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Treatment of a central giant cell lesion of the mandible with intralesional glucocorticosteroids
Vol. 91 No. 6 June 2001
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY CLINICAL NOTES Treatment of a central giant cell lesion of the mandible with intralesional glucocorticosteroids Marshall Kurtz, DMD,a Mayra Mesa, DMD, MSc,b and Pamela Alberto, DDS,c Newark, New Jersey UNIVERSITY OF MEDICINE AND DENTISTRY OF NEW JERSEY
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:636-7)
Central giant cell lesions (CGCLs) account for approximately 7% of all benign tumors of the jaws. They are most commonly found in children or young adults, and approximately 65% of cases occur in females. They are seen more often in the anterior regions of the mandible. CGCLs of the jaws appear radiographically as a welldefined unilocular or multilocular radiolucency that can cross the midline. There is a correlation between increase in size and increase in locularity.1 The most common treatment for CGCL of the jaws is surgery,1 ranging from simple curettage to resection. More recently, nonsurgical treatments have been reported. Systemic calcitonin2-4 and intralesional glucocorticosteroids6-9 have shown varying degrees of success and, when successful, have reduced the necessity for major reconstructive surgery, thus preventing any resultant large surgical defects. We report a case of a CGCL of the mandible that responded favorably to treatment with intralesional corticosteroids. CASE REPORT A 10-year-old girl was referred in May 1994 for evaluation of a radiolucent lesion in the area of her unerupted mandibular left canine that included the region of the mental foramen and produced buccal expansion. In June 1994, this CGCL was removed, and the area subsequently healed uneventfully. Four months later, she returned with a recurrent lesion that had caused expanPresented at the annual meeting of the American Academy of Oral Medicine, San Juan, Puerto Rico, April 1998. Abstract published in Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85(4):417. aIntern, Department of Oral and Maxillofacial Surgery. bProfessor, Oral Pathology, Biology and Diagnostic Science. cDirector, Undergraduate Oral and Maxillofacial Surgery. Received for publication Aug 28, 2000; returned for revision Nov 18, 2000; accepted for publication Mar 5, 2001. Copyright © 2001 by Mosby, Inc. 1079-2104/2001/$35.00 + 0 7/12/115721 doi:10.1067/moe.2001.115721
636
Fig 1. Panoramic radiograph (October 1994) shows a 5 × 3-cm partially corticated radiolucent lesion extending from mesial area of unerupted left first premolar to mesial area of right canine. sion of the symphysis and displacement of the anterior teeth (Fig 1). A radiolucent lesion extended from the mesial of the unerupted left premolar to the mesial of the right canine. Intralesional steroid treatment was used, following the protocol described by Terry and Jacoway.7 In December 1994, with the patient under local anesthesia, 15 cm3 of 10 mg/cm3 Kenalog was injected into the lesion. The injections were repeated weekly for a total of 6 injections. An oral and radiographic examination performed in January and February 1995 revealed few changes other than a decrease in tooth mobility. The patient did not report any changes in the size of the lesion. Five months later, the patient reported that the lesion appeared to have decreased in size and that she was able to place her tongue in the vestibule. A panoramic radiograph showed increased opacification. One year later, the patient reported an increase in the size of her chin. Radiographs revealed an increase in radiodensity, but a radiolucent area near the left inferior border was noted. A course of 6 weekly injections of Kenalog was performed. Six months later, she had no mobility of her lower incisors and increased radiodensity was noted on radiographic examination (Fig 2). One year later, the panoramic radiograph showed complete re-ossification of the area with the eruption of her permanent bicuspids (Fig 3).
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 91, Number 6
Kurtz, Mesa, and Alberto 637
Fig 2. Panoramic radiograph (July 1996) shows increased opacification, with septations becoming more organized and assuming patterns of nearly normal trabeculation.
Fig 3. Panoramic radiograph (October 1999) shows complete opacification of area, with almost normal pattern of trabeculation. Lamina dura appear intact. Remodeling with restoration of cortex of inferior border of mandible is seen.
DISCUSSION Although CGCLs of the jaws are benign, they have been placed into 2 clinical groups: nonaggressive and aggressive.10 Nonaggressive CGCLs are usually slowgrowing and asymptomatic, but they can cause root displacement. They can recur but are significantly less likely to recur than the aggressive type. The aggressive type is usually found in younger patients and is painful, grows rapidly, is larger overall, and often causes cortical perforation and root resorption. It is not yet possible to predict the behavior of CGCLs from known histologic, immunophenotypic, and proliferative parameters or through nuclear DNA analysis by using cytometry.11,12 The classical treatment for CGCL of the jaws is surgery, including simple curettage, curettage with peripheral ostectomy, and resection. Terry and Jacoway7 published a protocol derived by Francis Howell for treatment of CGCLs of the jaws. This protocol consists of the intralesional injection of a mixture consisting of equal parts of triamcinilone acetonide (Kenalog 10; 10 mg/mL) and a local anesthetic (Marcaine 0.5% with epinephrine 1:200,000). The suggested dosage is 2 mL/2 cm of radiolucency. The injections are given in multiple locations throughout the lesion in a weekly regimen for at least 6 weeks.6,7 Greater consideration should be given to intralesional steroids before surgery in selected cases—especially for the treatment of large lesions in which surgery can cause severe esthetic and functional deficits in the patient. The advantages of intralesional corticosteroid therapy in the treatment of selected cases of CGCLs include the following: the less-invasive nature of the procedure, the probable lower cost to the patient, the low risk, and the ability to treat the lesion surgically at a future point if necessary. The disadvantages of this technique are those of time, the inconvenience of a minimum of 6 weekly visits—which may be of concern if significant travel is necessary—and the lack of long-term outcome
studies. Because the histologic features of the CGCL of the jaw are indistinguishable from those of brown tumors of hyperparathyroidism, the latter condition should be ruled out before instituting treatment by performing the appropriate blood work-up. REFERENCES 1. Kaffe I, Ardekian L, Taicher S, Litnner M, Buchner A. Radiologic features of central giant cell granuloma of the jaws. Oral Surg Oral Med Oral Path Oral Radiol Endod 1996;81:720-6. 2. Ruggiero SL. Giant cell lesions of the jaw. Selected readings in oral and maxillofacial surgery. Vol 5. The University of Texas Southwestern Medical Center at Dallas: 3:1-32. 3. Harris M. Central giant cell granulomas of the jaws regress with calcitonin therapy. Br J Oral Maxillofac Surg 1993;31:89-94. 4. de Lange J, Rosenberg JWP, van den Akker, 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. 5. Body JJ, Jortay AM, De Jager R, Ardichvili D. Treatment with steroids of a giant cell granuloma of the maxilla. J Surg Oncol 1981;16:7-13. 6. Terry BC, Jacoway JR. Central giant cell granulomas—an alternative to surgery. Oral Surg Oral Med Oral Pathol 1988;5:572. 7. Terry BC, Jacoway JR. Management of central giant cell lesions. An alternative to surgical therapy. Oral Maxillofac Surg Clin North Am 1994;6:579-600. 8. 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. 9. Carlos R, Sedano H. Intralesional corticosteroids as an alternative treatment for central giant cell granuloma. Abstract presented at the annual meeting of the American Academy of Oral and Maxillofacial Pathology 1997. 10. Choung R, Kaban L, Kozakewich H, Perez-Atayde A. Central giant cell lesions of the jaws: a clinicopathologic study. J Oral Maxillofac Surg 1986;44:708-13. 11. O’Malley M, Pogrel MA, Stewart JCB, Silva RG, Regezi JA. Central giant cell granulomas of the jaws: phenotype and proliferation-associated markers. J Oral Pathol Med 1997;26: 159-63. 12. Eckardt A, Pogrel M, Kaban L, Chew K, Mayall B. Central giant cell granuloma of the jaws—nuclear DNA analysis using image cytometry. Int J Oral Maxillofac Surg 1989;18:3-6. Reprint requests: Marshall Kurtz, DMD 39 Hemingway St Pittsburgh, PA 15213 [email protected]
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY CLINICAL NOTES Treatment of a central giant cell lesion of the mandible with intralesional glucocorticosteroids Marshall Kurtz, DMD,a Mayra Mesa, DMD, MSc,b and Pamela Alberto, DDS,c Newark, New Jersey UNIVERSITY OF MEDICINE AND DENTISTRY OF NEW JERSEY
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:636-7)
Central giant cell lesions (CGCLs) account for approximately 7% of all benign tumors of the jaws. They are most commonly found in children or young adults, and approximately 65% of cases occur in females. They are seen more often in the anterior regions of the mandible. CGCLs of the jaws appear radiographically as a welldefined unilocular or multilocular radiolucency that can cross the midline. There is a correlation between increase in size and increase in locularity.1 The most common treatment for CGCL of the jaws is surgery,1 ranging from simple curettage to resection. More recently, nonsurgical treatments have been reported. Systemic calcitonin2-4 and intralesional glucocorticosteroids6-9 have shown varying degrees of success and, when successful, have reduced the necessity for major reconstructive surgery, thus preventing any resultant large surgical defects. We report a case of a CGCL of the mandible that responded favorably to treatment with intralesional corticosteroids. CASE REPORT A 10-year-old girl was referred in May 1994 for evaluation of a radiolucent lesion in the area of her unerupted mandibular left canine that included the region of the mental foramen and produced buccal expansion. In June 1994, this CGCL was removed, and the area subsequently healed uneventfully. Four months later, she returned with a recurrent lesion that had caused expanPresented at the annual meeting of the American Academy of Oral Medicine, San Juan, Puerto Rico, April 1998. Abstract published in Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85(4):417. aIntern, Department of Oral and Maxillofacial Surgery. bProfessor, Oral Pathology, Biology and Diagnostic Science. cDirector, Undergraduate Oral and Maxillofacial Surgery. Received for publication Aug 28, 2000; returned for revision Nov 18, 2000; accepted for publication Mar 5, 2001. Copyright © 2001 by Mosby, Inc. 1079-2104/2001/$35.00 + 0 7/12/115721 doi:10.1067/moe.2001.115721
636
Fig 1. Panoramic radiograph (October 1994) shows a 5 × 3-cm partially corticated radiolucent lesion extending from mesial area of unerupted left first premolar to mesial area of right canine. sion of the symphysis and displacement of the anterior teeth (Fig 1). A radiolucent lesion extended from the mesial of the unerupted left premolar to the mesial of the right canine. Intralesional steroid treatment was used, following the protocol described by Terry and Jacoway.7 In December 1994, with the patient under local anesthesia, 15 cm3 of 10 mg/cm3 Kenalog was injected into the lesion. The injections were repeated weekly for a total of 6 injections. An oral and radiographic examination performed in January and February 1995 revealed few changes other than a decrease in tooth mobility. The patient did not report any changes in the size of the lesion. Five months later, the patient reported that the lesion appeared to have decreased in size and that she was able to place her tongue in the vestibule. A panoramic radiograph showed increased opacification. One year later, the patient reported an increase in the size of her chin. Radiographs revealed an increase in radiodensity, but a radiolucent area near the left inferior border was noted. A course of 6 weekly injections of Kenalog was performed. Six months later, she had no mobility of her lower incisors and increased radiodensity was noted on radiographic examination (Fig 2). One year later, the panoramic radiograph showed complete re-ossification of the area with the eruption of her permanent bicuspids (Fig 3).
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 91, Number 6
Kurtz, Mesa, and Alberto 637
Fig 2. Panoramic radiograph (July 1996) shows increased opacification, with septations becoming more organized and assuming patterns of nearly normal trabeculation.
Fig 3. Panoramic radiograph (October 1999) shows complete opacification of area, with almost normal pattern of trabeculation. Lamina dura appear intact. Remodeling with restoration of cortex of inferior border of mandible is seen.
DISCUSSION Although CGCLs of the jaws are benign, they have been placed into 2 clinical groups: nonaggressive and aggressive.10 Nonaggressive CGCLs are usually slowgrowing and asymptomatic, but they can cause root displacement. They can recur but are significantly less likely to recur than the aggressive type. The aggressive type is usually found in younger patients and is painful, grows rapidly, is larger overall, and often causes cortical perforation and root resorption. It is not yet possible to predict the behavior of CGCLs from known histologic, immunophenotypic, and proliferative parameters or through nuclear DNA analysis by using cytometry.11,12 The classical treatment for CGCL of the jaws is surgery, including simple curettage, curettage with peripheral ostectomy, and resection. Terry and Jacoway7 published a protocol derived by Francis Howell for treatment of CGCLs of the jaws. This protocol consists of the intralesional injection of a mixture consisting of equal parts of triamcinilone acetonide (Kenalog 10; 10 mg/mL) and a local anesthetic (Marcaine 0.5% with epinephrine 1:200,000). The suggested dosage is 2 mL/2 cm of radiolucency. The injections are given in multiple locations throughout the lesion in a weekly regimen for at least 6 weeks.6,7 Greater consideration should be given to intralesional steroids before surgery in selected cases—especially for the treatment of large lesions in which surgery can cause severe esthetic and functional deficits in the patient. The advantages of intralesional corticosteroid therapy in the treatment of selected cases of CGCLs include the following: the less-invasive nature of the procedure, the probable lower cost to the patient, the low risk, and the ability to treat the lesion surgically at a future point if necessary. The disadvantages of this technique are those of time, the inconvenience of a minimum of 6 weekly visits—which may be of concern if significant travel is necessary—and the lack of long-term outcome
studies. Because the histologic features of the CGCL of the jaw are indistinguishable from those of brown tumors of hyperparathyroidism, the latter condition should be ruled out before instituting treatment by performing the appropriate blood work-up. REFERENCES 1. Kaffe I, Ardekian L, Taicher S, Litnner M, Buchner A. Radiologic features of central giant cell granuloma of the jaws. Oral Surg Oral Med Oral Path Oral Radiol Endod 1996;81:720-6. 2. Ruggiero SL. Giant cell lesions of the jaw. Selected readings in oral and maxillofacial surgery. Vol 5. The University of Texas Southwestern Medical Center at Dallas: 3:1-32. 3. Harris M. Central giant cell granulomas of the jaws regress with calcitonin therapy. Br J Oral Maxillofac Surg 1993;31:89-94. 4. de Lange J, Rosenberg JWP, van den Akker, 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. 5. Body JJ, Jortay AM, De Jager R, Ardichvili D. Treatment with steroids of a giant cell granuloma of the maxilla. J Surg Oncol 1981;16:7-13. 6. Terry BC, Jacoway JR. Central giant cell granulomas—an alternative to surgery. Oral Surg Oral Med Oral Pathol 1988;5:572. 7. Terry BC, Jacoway JR. Management of central giant cell lesions. An alternative to surgical therapy. Oral Maxillofac Surg Clin North Am 1994;6:579-600. 8. 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. 9. Carlos R, Sedano H. Intralesional corticosteroids as an alternative treatment for central giant cell granuloma. Abstract presented at the annual meeting of the American Academy of Oral and Maxillofacial Pathology 1997. 10. Choung R, Kaban L, Kozakewich H, Perez-Atayde A. Central giant cell lesions of the jaws: a clinicopathologic study. J Oral Maxillofac Surg 1986;44:708-13. 11. O’Malley M, Pogrel MA, Stewart JCB, Silva RG, Regezi JA. Central giant cell granulomas of the jaws: phenotype and proliferation-associated markers. J Oral Pathol Med 1997;26: 159-63. 12. Eckardt A, Pogrel M, Kaban L, Chew K, Mayall B. Central giant cell granuloma of the jaws—nuclear DNA analysis using image cytometry. Int J Oral Maxillofac Surg 1989;18:3-6. Reprint requests: Marshall Kurtz, DMD 39 Hemingway St Pittsburgh, PA 15213 [email protected]