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Recurrent giant cell reparative granuloma of hard palate: role of Tc-99m-MDP three-phase bone scan
Journal of Clinical Imaging 24 (2000) 143 ± 145
Recurrent giant cell reparative granuloma of hard palate: role of Tc-99m-MDP three-phase bone scan Rakesh Kumara,*, Atul Marwaha, Ritesh Guptaa, Budhadev Chaudharyb, Sanjay Sharmac a
Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India b Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, India c Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India Received 20 March 2000; accepted 30 May 2000
Abstract A 42-year-old female presented with pain in the hard palate following surgical curettage for giant cell reparative granuloma. Radiographs of the face at this time did not reveal any abnormality. The surgeons' query was to differentiate fibrosis from recurrence before considering her for recurettage. The three-phase bone scan helped in establishing the diagnosis of recurrence, which was confirmed after histological examination of the curettaged tissue. D 2000 Elsevier Science Inc. All rights reserved. Keywords: Giant cell reparative granuloma; Bone scan; Recurrence
1. Introduction Giant cell reparative granuloma is an uncommon benign lesion that possibly represents reparative process in response to bone hemorrhage, trauma or inflammation. Though the jawbone is the commonest site [1], it may also involve the paranasal sinuses [2], bones at the base of the skull [3], the facial bones [4], the shaft or the metaphysis of the phalanges, metacarpals and metatarsal bones [5,6]. However, giant cell reparative granuloma of the hard palate is a rare entity. Our literature review revealed no previously reported cases of the same. We present the case of a 42-year-old female patient who had a giant cell reparative granuloma of the hard palate. After surgical removal, she had a recurrence that was detected by Tc-99m-methylene diphosphonate (MDP) bone scan. 2. Case report A 42-year-old female presented with a 2-month history of a swelling and dull aching pain in the hard palate. There
* Corresponding author. c/o Dr. G.S. Pant, E-77, Ansari Nagar (East), New Delhi 110029, India. Tel.: +91-11-625-9597; fax: +91-11-686-2663. E-mail address: [email protected] (R. Kumar).
was no history of trauma. There was no history of anaesthesia, headache or any nasal symptoms. The previous medical history was unremarkable. Physical examination revealed a 1 1 cm2 non-mobile mass on the hard palate. It was non-pulsatile and non-tender. The blood counts and biochemical tests were normal. Serum calcium was 9.9 mg/ dl (normal, 9.0 ±11.5 mg/dl) and phosphate levels were 4.0 mg/dl (normal, 2.5 ± 4.5 mg/dl). The serum parathyroid levels were 20 pg/ml (normal, 12 ±72 pg/ml). The radiographs of the skull showed a multilocular cystic lesion arising from palatine process of maxillary bone. The CT scan revealed an expanding multilocular, non-homogeneous density lesion with scalloped margin. A biopsy revealed many multinucleated giant cells, distributed among the collagenous tissue and foci of hemorrhage, which were compatible with the diagnosis of giant cell reparative granuloma. Surgical curettage of the mass was performed with subsequent relief from symptoms. The patient was asymptomatic for 3 years, after which she complained of pain in the same region. X-ray done at this time did not reveal any abnormality. She was referred for evaluation of the possibility of recurrence. A three-phase bone scan was performed after injecting 740 MBq of Tc-99m-MDP intravenously (Fig. 1). The three-phase bone scan revealed an abnormal focus of increased blood flow and blood pool in the region of the hard palate. Three-hour delayed images showed abnormal increased radiotracer uptake in the same
0899-7071/00/$ ± see front matter D 2000 Elsevier Science Inc. All rights reserved. PII: S 0 8 9 9 - 7 0 7 1 ( 0 0 ) 0 0 1 8 6 - 8
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R. Kumar et al. / Journal of Clinical Imaging 24 (2000) 143±145
region. These findings were suggestive of recurrence of the giant cell reparative granuloma. Re-curettage was performed and the histopathology confirmed the recurrence. The patient has remained asymptomatic since then.
years. (2) The central or bony type generally involves the mandible, but may also involve the maxilla, ethmoids, sphenoids or temporal bone. It typically presents with a painless enlargement usually in the second or third decade of life [7]. Radiographically, giant cell reparative granuloma shows a well-defined multilocular lucency within the bone. Some lesions may be unilocular or ill defined. Microscopically, the lesion shows prominent fibrovascular proliferation with associated hemorrhage and variable number of giant cells. Giant cells are most densely concentrated around the areas of hemorrhage and related vascular spaces. Interspersed are hemosiderin deposits and areas of bone formation. The histological picture is indistinguishable from a brown tumor; hence, parathyroid levels should be done in all cases. Other differential diagnosis includes aneurysmal bone cyst, cherubism and true giant cell tumors. Giant cell reparative granuloma generally contains fewer nuclei than the true giant cell tumors of the bone [1,5]. Giant cell reparative granuloma has a benign clinical course with treatment based on surgical debulking and curettage. There is good response to treatment and recurrence is rare (4 ± 12%) [1]. Biopsy with histological confirmation remains the only investigation to definitively diagnose a recurrence. Bone scan can help in such cases to differentiate between recurrence and fibrosis. Increased blood flow, blood pool and bone uptake in bone scan are suggestive of abnormal increased bone vascularity and bone remodeling. These features are seen in primary bone tumor as well as recurrence. Other radiotracers like thallium-201 chloride and Tc-99m-Sestamibi have also been reported to be more accurate than CT scan or MRI in follow-up of the patients with treated bone and soft tissue sarcoma [8]. In the present case report, the surgeons' query was to differentiate fibrosis from recurrence before considering him for recurettage. The three-phase bone scan helped in establishing the diagnosis of recurrence, which was confirmed after histological examination of the curettaged tissue. Recurrence in giant cell reparative granuloma is rare, but in cases of clinical suspicion, bone scan can be a useful diagnostic modality and may preclude the need for biopsy.
3. Discussion
References
Jaffe [1] initially described giant cell reparative granuloma in the jawbone. The hypothesis that it is a reparative reaction to a traumatic injury is questionable, as the history of trauma is not usually elicitable. Clinical symptoms include local swelling, pain, tenderness, anaesthesia, headache, diplopia and epistaxis. Clinically, it can be of two types. (1) The peripheral or soft tissue type presents as a mass on the gingival region or alveolar mucosa and anterior to the molars, more commonly in the mandible than the maxilla. It is more common in women over the age of 20
[1] Jaffe HL. Giant cell reparative granuloma, traumatic bone cyst and fibrous (fibro-osseous) dysplasia of the jaw bone. Oral Surg 1953;6:159 ± 75. [2] Rhea JT, Weber AL. Giant cells granuloma of the sinuses. Radiology 1983;147:135. [3] Cohen D, Granda-Ricart MC. Giant cell reparative granuloma of the base of the skull in 4-month infant CT findings. Pediatr Radiol 1993;23:319 ± 20. [4] Som PM, Lawson W, Cohen BA. Giant cell lesions off the facial bones. Radiology 1983;147:129 ± 34. [5] Lorenzo JC, Dorfman HD. Giant cell reparative granuloma of short tubular bones of the hands and feet. Am J Surg Pathol 1980;4:551 ± 63.
Fig. 1. The Tc-99m-MDP three-phase bone scan. (A) Blood flow images show an area of increased blood flow in the region of hard palate (arrow). (B) Blood pool images (anterior and lateral views) show increased blood pool (open curved arrow) in the same region. (C) Delayed images (anterior and lateral views) show increased radiotracer uptake (solid curved arrow) in the same region of hard palate.
R. Kumar et al. / Journal of Clinical Imaging 24 (2000) 143±145 [6] Ayula AG, Ro JY, Raymond AK. Anderson's Pathology: Bone Tumors. 10th ed. New York: Mosby Yearbook Inc, 1996. pp. 2531 ± 73. [7] McFarland M, Abaza NA, El-Mofty S. Anderson's Pathology: Mouth, Teeth, and Pharynx. 10th ed. New York: Mosby Yearbook Inc, 1996. pp. 1563 ± 651.
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[8] Kostakoglu L, Panicek DM, Divgi CR, Botet J, Healey J, Larson SM, Abdel-Dayem HM. Correlation of the findings of Thallium-201 chloride scans with those of other imaging modalities and histology following therapy in patients with bone and soft tissue sarcoma. Eur J Nucl Med 1995;22:1232 ± 7.
Recurrent giant cell reparative granuloma of hard palate: role of Tc-99m-MDP three-phase bone scan Rakesh Kumara,*, Atul Marwaha, Ritesh Guptaa, Budhadev Chaudharyb, Sanjay Sharmac a
Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India b Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, India c Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India Received 20 March 2000; accepted 30 May 2000
Abstract A 42-year-old female presented with pain in the hard palate following surgical curettage for giant cell reparative granuloma. Radiographs of the face at this time did not reveal any abnormality. The surgeons' query was to differentiate fibrosis from recurrence before considering her for recurettage. The three-phase bone scan helped in establishing the diagnosis of recurrence, which was confirmed after histological examination of the curettaged tissue. D 2000 Elsevier Science Inc. All rights reserved. Keywords: Giant cell reparative granuloma; Bone scan; Recurrence
1. Introduction Giant cell reparative granuloma is an uncommon benign lesion that possibly represents reparative process in response to bone hemorrhage, trauma or inflammation. Though the jawbone is the commonest site [1], it may also involve the paranasal sinuses [2], bones at the base of the skull [3], the facial bones [4], the shaft or the metaphysis of the phalanges, metacarpals and metatarsal bones [5,6]. However, giant cell reparative granuloma of the hard palate is a rare entity. Our literature review revealed no previously reported cases of the same. We present the case of a 42-year-old female patient who had a giant cell reparative granuloma of the hard palate. After surgical removal, she had a recurrence that was detected by Tc-99m-methylene diphosphonate (MDP) bone scan. 2. Case report A 42-year-old female presented with a 2-month history of a swelling and dull aching pain in the hard palate. There
* Corresponding author. c/o Dr. G.S. Pant, E-77, Ansari Nagar (East), New Delhi 110029, India. Tel.: +91-11-625-9597; fax: +91-11-686-2663. E-mail address: [email protected] (R. Kumar).
was no history of trauma. There was no history of anaesthesia, headache or any nasal symptoms. The previous medical history was unremarkable. Physical examination revealed a 1 1 cm2 non-mobile mass on the hard palate. It was non-pulsatile and non-tender. The blood counts and biochemical tests were normal. Serum calcium was 9.9 mg/ dl (normal, 9.0 ±11.5 mg/dl) and phosphate levels were 4.0 mg/dl (normal, 2.5 ± 4.5 mg/dl). The serum parathyroid levels were 20 pg/ml (normal, 12 ±72 pg/ml). The radiographs of the skull showed a multilocular cystic lesion arising from palatine process of maxillary bone. The CT scan revealed an expanding multilocular, non-homogeneous density lesion with scalloped margin. A biopsy revealed many multinucleated giant cells, distributed among the collagenous tissue and foci of hemorrhage, which were compatible with the diagnosis of giant cell reparative granuloma. Surgical curettage of the mass was performed with subsequent relief from symptoms. The patient was asymptomatic for 3 years, after which she complained of pain in the same region. X-ray done at this time did not reveal any abnormality. She was referred for evaluation of the possibility of recurrence. A three-phase bone scan was performed after injecting 740 MBq of Tc-99m-MDP intravenously (Fig. 1). The three-phase bone scan revealed an abnormal focus of increased blood flow and blood pool in the region of the hard palate. Three-hour delayed images showed abnormal increased radiotracer uptake in the same
0899-7071/00/$ ± see front matter D 2000 Elsevier Science Inc. All rights reserved. PII: S 0 8 9 9 - 7 0 7 1 ( 0 0 ) 0 0 1 8 6 - 8
144
R. Kumar et al. / Journal of Clinical Imaging 24 (2000) 143±145
region. These findings were suggestive of recurrence of the giant cell reparative granuloma. Re-curettage was performed and the histopathology confirmed the recurrence. The patient has remained asymptomatic since then.
years. (2) The central or bony type generally involves the mandible, but may also involve the maxilla, ethmoids, sphenoids or temporal bone. It typically presents with a painless enlargement usually in the second or third decade of life [7]. Radiographically, giant cell reparative granuloma shows a well-defined multilocular lucency within the bone. Some lesions may be unilocular or ill defined. Microscopically, the lesion shows prominent fibrovascular proliferation with associated hemorrhage and variable number of giant cells. Giant cells are most densely concentrated around the areas of hemorrhage and related vascular spaces. Interspersed are hemosiderin deposits and areas of bone formation. The histological picture is indistinguishable from a brown tumor; hence, parathyroid levels should be done in all cases. Other differential diagnosis includes aneurysmal bone cyst, cherubism and true giant cell tumors. Giant cell reparative granuloma generally contains fewer nuclei than the true giant cell tumors of the bone [1,5]. Giant cell reparative granuloma has a benign clinical course with treatment based on surgical debulking and curettage. There is good response to treatment and recurrence is rare (4 ± 12%) [1]. Biopsy with histological confirmation remains the only investigation to definitively diagnose a recurrence. Bone scan can help in such cases to differentiate between recurrence and fibrosis. Increased blood flow, blood pool and bone uptake in bone scan are suggestive of abnormal increased bone vascularity and bone remodeling. These features are seen in primary bone tumor as well as recurrence. Other radiotracers like thallium-201 chloride and Tc-99m-Sestamibi have also been reported to be more accurate than CT scan or MRI in follow-up of the patients with treated bone and soft tissue sarcoma [8]. In the present case report, the surgeons' query was to differentiate fibrosis from recurrence before considering him for recurettage. The three-phase bone scan helped in establishing the diagnosis of recurrence, which was confirmed after histological examination of the curettaged tissue. Recurrence in giant cell reparative granuloma is rare, but in cases of clinical suspicion, bone scan can be a useful diagnostic modality and may preclude the need for biopsy.
3. Discussion
References
Jaffe [1] initially described giant cell reparative granuloma in the jawbone. The hypothesis that it is a reparative reaction to a traumatic injury is questionable, as the history of trauma is not usually elicitable. Clinical symptoms include local swelling, pain, tenderness, anaesthesia, headache, diplopia and epistaxis. Clinically, it can be of two types. (1) The peripheral or soft tissue type presents as a mass on the gingival region or alveolar mucosa and anterior to the molars, more commonly in the mandible than the maxilla. It is more common in women over the age of 20
[1] Jaffe HL. Giant cell reparative granuloma, traumatic bone cyst and fibrous (fibro-osseous) dysplasia of the jaw bone. Oral Surg 1953;6:159 ± 75. [2] Rhea JT, Weber AL. Giant cells granuloma of the sinuses. Radiology 1983;147:135. [3] Cohen D, Granda-Ricart MC. Giant cell reparative granuloma of the base of the skull in 4-month infant CT findings. Pediatr Radiol 1993;23:319 ± 20. [4] Som PM, Lawson W, Cohen BA. Giant cell lesions off the facial bones. Radiology 1983;147:129 ± 34. [5] Lorenzo JC, Dorfman HD. Giant cell reparative granuloma of short tubular bones of the hands and feet. Am J Surg Pathol 1980;4:551 ± 63.
Fig. 1. The Tc-99m-MDP three-phase bone scan. (A) Blood flow images show an area of increased blood flow in the region of hard palate (arrow). (B) Blood pool images (anterior and lateral views) show increased blood pool (open curved arrow) in the same region. (C) Delayed images (anterior and lateral views) show increased radiotracer uptake (solid curved arrow) in the same region of hard palate.
R. Kumar et al. / Journal of Clinical Imaging 24 (2000) 143±145 [6] Ayula AG, Ro JY, Raymond AK. Anderson's Pathology: Bone Tumors. 10th ed. New York: Mosby Yearbook Inc, 1996. pp. 2531 ± 73. [7] McFarland M, Abaza NA, El-Mofty S. Anderson's Pathology: Mouth, Teeth, and Pharynx. 10th ed. New York: Mosby Yearbook Inc, 1996. pp. 1563 ± 651.
145
[8] Kostakoglu L, Panicek DM, Divgi CR, Botet J, Healey J, Larson SM, Abdel-Dayem HM. Correlation of the findings of Thallium-201 chloride scans with those of other imaging modalities and histology following therapy in patients with bone and soft tissue sarcoma. Eur J Nucl Med 1995;22:1232 ± 7.