| IS IT A CENTRAL GIANT CELL TUMOR OR GRANULOMA: - AN UNUSUAL CASE REPORT | 
| | A 20 year old female patient came to our dental hospital with a chief complaint of painless swelling in the left side of the face since two months.
The swelling was smaller in size to start with and was present only in the upper left back tooth region, after which it gradually increased to the present size to become evident on the face also and associated with mild pain. Patient gave a history of nasal blockage on left side since one and half months. Her past dental history revealed exfoliation of tooth from the upper left back tooth region while brushing one and half months back and about two teeth were exfoliated. Patient also gave a history of application of hot fomentation 2 months back when the swelling was associated with pain and regression in the size of the swelling after taking medications prescribed to her by a local doctor i.e. Analgesics (combination of Ibuprofen and Paracetamol) and antibiotics
On extra oral examination gross facial asymmetry was noted, with deviated nasal septum on to right side. Obliteration of the nasolabial fold present on left side. A large solitary diffuse swelling was present on left middle third of the face leading to gross facial asymmetry and distortion of the shape of the upper lip, measuring about 4 × 5 cm, roughly spherical in shape extending anteroposteriorly from midline to about 3 cm beyond the lateral canthus of eye and superoinferiorly from medial angle of eye and infra orbital margin to about one cm above the lower border of mandible. On palpation surface temperature was raised, swelling was firm in consistency and tender in the area of the medial part of swelling near the medial canthus of eye.
Intra orally diffuse swelling was present on the buccal aspect in the vestibular region, obliterating the fornix and extending anteroposteriorly from mesial aspect of left maxillary central incisor to tuberosity area and laterally extending onto labial and buccal mucosa and lifting up the left side of the upper lip and drooping the left corner of mouth. Palatally the swelling extended anteroposteriorly from the mesial aspect of left maxillary first premolar till the tuberosity area and also medially till midline. Surface of the swelling appeared to be normal elsewhere except in the area in relation to 26 (edentulous area) where the surface had some superficial ulcerations and sloughing was evident with the surrounding erythematous area and no other changes were evident. | | | | Soft tissue findings included deep periodontal pockets in relation to 24, 25, 28 and shallow periodontal pockets in relation to 21, 22 and 23 and there was generalized gingival inflammation. Hard tissue examination showed diffuse stains, plaque and calculus on all the teeth surfaces. Proclined upper anteriors was present. Grade III mobility was present in relation to 24, 25, 28 and grade I mobility in relation to 21, 22, 23. There was a clinically missing 26 and 27. Supraerupted 36 and 25 was present with 36 impinging on to the edentulous area in relation to 26 on the surface of the swelling and leading to surface ulceration and sloughing.
Considering the history of patient and clinical features lesion was thought to be a benign growth in the left maxilla and following differential diagnosis were considered juvenile ossifying fibroma, aggressive variant of central giant cell granuloma, central giant cell tumor, browns tumor of hyperparathyroidism.
Investigations such as complete hemogram and also serum biochemistry profiles and all the parameters were within the normal limits.
Radiographic examination the OPG revealed a solitary radio dense area present in the region of left maxilla extending anteroposteriorly from distal aspect of 21 to involve whole of maxilla with indistinct posterior extent. Superiorly extent of the lesion was not clear and inferiorly the lesion extended till the interdental bone of the maxilla which was destroyed. Internal structure appeared radio dense where as superiorly it appeared radioopaque. The medial margin of the lesion appeared scalloped. The tooth appeared extruded and varied amount of root resorption in relation to 25 was evident which ranged from resorption involving apical 3rd to more than half of the root structure. | | | | Computed tomography revealed presence of heterogeneous mass of soft tissue density of 20 to 24 HU enhancing up to 40 to 46 HU measuring about 6.3 × 5.4 cm noted arising from the floor of left maxillary antrum with mass effect causing total erosion or destruction of the anterior wall, lateral wall and causing pressure effect on the posterior wall and medial wall of the left maxillary sinus. No evidence of calcification or cavitation was noted. There was evidence of mass effect over the nasal septa with total obliteration of the normal airway passage of left side as evident in the coronal and axial sections of the image and is evident in the (fig-6, 7). | | | | Lesion was excised in toto with adequate safe margins and then sent for the histopathological examination which revealed numerous diffusely distributed ovoid, round and irregular shaped multinucleated giant cells with number of nuclei varying from 8 to 20 in a background of predominantly cellular connective tissue stroma. The giant cell nuclei resemble to that of mononuclear cells. In the stroma, fibrillar connective tissue with interspersed proliferating plump fibroblasts, few chronic inflammatory cells and small capillaries were evident. Certain areas of extravasated RBCs are also observed as evident in the (fig.8). | | | | The clinical, radiological and histopathological features are compatible with Central Giant Cell Tumor. Since there is a lot of controversy regarding central giant cell granuloma and central giant cell tumor, hence we subjected the surgical specimen was subjected for immunohistochemical investigations for markers like PCNA and p53. As such no specific marker exists for distinguishing granuloma and tumor; it’s only the variation in the expression of different markers that establishes the final diagnosis. It’s found that PCNA is intensely stained in case of a granuloma and mildly stained in case of a tumor. The Staining with PCNA was mild as seen in (fig 9) and that with p53 was negative as evident in (fig10). | | | | | | | | | | | | This is suggestive of a benign type of central giant cell tumor and a final diagnosis of central giant cell tumor was established. | | | | Patent when reviewed on subsequent appointments was tumor free & the profile of patient improved tremendously as evident in (fig11) & intraorally the graft was showing good sign of healing as evident in fig (12). | | | |
