed. 2. Clinically, giant cell reparative gratinlotna is seen in children or yout~g adult,s, frequently follows trauma, appears roentgenographically as ZIII V’Sl)nnsi\-e radiolucent lesion, and is probably best treated by simple curettagtl. 3. Pathologicall;-, wrtain ddinitc ar~~hittV~tI1lYll illld c~?-tomor~~holo~ic Pvaiurcs
tliffcretitiatc
this
~t’~~ll~llO~~lii
f’roni
trw
yiarlt
wll
tlllnor.
4. In each case of giant ccl1 reparative granulomn of the ,jaw, blood c~hcmistry studies should 1~ 1wrformrd to rule out hvpel,parathvl,oidisnl. The authors are indebted to I)r. Henry Jaffe for his permission to photograph and lultlish the histologic section of the true giant cell tumor seen in Figs. 13 and 14 and also for his encouragement and helpful criticism. The photomicrographs were prepared hy Mr. Mart R,ussin.
References 1. Jaffe,
H. L., Lichtenstein, L., and Portia, B. B.: Giant Cell Tumor of Bone, Its Pathologic Appearance, Grading, Supposed Variants and Treatment, Arch. Path. 30: 993, 1940. 2. Geschickter, C. F.: Tumors of Rone, Lancaster, Pa., 1931, The American Journal 01 Cancer, Lancaster Press, Inc., p. 287.
Ii. Jaffe,
11.. L.: Giant-Cell Reparative Granuloms, (Fibro-osseous) Dysplasia of the Jawbones. Z~ATH. 6: 159, 1953‘. Treatment of Gisnt Cell Tumors 7. Presser, T. M.: 252,
11. 12. 1X
of JZonc: J. Hone 85 Joint
Surg. 31:
1949.
Treatment of Osteoclastoma by Radiation, .J. Bone & .Joint Surg. 31: Frank: Bti8, 1949. Coley, B. I~.: Neoplasms of Bone, New York, 1!)49, Paul B. Hoeber, Inc., pp. 164, 434. &I.: ConsidErations pathogSniyues et th+rapeutiques sur les turrreurs h Dechaume, my@loplaxes, Bull. Acad. nationale med. 134: ii, 1950. Die Riesenzellgeschwulste des Kiefers, Rrosch, F.: Xeoplastnen oder Entzundungs produckte, Zahnarztlichewelt 5: 59, 1950. “lokalisierte Ostitis Fibrosa” Ein Beitrag zur Konjetzny, G. E.: Die sogenannte Kenntnis der solitaren Knochenzysten der sogonannte “schaligen myelogenen Riesenzellersarkome,” Arch. f. klin. Chir. 121: 567, 1922. Major. S. G.: Giant Crll Tumors of the Jaws, Ann. Rurg. 104: 1068, 1936.
8. Ellis, 9. 10.
Traumatic Bone Cyst, and Fibrous O~ar, St-I%., (&<.\I, RIJw., AKJ) ORAI~
Oral
Surgery
CELL TUMOR (REPARATIVE THE JAW
GRANULOMA)
OF
the the the
Of
tee ma
Fig.
l.--Case 1. Intraoral surfaces of the teeth. Fig. Z.-Case 1. Occlusal corticcs. mamdibular
actAusal
1 il.\\
showing
roentwmograph
elevatiun showing
uf ftovr bony
of nwuth expansion
to tlw nnrl
Iwel thinning
of tllr.
of
Fig Fig. %--Case locular uwearance Fig. 4.-Case wir of defect.
4.
1. Lateral oblique roentgenogranl of Ivft side of manrliblc showing: nlultiand normal and displaced tooth buds. 1. Occlusal roentgenogmm six montlls postolwr‘nti~~~ly showing: hrmy re-
Pathologic
Examination.--
1’SI’:l’liO
(;I.\.\;‘i’
(‘i<:I,I,
‘l’I’~I(~Ii
il:I~:1’.\1:.\‘1.i\‘I,:
c:1~.\sl~I.o.\I.\
01,’ .I \\\’
11;
Itaft IIl:txillary premolars had to be esfracted with a~lministration of 1,500 C.C. of whole blood. The WV~II weeks postoperatively the patient was prosthesis. The contour of the alveolar portion matc!ly normal ant1 was firm and noncompressible. of early osseous repair of the defect.
the ;* tumor. ‘I 1310011loss necessitated 111~: postoperative course was uneventful, and asymptomati( arili reai1y for temporary of the masilla Ilad returned to approxiI~:~~lia~ral~hi~~~ll~, there was evidences
Discussion ‘J’he~
is
clinical
convincing
and pathologic: evitlcnce to support the
Iwlirf that giant cell tumors of the maxilla anti Illalldible are rare nucl th:tt nlost giant cell lesions in these bones are not true giant cell tumors. It apl~ars very likely that many of the lesions mistaken for giwt ccl1 tumors are giant cell reparative granulomas. The clinical, and l)nthologic differences lwtwwn these two lesions are presented iu Table I. Much of the present confusion SLIT*wunding t.hc reported incidence, clinical behavior. illlil treatment OP giant Cell tlinlors n~ay he attributed to the failure to separate giant cell WpilELt,iY(a granulonla ant1 other pseudo-giant ccl1 tumors fr0~11 the t we giant wll tumor.
Cl:\NT
I
CRLT, TI:MOR
I Gidmcc:
IL:1 rc!
Age of patients lktory of trauma
lisually ahove 21 years Orr,asional A2gjiressivc!
Uilliwl
Therapy
lx41:trior
response
Ikws not sul,sidc spoiitanc~tnisi~ I~~~(~rlrsfroquentl) O(,casionally metastasizes lielxtivcly uniform appearance throughout Nuclear preponderance of stroma1 cells Giant cells numerous Giant cells uniformly distributed FIcmorrhages frequently prcscnt No collagen, ostcoid, or bone formation Recurs if incomplctelv re~lorcrl or inadequateIy irradiated
Vi’:. 13
Vi x. I 4
Fig’. 13.-.\ true giant cell tumor of bone (tibia). In contras:;05(i:le giant cell granuloma, the giant cells are uniformly distributed and more abundant. Fig. 14.---Iligher power of same section. Compare the appear&e of the stromal cells with those of the piant cell gr:~nilloms~ They are more clowly packed and haw a neoplastic :\ppenmnce. (X3.50.)
~lorlulcs widely scparatcd by dcnscr stromal clrmcnts which arc largcl~- devoid oC giant cells. These nodules arc characterixcd h,v more edematous or loosely giant cells, ervthrucytcs, or hrmosiderin pigment &lTi~IlgC?d St,rOIIl:Ll elements, anti small numbers of nonspecific chronic inflammatory cells. The stromal cells of giant cell reparative granulomn ma?- resemble those of giant cell tumor but usually thtyv are more spindle-shaped and fibrillar with less hyperchromatic
Itiwlci
a,rlil
I)rominent i’orrnation
are
selclon~
is not
‘Fliere
are
oCten otllcr
es
and
/ sllelr
as
l’oam”Tmay
R m;~~*kcvl boll)-
I’w~~IIY’,
Iwions
ohtaincd
il
which
i re
hilt Ii!.
t)rl
drill
is
j)ig:.lhcllt,
while
is c,llc’ollnl(,l.c’cI mlisl.
with it
irtrti
;111(1
its
frcqncklti
c7)lisitlc~rcct
~II~Y;I~~
possible
IJiopq-)
may
all
sliw~~
is
1111’ tlift’eIY~~lti;ll
IJe lilt
le clifficdt!,
cosinophilic iilRCll’(~lllllo onI?.
iolk ostcwitl
I>iti
christic
1 Ililt
~I~~posil
Iwlic~ iIll(l
There should
~~~lIlUlOlllit.
uior~tr
IllaclQpllagc‘s. be
~i’illllllOlll~i.
rc~~miativc~
diagnosis or giant ccl 1 t’epat3, ill excluding eosinophdic !/rw)r q-t
1 lc~mc~ri~l~i~~~~
as c~l~~sc~l~- pacli~d.
in giant, wll
liort
lc~uko-
spwi1ric~i io:ls
oi’
the
cwino~~liilie granuloma wit Ii fibrosis and giant ~11s and witho~lt. lii(~ 01~1~1, clitwacteristic findings. In fibrous t~,tJSp~kSick thew is n~orc collagen. osleoitl or ttonc formation, and fewer giant cells or hemorrhag’c. Sane 01’ the maligriaikl ;lw SW11 in gianl veil wlwxtivc~ ~t~i~ll~~lOlll~l. i’cwhws of ostc-ogctzic sc17-w)tw More difficult or occasionallp impossible to diffcrcntiate is tllc, hrvcr~ t~tw~r 0J’ Ilyperptrrn thyt-oidism. I rlasmuch as the pathogenesis of both lwions is I)rot)ably closely related, it is not swprising that it may not be possihlc to tliff’ercntiatv ti;cm Iii.;tologically. Thrwl’ore. it is important, that in c>ac:h itwtallcc~ of II histologic lesion of this kind, blood calcium, phosphorus, and ;Ilkalinc l)hosphatase determinations be pc~rformed. The possibility of hyperparat hyroidism ?:hollltl bc CV(fll lnoI’(: stro11plp snspcct,ed when rcc*~~l’rellces arc cw~ollt~twxl ( iood rwults have lwn obtained in patient,s with giant cell I(Gons ol’ thv In view crf th heriigli ,jaws I))- cm’cttagc, rescct,ionz or small doses of rildiat~iurl. tlatare ot’ this lesion, it wo111(1seem that simple currt,tagr is tllc trvatnro~lt 01 ctioiw.
Summary and Conclusions 1. True giant cell tumor 01’ the tjaw is a rt1I.e lesion while giant cell reparative granuloma, with \vhivh it, is Irequenlly conl’used, is not uncom~~~on. Two typical cases of giant cell reparative granulonia Of the ,jii\VS IlaIr? l,fV1ll clcwribed ancl the differential tliagnosis, especially as it wlntrs to giant wll I llmor, briefly discussed. 2. Clinically, giant cell reparative gratinlotna is seen in children or yout~g adult,s, frequently follows trauma, appears roentgenographically as ZIII V’Sl)nnsi\-e radiolucent lesion, and is probably best treated by simple curettagtl. 3. Pathologicall;-, wrtain ddinitc ar~~hittV~tI1lYll illld c~?-tomor~~holo~ic Pvaiurcs
tliffcretitiatc
this
~t’~~ll~llO~~lii
f’roni
trw
yiarlt
wll
tlllnor.
4. In each case of giant ccl1 reparative granulomn of the ,jaw, blood c~hcmistry studies should 1~ 1wrformrd to rule out hvpel,parathvl,oidisnl. The authors are indebted to I)r. Henry Jaffe for his permission to photograph and lultlish the histologic section of the true giant cell tumor seen in Figs. 13 and 14 and also for his encouragement and helpful criticism. The photomicrographs were prepared hy Mr. Mart R,ussin.
References 1. Jaffe,
H. L., Lichtenstein, L., and Portia, B. B.: Giant Cell Tumor of Bone, Its Pathologic Appearance, Grading, Supposed Variants and Treatment, Arch. Path. 30: 993, 1940. 2. Geschickter, C. F.: Tumors of Rone, Lancaster, Pa., 1931, The American Journal 01 Cancer, Lancaster Press, Inc., p. 287.
Ii. Jaffe,
11.. L.: Giant-Cell Reparative Granuloms, (Fibro-osseous) Dysplasia of the Jawbones. Z~ATH. 6: 159, 1953‘. Treatment of Gisnt Cell Tumors 7. Presser, T. M.: 252,
11. 12. 1X
of JZonc: J. Hone 85 Joint
Surg. 31:
1949.
Treatment of Osteoclastoma by Radiation, .J. Bone & .Joint Surg. 31: Frank: Bti8, 1949. Coley, B. I~.: Neoplasms of Bone, New York, 1!)49, Paul B. Hoeber, Inc., pp. 164, 434. &I.: ConsidErations pathogSniyues et th+rapeutiques sur les turrreurs h Dechaume, my@loplaxes, Bull. Acad. nationale med. 134: ii, 1950. Die Riesenzellgeschwulste des Kiefers, Rrosch, F.: Xeoplastnen oder Entzundungs produckte, Zahnarztlichewelt 5: 59, 1950. “lokalisierte Ostitis Fibrosa” Ein Beitrag zur Konjetzny, G. E.: Die sogenannte Kenntnis der solitaren Knochenzysten der sogonannte “schaligen myelogenen Riesenzellersarkome,” Arch. f. klin. Chir. 121: 567, 1922. Major. S. G.: Giant Crll Tumors of the Jaws, Ann. Rurg. 104: 1068, 1936.
8. Ellis, 9. 10.
Traumatic Bone Cyst, and Fibrous O~ar, St-I%., (&<.\I, RIJw., AKJ) ORAI~