Atormac
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 7064  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  » Next article
  » Previous article 
  » Table of Contents
  
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (102 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  


  In this Article
 »  Abstract
 »  Introduction
 »  Case Report
 »  Discussion
 »  References

 Article Access Statistics
    Viewed10007    
    Printed165    
    Emailed6    
    PDF Downloaded146    
    Comments [Add]    
    Cited by others 1    

Recommend this journal

   
CASE REPORT
Year : 2003  |  Volume : 51  |  Issue : 2  |  Page : 260-262

Giant cell reparative granuloma of the base of the skull presenting as a parapharyngeal mass


Departments of Radiology, Pt. B.D. Sharma PGIMS, Rohtak-124001, Haryana

Correspondence Address:
22/8 FM Medical Campus, Pt. B.D. Sharma PGIMS, Rohtak-124001, Haryana

  »  Abstract

Giant cell reparative granuloma is an infrequent non-tumoral lesion affecting the maxillary and mandibular bones and only rarely, the cranial bones. We report a case of giant cell reparative granuloma of the base of the skull in a 12-year-old female who presented with a parapharyngeal mass. Computerized Tomography (CT) showed the intracranial extension and destruction of surrounding bones.

How to cite this article:
Magu S, Mathur S K, Gulati S P, Yadav A, Kaushal V. Giant cell reparative granuloma of the base of the skull presenting as a parapharyngeal mass . Neurol India 2003;51:260-2


How to cite this URL:
Magu S, Mathur S K, Gulati S P, Yadav A, Kaushal V. Giant cell reparative granuloma of the base of the skull presenting as a parapharyngeal mass . Neurol India [serial online] 2003 [cited 2019 Dec 15];51:260-2. Available from: http://www.neurologyindia.com/text.asp?2003/51/2/260/1102


   »   Introduction Top


Jaffe coined the term 'giant cell reparative granuloma' (GCRG) in 1953 to describe lesions of the maxilla and the mandible.[1] There have been occasional reports of GCRG of the skull, especially involving the bones of the skull base. Similar tumors have been reported in the small bones of the hand and feet and long bones of the axial skeleton.[2] Although regarded as a benign process, GCRG may be locally aggressive, and surgical excision is recommended wherever possible. We report a case of GCRG presenting as a parapharyngeal mass and having an intracranial extension.

   »   Case Report
 Top

A 12-year-old female presented with complaints of headache for 7 months. This was associated with right-sided facial swelling and episodes of epistaxis for the past 3 months. The swelling was tender on examination. Peroral examination revealed a swelling around the last upper molar tooth on the right side. As the patient had trismus, a thorough examination was not possible. Radiograph showed a soft tissue shadow in the region of the nasopharynx. CT at the level of the paranasal sinuses showed a homogeneous enhancing soft tissue mass in the right parapharyngeal region with associated destruction of the posterolateral wall of the right maxillary sinus eroding the base of the skull and extending intracranially into the region of the cavernous sinus [Figure - 1] & [Figure - 2]. Laterally, the mass extended into the infratemporal fossa. Calcium phosphate, alkaline phosphatase, parathyroid hormone levels and urinalysis were normal. Fine needle aspiration smears from the swelling showed oval to spindle cells present in large and small groups and dispersed singly in a background of a large number of multinucleated giant cells, foamy macrophages, a few osteoblasts and RBCs. The cells showed moderate to abundant poorly defined cytoplasm with nuclei having fine reticulogranular chromatin and prominent nucleoli suggestive of giant cell lesion. Biopsy of the lesion showed benign osteoclastic giant cells scattered in a cellular fibroblastic stroma which was highly vascular [Figure - 3]. All these findings supported the diagnosis of GCRG and the patient was given radiotherapy as the tumor was inoperable.

   »   Discussion Top


The pathogenesis of GCRG was initially thought to be a hyperplastic reparative reaction to intraosseous hemorrhage induced by trauma.[1] Other theories on the pathogenesis include infectious and developmental causes.[4],[5] There are two forms of GCRG, central arising from bone and peripheral arising from the soft tissues of the mandible or the maxilla. The preferred site is the facial bones. There have been sporadic reports of GCRG in other parts of the body.
It is rare in the skull and has been found chiefly in the bones of the skull base: sphenoid, ethmoid and temporal bone.[2]
Chuong et al[6] have outlined six criteria (pain, rate of growth, swelling, tooth root resorption, cortical perforation and recurrences) that may be used to classify the lesion as aggressive or non-aggressive. The symptoms vary according to the site of origin. The GCRG in our patient was quite large in size. Such large enhancing masses should undergo angiography to help pre-surgical planning. The differential diagnosis of GCRG includes aneurysmal bone cyst, benign chondroblastoma, the brown tumor of hyperparathyroidism, cherubism, fibrous dysplasia, non-osteogenic fibroma, osteosarcoma and true giant cell tumor (GCT).[3] The hardest to distinguish from GCRG is the true GCT. In fact some believe that these lesions represent a continuum of the same disease process.[7],[8]
Radiological examination rarely confirms the nature of the lesion. A differential diagnosis is to exclude other lytic and expansile lesions. On radiologic evaluation GCRG and GCT are indistinguishable. Both appear as non-specific lytic lesions of bone. Although usually solitary, these lesions can be multilocular. CT is excellent at detecting bony destruction and may represent the best tool for follow-up evaluation.[9] In the case report of GCRG of the base of the skull by Cohen et al[9] there was significant enhancement of mass after injection of intravenous contrast media as also observed in the present case. MRI is best used for evaluating the soft tissue structure surrounding the tumor. Both GCRG and GCT appear as low intensity signals on T1 and T2 weighted images which enhance slightly with Gadolinium contrast.[10] Because of the non-specific nature of radiologic findings, histological evaluation and clinical behavior have been used in an attempt to distinguish GCRG from GCT.[3]
A GCT generally affects individuals between 25 and 40 years of age and very rarely under the age of 20. The stroma contains little or no intercellular material. Deposition of osteoid substance is rarely observed. The giant cells are uniformly scattered with a large quantity of nuclei and scanty cytoplasm. In GCRG the age at onset is usually younger (10 to 25 years), there are fewer giant cells with a smaller number of nuclei and a larger cytoplasmic component. Further, they are less uniformly distributed and are closely associated with microcystic or hemorrhagic zones.[2]
Differential diagnosis from brown tumors of hyperparathyroidism is based mainly on clinical and laboratory data such as serum and urinary levels of calcium, phosphates, nephrogenous CAMP, radioimmunoassay for parathyroid hormone, phosphate clearance, bone and serum alkaline phosphatase, and hydroxyprolinurea. One has to take into consideration the late onset and frequent multiplicity of the lesions. Aneurysmal cyst rarely poses problems of differentiation, especially if several zones of the sampled tissue, also involving the non-solid portion of the lesion, are studied.[2]
Treatment consists of curettage of the affected area, partial resection followed by low total dose of high-voltage radiotherapy. The main concern with radiation therapy is the potential for sarcomatous transformation.[11] As the present case was not amenable to surgery, radiotherapy was instituted and long-term results of the same will have to be observed. Prior embolization to devascularize such masses is suggested to minimize preoperative bleeding. Such devascularized tumors also respond better to radiotherapy. It is important to recognize GCRG and differentiate it from GCT of bone, for while surgery or surgery plus radiotherapy often affords permanent cure from GCRG (only 12% to 16% of recurrences in large series) GCT calls for more aggressive treatment.[2]
GCT are associated with a higher incidence of recurrence (45-62%), metastasis (1-6%) and malignant transformation in contrast to low recurrence rates of GCRG (10-15%) and absence of metastasis.[3] The histologic identification of the admixture of spindle cells, collagen, giant cells, and bony trabeculae are the most important features for the diagnosis of GCRG.[12] There is an increased incidence of osteoid hemorrhage and hemosiderin in GCRG as compared with GCT. Other characteristics include fibrosis in GCRG, the absence of necrosis in GCRG, and a greater incidence of mitotic figures in GCT.[3] GCRG affects females more often than males, mainly in the second and third decade.[13]  

  »   References Top

1.Jaffe HL. Giant-cell reparative granuloma, traumatic bone cyst, and fibrous (fibroosseous) dysplasia of the jaw bones. Oral Surg 1953;6:159-75.  Back to cited text no. 1  [PUBMED]  
2.Ciappetta P, Salvati M, Bernardi C. Giant Cell Reparative Granuloma of the skull base mimicking an intracranial tumor. Surg Neurol 1990;33:52-6.  Back to cited text no. 2    
3.Ung F, Li KK, Keith DA, McKenna MJ. Giant cell reparative granuloma of the temporal bone: case report and review of the literature. Otolaryngol Head Neck Surg 1998;118:525-9.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Hirschl S, Katz A. Giant cell reparative granuloma outside the jaw bone. Human Pathol 1974;5: 171-81.  Back to cited text no. 4  [PUBMED]  
5.Tallan EM, Olsen KD, McCaffrey TV, Unni KK, Lund BA. Advanced giant cell granuloma: a twenty-year study. Otolaryngol Head Neck Surg 1994;110:413-8.  Back to cited text no. 5  [PUBMED]  
6.Chuong R, Kaban LB, Kozakewich H, Perez-Atayde A. Central giant cell lesions of the jaws: a clinicopathologic study. J Oral Maxillofac Surg 1986;44:708-13.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Eisenbud L, Stern M, Rothberg M, Sachs SA. Central giant cell granuloma of the jaws: experiences in management of thirty seven cases. J Oral Maxillofac Surg 1988;46:376-84.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Auclair PL, Cuenin P, Kratochvil FJ, Slater LJ, Ellis GL. A clinical and histomorphologic comparison of the central giant cell granuloma and the giant cell tumor. Oral Surg 1988;66:197-208.  Back to cited text no. 8  [PUBMED]  
9.Cohen D, Granda-Ricart MC. Giant cell reparative granuloma of the base of the skull in a 4-month old infant - CT findings. Pediatr Radiol 1993;23:319-20.  Back to cited text no. 9  [PUBMED]  
10.Lewis ML, Weber AL, McKenna MJ. Reparative cell granuloma of the temporal bone. Ann Otol Rhinol Laryngol 1994;103:826-8.  Back to cited text no. 10  [PUBMED]  
11.Findlay JM, Chiasson D, Hudson AR, Chui M. Giant-cell tumor of the middle cranial fossa: case report. J Neurosurg 1987;66:924-8.  Back to cited text no. 11  [PUBMED]  
12.Bertoni F, Biscaglia R, Bacchini P. Giant cell reparative granula of the phalanx of the hand with aggressive radiographic features. Skeletal Radiol 1998;27:584-7.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Hernandez HN, Yousem DM, Clerico DM, Weinstein GS. Central giant cell granuloma of the hard palate. Otolaryngol Head Neck Surg 1998;118:871-3.  Back to cited text no. 13    

 

Top
Print this article  Email this article
Previous article Next article
Online since 20th March '04
Published by Wolters Kluwer - Medknow