Central Giant Cell Granuloma (CGCG)

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The age of this patient, the swelling, and the location in the anterior mandible crossing the midline are all clinical characteristics that can be consistent with central giant cell granuloma (CGCG). The histology, however, is not supportive of CGCG.

Jaffe first coined the term "reparative" for central giant cell granuloma. Most pathologists have since dropped the term "reparative" for lack of evidence that the pathogenesis is a reparative process. CGCG is described as a non-neoplastic process and yet can behave in a very aggressive and expansile manner, destroying bone and displacing teeth. Over 60% of CGCG cases occur in patients younger than 30 years of age, with twice as many occurrences in females as in males. CGCG is classified into aggressive and non-aggressive types; the aggressive type tends to occur in younger patients and causes disfiguration, especially after surgery. Over 70% of cases occur in the mandible anterior to the first molar tooth. This lesion has also been described in other cranio-facial and small long bones such as those of the hands and feet.

The usual treatment for CGCG is surgery, ranging from curettage and en bloc to resection. The latter is used in aggressive and recurring cases. In the past ten years or so, alternatives to surgery have emerged with successful results, saving some patients from facial disfigurement. Steroid injections are the most successful alternative treatment thus far; they require injections weekly or every 2-3 weeks, have no known side effects (even in children), and are the least expensive alternative treatment. Other treatments include: calcitonin injections or nasal spray, which require daily injections or a nasal spray of salmon calcitonin for about a year and are safe for pregnant females; and interferon alfa-2a injections, which are administered 2-3 times per week for several months and are the most expensive alternative treatment. A report by Carlos and Sedano from Guatemala presented four patients with large CGCG cases treated with steroid injections. They demonstrated that regular steroid injections led to remarkable responses in all four patients without any side effects. All four patients had initial biopsies confirming the histological diagnosis of CGCG and had endocrine testing to rule out hyperparathyroidism. Two were pediatric patients, two-and-a-half and six years of age, with large lesions of the mandible and maxilla, respectively. They responded more rapidly to steroid injections than did the other two patients, who were adults of 31 and 34 years of age with large lesions of the maxilla and mandible, respectively. Injections were administered every two to three weeks. Complete healing, with small residual radiolucency requiring no further treatment, was noted in three of the patients. One patient, the six-year-old boy, had a maxillary swelling that was reduced from 5 cm in size to only 0.5 cm after four injections. The surgical specimen from the six-year-old consisted of fibrocollagenous stroma with few giant cells in comparison to the original biopsy, which consisted of loose and vascular granulation tissue with many giant cells. Fibrocollagenous stroma, with or without giant cells, has been described in association with both calcitonin and steroid treatment. There was no evidence of recurrence in these patients after 2-7 years of follow-up, nor were there any steroid-related complications in any of the patients. One must keep in mind that this report involves a very small number of cases; few firm conclusions can be reached, but the results are remarkable and show a more favorable outcome than surgical intervention, particularly in large and aggressively behaving pediatric cases.