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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 19  |  Issue : 2  |  Page : 157-160

Massive maxillary peripheral giant cell granuloma in a 12-year-old male: Case report


1 Department of Oral Diagnostic Sciences, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Radiology, Faculty of Clinical Sciences, Bayero University, Kano, Nigeria
3 Department of Pathology, Faculty of Clinical Sciences, Bayero University, Kano, Nigeria
4 Department of Child Dental Health, Faculty of Dentistry, Bayero University Kano, Aminu Kano Teaching Hospital, Kano, Nigeria
5 Department of Oral Diagnostic Sciences, Aminu Kano Teaching Hospital; Department of Oral Diagnostic Sciences, Faculty of Dentistry, Bayero University Kano, Nigeria; Department of Oral and Maxillofacial Radiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
6 Department of Oral and Maxillofacial Radiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Department of Oral Diagnosis and Dentomaxillofacial Radiology, Okayama University Hospital, Okayama, Japan

Date of Submission11-Apr-2021
Date of Decision20-Oct-2021
Date of Acceptance03-Nov-2021
Date of Web Publication23-Nov-2022

Correspondence Address:
Babatunde O Bamgbose
Department of Oral Diagnostic Sciences, Bayero University Kano, Kano

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_18_21

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  Abstract 


Peripheral giant cell granuloma (PGCG) is a benign, hyperplastic reactive lesion arising from the mucoperiosteum of the alveolar ridge following chronic irritation or trauma. It is characterized by the presence of multinucleated giant cells. We report a 12-year-old male with massive maxillary PGCG where ultrasonography was used as the first line of investigation to determine the severity and vascularity of the lesion based on differential diagnosis. The ultrasonographic findings showed well-defined hyperechoic multifocal echogenic areas and low-resistant spectral waveforms obtained on Doppler were consistent with benign soft tissue lesions. The histopathological examination showed that of a typical multinucleated giant cell with the diagnosis of PGCG.

Keywords: Diagnosis, giant cells, gingival lesions, hyperechoic, osteoclast


How to cite this article:
Ewansiha G, Goshi AA, Ibrahim IM, Yahaya A, Bamgbose BO, Asaumi JI. Massive maxillary peripheral giant cell granuloma in a 12-year-old male: Case report. Niger J Basic Clin Sci 2022;19:157-60

How to cite this URL:
Ewansiha G, Goshi AA, Ibrahim IM, Yahaya A, Bamgbose BO, Asaumi JI. Massive maxillary peripheral giant cell granuloma in a 12-year-old male: Case report. Niger J Basic Clin Sci [serial online] 2022 [cited 2022 Nov 29];19:157-60. Available from: https://www.njbcs.net/text.asp?2022/19/2/157/361889




  Introduction Top


Gingival overgrowths are common features of gingival disease encountered regularly by clinicians. They result from local inflammatory response, drugs or systemic disease, and manifest with a wide range of gingival lesions from reactive, inflammatory to neoplastic.[1] Peripheral giant cell granuloma (PGCG) is a benign, hyperplastic reactive lesion that develops on the gingival or alveolar ridge of the jaw. It is thought to arise either from periodontal ligament or from the mucoperiosteum of the alveolar ridge. It is seen anywhere on the gingival or alveolar mucosa, but most of them occur anterior to the molars and vary widely in size commonly between 0.5–1.5 cm in diameter. Therefore, lesions larger than 1.5 cm are rare.[1],[2],[3],[4] The etiology is unclear, but the roles of trauma and local irritation has significantly contributed to the development of the lesion.

PGCG is one of the most prevalent giant cell lesions of the jaws and seen commonly in females, occurring more frequently in the mandible than the maxilla.[2],[3],[4] The most common sites of occurrence, in descending order, are posterior of the mandible (35.2%), anterior of the mandible (29.5%), anterior of the maxilla (28.2%), and posterior of the maxilla (7.1%).[2] It presents as a pedunculated or sessile painless mass on the gingival and may vary from dark red to reddish purple color.[4],[5] Histologically, it is characterized by abundant proliferating multinucleated giant cells in connective tissue stroma containing ovoid or spindle-shaped cells of mesenchymal origin.[3],[4] Surgical excision is the appropriate treatment.

We describe the clinical, sonographic, and histopathological findings as well as management of a large peripheral giant cell granuloma seen on the anterior maxillary gingivae of a young male.


  Case Report Top


A 12-year-old boy accompanied by his father presented to the Department of Radiology of Aminu Kano Teaching Hospital with growth on the anterior maxillary gingivae that started 3 months prior to presentation and has progressively increased in size. The family and medical history were non-contributory. There was no history of trauma or medications before the onset of swelling. The father reported the use of herbal medicament during the earlier stage of swelling. There was an episode of unprovoked mild bleeding from the lesion 2 weeks prior to presentation at the Department.

Ethical approval was obtained from Ethic and Research Committee of the hospital with approval number NHREC/28/01/2020/AKTH/EC/2946. Approved date: 05 –Dec- 2020.

Physical examination was unremarkable. The intraoral examination revealed a large purplish-red, nodular surface, well-demarcated, solitary, ovoid-shaped, pedunculated, soft in consistency, soft-tissue mass, measuring 8 × 6 cm, located on the attached maxillary gingivae between the upper right permanent first premolar and upper left permanent canine with an extension into the anterior palatal mucosa [Figure 1]a and [Figure 1]b. The mass bled on provocation. Patient dentition was adequate for his age except for gross displacement of maxillary right central incisor, lateral incisor, canine, maxillary left central and lateral incisors, and associated poor oral hygiene. Based on clinical findings, the preliminary differential diagnosis included pyogenic granuloma, peripheral giant cell granuloma, peripheral ossifying fibroma, metastatic carcinoma of gingiva, and hemangioma. Ultrasound scan was requested to refine the diagnosis.
Figure 1: (a) Clinical photograph of the gingival soft tissue lesion involving the attached maxillary gingiva, (b) Intraoral view of gingival soft tissue swelling involving 11,12,13,14,21,22 and 23 extending into the anterior palatal mucosa

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Using a 7.5-MHz linear transducer, the upper lip was retracted to reveal a huge, well-defined, fairly ovoid-shaped, hyperechoic mass, measuring 43.5 x 25.6 mm with multifocal echogenic areas due to calcification. On Doppler interrogation, it showed high intraparenchymal flow with low-resistant spectral pattern. The findings were those of benign, soft-tissue lesion [Figure 2] and [Figure 3]. CT angiogram was advised to determine the extent of the mass and its vascularity. Due to patient's financial constraints, CT angiography could not be performed.
Figure 2: Sonographic features of a massive gingival lesion demonstrating hyperechogenic mass with echogenic area due to calcification

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Figure 3: On Doppler interrogation showing low resistance arterial wavefront

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Complete blood count and renal function test showed normal results. Patient was referred for incisional biopsy and routine histopathological investigation. The Hematoxylin and Eosin (H and E) sections revealed an irregular-shaped tissue comprising an edematous fibro-collagenous connective tissue stroma containing ovoid plumb to spindle-shaped fibroblasts, chronic inflammatory cells predominantly lymphocytes and plasma cells and within were embedded abundant multi-sized osteoclast-like multinucleated giant cells with few areas of hemorrhage. The histopathological diagnosis revealed a PGCG [Figure 4].
Figure 4: Photomicrograph of H and E X20 stained section of peripheral giant cell granuloma showing fibrocollageneous tissue containing numerous multinucleated giant cells with bland nuclei, moderate lymphocytic, and histiocytic infiltrates

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The treatment plan was surgical excision, but the patient could not afford the cost of treatment, and defaulted after final diagnosis.

The problem encountered in managing this patient included the late presentation, which resulted in a huge mass and the inability to optimize nutrition due to difficulty in feeding occasioned by the intra-oral mass. A local Non-Governmental Organization offered to fund surgery, but the patient could not be reached on phone. At the last attempt by telephone, it was confirmed that the patient passed away and the cause of death could not be ascertained.


  Discussion Top


Reactive lesions of the gingiva are tumor-like hyperplasia that develop in response to chronic local irritation or trauma and may present as PGCG, pyogenic granuloma, peripheral ossifying fibroma and gingival fibromatosis.[6],[7] The prevalence rate of reactive gingival lesions is 5.6%–30.12%, and they are not uncommon among oral reactive lesions.[1],[6] The etiology is not clear, but several factors can be attributed including tooth extraction, ill-fitting denture, defective dental restoration, and chronic irritation.[2],[3],[7] Reactive gingival lesions may present, in some instances, with similar clinical appearance that pose a great challenge in the differential diagnosis. However, the PGCG, also called giant cell epulis, can be differentiated from other reactive lesions mainly by the abundance of multinucleated giant cells, and only radiological evaluation can establish the distinction between the central giant cell granulomas and the peripheral giant cell granulomas.[1],[7] PGCG is one of the most prevalent giant cell lesions of the jaws.[2],[6] Effiom et al.,[1] Shadman et al.,[2] and Naderi et al.[6] reported that it occurred more in female patients than in males, possibly due to the expression of estrogen receptor protein observed in nuclear and cytoplasmic component of multinucleated giant cells in PGCG.[8] PGCG appears to have a mandibular site predilection, particularly the buccal posterior region.[1],[2],[4],[5],[7] It can present at any age, but commonly seen in fourth to sixth decades of life.

In the present case, the PGCG was located on the anterior region of maxilla of a young male; and excessively large, measuring 8 x 6 cm, which grew progressively over a period of 3 months. This size was beyond the average size of 3 cm reported in the literature.[4] Radiograph may serve little or no contribution in the diagnosis of PGCG, as it is a soft-tissue lesion, but it may be useful to determine if the lesion arises from gingiva or is intraosseous. Typical feature will demonstrate an erosion or saucerization of the alveolar bone that underlies a PGCG.[3],[5] In the presented case, ultrasound was utilized as a first-line investigation to determine the severity and the vascularity of the lesion. It revealed a well-defined, hyperechoic lesion with multifocal echogenic areas due to calcification and low-resistant spectral pattern that was consistent with benign, soft-tissue lesion.

On microscopic examination, the PGCG presented as a typical giant cell lesion. Although the origin of these giant cells remains unclear, it is assumed that they may be osteoclastic remains from the physiological resorption of deciduous teeth or may be a constituent of a reactive component of the lesion that arises from differentiated mononuclear cells.[3],[4],[5],[7] This latter concept can be attributed to the receptor activator of nuclear factor-κβ ligand (RANKL). The transmembrane molecules produced by osteoblasts/stromal cells bind to RANK receptors found on the surface of osteoclast progenitor cells. This RANK–RANKL complex promotes the differentiation of osteoclast progenitor cells into mature osteoclasts.[5],[8],[9] Also, a study by Kumar et al.[10] demonstrated strong expressions of CD68 and CD45 in PGCG, suggesting the origin from mononuclear-phagocyte system. CD 68 positivity enables in differentiating the giant cells and histiocytes from the stromal cell elements in giant cell lesions. Histopathology remains the investigation for definitive diagnosis and is characterized by a non-encapsulated, highly cellular mass with abundant proliferation of multinucleated giant cells and inflammatory cells, within delicate reticular or fibrillar connective tissue stroma containing ovoid or spindle-shaped mesenchymal cell foci, area of hemorrhage and osteoid tissue.[3],[4] Surgical excision and removal of local irritants has always been the primary treatment. Evidence of recurrence following surgical excision is low with general incidence documented to be approximately 10%. Recurrence is associated with inadequate surgical technique.[1],[4],[5]


  Conclusions Top


PGCG is a reactive, exophytic gingival growth that develops on the gingival or alveolar ridge caused by local irritation or trauma. It has similar clinical appearance as other reactive lesions of the jaw, and often present as an abundant multinucleated giant cell lesion on routine H and E section. Though histopathologic examination is useful for definitive diagnosis, ultrasound features show typical, benign, soft-tissue lesion and is a quick modality to rule out malignancies, especially in masses with size greater than 3 cm.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Effiom OA, Adeyemo WL, Soyele OO. Focal reactive lesions of the Gingiva: An Analysis of 314 cases at a tertiary health institution in Nigeria. Niger Med J 2011;52:35-40.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Shadman N, Ebrahimi SF, Jafari S, Eslami M. Peripheral giant cell granuloma: A review of 123 cases. Dent Res J (Isfahan) 2009;6:47-50.  Back to cited text no. 2
    
3.
Rajendran R. Benign and malignant tumors of the oral cavity. In: Rajendran R, Sivapathasundharam B, editors. Shafer's Textbook of Oral Pathology. 7th ed. New Delhi: Elsevier Publishers; 2012. p. 575-9.  Back to cited text no. 3
    
4.
Rodrigues SV, Mitra DK, Pawar SD, Vijayakar HN. Peripheral giant cell granuloma: This enormity is a rarity. J Indian Soc Periodontol 2015;19:466-9.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Vasconcelos RG, Vasconcelos MG, Queiroz LMG. Peripheral and central giant cell lesions: Etiology, origin of giant cells, diagnosis and treatment. J Bras Patol Med Lab 2013;49:446-50.  Back to cited text no. 5
    
6.
Naderi NJ, Eshghyar N, Esfehanian H. Reactive lesions of the oral cavity: A retrospective study on 2068 cases. Dent Res J (Isfahan) 2012;9:251-5.  Back to cited text no. 6
    
7.
Volpato LE, Leite CA, Anhesini BH, Aguilera JM, Borges AH. Peripheral giant cell granuloma in a child associated with ectopic eruption and traumatic habit with control of four years. Case Rep Dent 2016;2016:6725913.  Back to cited text no. 7
    
8.
Metwaly H, Ebrahem MA. Expression of estrogen receptors protein in peripheral and central giant cell granulomas: Relation to clinical parameters. Egypt Dent J 2013;59:682-3.  Back to cited text no. 8
    
9.
Khiavi MM, Aghbali AA, Halima M, Kouhsoltani M, Hamishehkar H. Immunohistochemical expression of Src protein in peripheral and central giant cell granulomas of the jaws. J Oral Maxillofac Pathol 2013;17: 358 60.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Kumar A, Sherlin HJ, Ramani P, Natesan A, Premkumar P. Expression of CD 68, CD 45 and human leukocyte antigen-DR in central and peripheral giant cell granuloma, giant cell tumor of long bone and tuberculous granuloma: An immunohistochemical study. Indian J Dent Res 2015;26:298-300.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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