Introduction: Synchronous lesions of the jaws are reported in the literature and the etiopathogenesis can be similar in some cases. The oral surgeon must know the diseases that may occur simultaneously. Objective: The aim of this study was to report a case of synchronous lesions, your management, additionally discuss the etiopathogenesis correlation among these lesions and the possible evolution from one disease to the other in order to aid the professional about the management of this occurrence. Methods: This study reported a case of a 14-year-old female patient presenting a reddish sessile nodule in mandibular left premolars gingival region. Results: Radiographically, a well-defined radiolucent area involving left mandibular body was observed. An incisional biopsy of the extra-osseous lesion was performed and a giant cell lesion was histopathologically diagnosed. A surgical bone exploratory procedure revealed an empty cavity; therefore curettage to stimulate bleeding was performed in addition to the extra-osseous lesion excision. The final diagnosis was synergistic peripheral giant cell lesion and traumatic bone cyst. The 12 months follow-up did not show any relapse, moreover, the complete bone neoformation was observed. Conclusions: The pathogenesis of both lesions remains uncertain and a complete and detailed clinical and histopathological examination added to rigorous follow up with image exams resulted in a correct diagnosis and good prognosis of this case

Cunha Filho, João Julio da

Daroit, Natália Batista

Nunes, Júlia Silveira

Prunes, Bianca de Bem

Rados, Pantelis Varvaki

Visioli, Fernanda

JORDI - Journal of Oral Diagnosis

English

Lume 5.8

1Journal of oral Diagnosis 2019Giant cell lesion and traumatic bone cyst: pathologically related lesions? Bianca de Bem Prunes 1*Natália Batista Daroit 1Júlia Silveira Nunes 1João Júlio da Cunha Filho 1Pantelis Varvaki Rados 1Fernanda Visioli 11 Universidade Federal do RIo Grande do Sul - UFRGS, Department of Conservative Dentistry - Porto Alegre - Rio Grande do Sul - Brasil.Correspondence to:Fernanda Visioli.E-mail: fevisioli@gmail.comArticle received on October 9, 2018.Article accepted on November 23, 2018.ORIGINAL ARTICLEJ. Oral Diag. 2019; 04:e20180028Keywords: Peripheral Giant Cell Granuloma; Bone Cysts; Jaw Cysts; Jaw Cysts/Etiology.Abstract:Introduction: Synchronous lesions of  the jaws are reported in the literature and the etiopathogenesis can be similar in some cases. The oral surgeon must know the diseases that may occur simultaneously. Objective: The aim of  this study was to report a case of  synchronous lesions, your management, additionally discuss the etiopathogenesis correlation among these lesions and the possible evolution from one disease to the other in order to aid the professional about the management of  this occurrence. Methods: This study reported a case of  a 14-year-old female patient presenting a reddish sessile nodule in mandibular left premolars gingival region. Results: Radiographically, a well-defined radiolucent area involving left mandibular body was observed. An incisional biopsy of  the extra-osseous lesion was performed and a giant cell lesion was histopathologically diagnosed. A surgical bone exploratory procedure revealed an empty cavity; therefore curettage to stimulate bleeding was performed in addition to the extra-osseous lesion excision. The final diagnosis was synergistic peripheral giant cell lesion and traumatic bone cyst. The 12 months follow-up did not show any relapse, moreover, the complete bone neoformation was observed. Conclusions: The pathogenesis of  both lesions remains uncertain and a complete and detailed clinical and histopathological examination added to rigorous follow up with image exams resulted in a correct diagnosis and good prognosis of  this case.DOI: 10.5935/2525-5711.201800282Journal of oral Diagnosis 2019INTRODUCTIONPeripheral giant cell lesion (PGCL) is a benign hyperplastic lesion with well-defined borders and is characterized by a nodular or pedicled nodule. It may affect individuals of  any age, and it is more prevalent in female subjects. In addition, the most commonly affected site is the mandible1. Histologically PGCL presents a spindle cell proliferation with giant cells, interstitial hemorrhage, hemosiderin pigments, possi-bly with inflammation, mature bone or osteoid matrix2. The treatment of  this condition is the surgical excision. Additional therapy (curettage or peripheral osteotomy) decreased significantly the recurrence rate. The recur-rence rate  reported for excision only is 16%, and 2.8% when associated with curettage or 0% when peripheral osteotomy was also performed3.Simple bone cysts (SBC) are lesions classified as a pseudocyst because it has no epithelial lining. Clinically, it is characterized by the presence of  an intraosseous cavity which may be empty or contain blood or mucous fluid. It is more frequent in young individuals in the first decades of  life, and usually affects the lower molar region. Radiographically, SBC presents as a radiolucent lesion with well-defined margins and may acquire a scal-loped appearance. SBCs are often diagnosed accidentally since most of  these lesions are asymptomatic4. Histo-logically, the specimen shows fibrovascular connective tissue, hemorrhage and vital bone fragments from the bone walls, cystic epithelium is not present5. The recom-mended SBC treatment is exploratory surgery and bone curettage; posterior bone healing was observed in the recommended SBC treatment is exploratory surgery and bone curettage; posterior bone healing was observed in most of  the cases after this procedure6.Concomitant bone lesions may affect the jaws, and SBCs are most commonly associated with benign fibro-osseous lesions, especially fibrous dysplasia and bone cement dysplasia7. In the case of  PGCL, a previous re-port has documented an association with florid cemento-osseous dysplasia in a patient with neurofibromatosis8.To our knowledge, no reports to date have docu-mented an association between PGCL and SBC9,10. The aim of  this paper is to report a case of  concomitant PGCL and SBC lesions and discuss about their as-sociation and pathogenesis. The correct diagnosis is very important because treatment is different for each of  these lesions. Therefore, inappropriate conduct will result in worse prognosis. This study was conducted in accordance with theDeclaration of  Helsinki.CASE REPORTA 14-year-old female sought the Oral Medicine Department because of  a lesion in the inferior alveolar ridge. The social and familiar history was impaired be-cause this girl was confined in a young offender institu-tion. This patient did not use any medication, however reported previous regular consumption of  marijuana. Clinical examination revealed an asymptomatic, red-dish, nodule with a smooth surface, firm consistency and measuring 2 cm. The patient reported an approximately 8-month history of  this lesion located in the region of  the left mandibular premolars, which were displaced (Figure 1A). The patient did not report traumatism in the affected zone. The thermal sensibility pulp test was positive in left inferior molars (36 and 37). Panoramic radiography revealed a well-delimited radiolucent le-sion extending from tooth 33 to the ascending branch of  the left jaw (Figure 1B). The patient did not present any systemic alterations.On the basis of  the clinical presentation, two possibilities were considered: a single lesion with an extraosseous and intraosseous component or two differ-ent synchronous entities. If  the lesions are considered a single disease, the diagnostic hypothesis should consider Figure 1. Initial aspect of the patient. A) Clinical image of extra-osseous nodule. B) Initial panoramic radiography.3Journal of oral Diagnosis 2019lesions are caused by mechanical factors that produce an intraosseous vascular lesion with a hematoma. Three possible outcomes have been proposed for this intraosseous lesions that can perforate the cortical bone and result in extraosseous progression.Initially, an incisional biopsy of  the extraosseous lesion was performed. Analysis of  the anatomopathologi-cal specimen revealed a proliferation of  young spindle cells, presence of  multinucleated foreign body type cells, and a richly vascularized stroma with areas of  hemorrhage and mononuclear inflammatory cells. These features are compatible with those of  giant cell lesions (Figure 2). In the intraosseous surgical exploration, after the mucoperiosteal flap, the cortical bone was removed with carbide bur, the aspiration was negative, and an empty cavity was found. Thus, bone walls were cured to stimulate bleeding for bone repair11. The extraosseous lesion was completely removed via excision and curet-tage; also the traumatic factors were eliminated and one premolar (34) involved inside the lesion was extracted. Thus, the final diagnosis was a SBC and a concomitant PGCL.After 1 year of  clinical and radiographic control, no recurrence of  the extraosseous lesion was observed, and bone neoformation was observed in the curetted cavity (Figure 3). The patient remains under clinical and radiographic control.DISCUSSIONThere is no consensus regarding the etiopatho-genesis of  PGCL and SBC. Some authors suggest that PGCL may have a neoplastic character. However, others suggest a reactive origin, because these lesions are often associated with local traumatic factors such as biofilm accumulation, dental calculus, higher gingival bleeding index, and deep periodontal pockets12. In the present case, dental crowding and poor oral hygiene were local traumatic factors, and the patient was unable to confirm a previous trauma in the region.Some hypotheses have been suggested about the etiopathogenesis of  SBCs. These include calcium defi-ciency, degeneration of  bone tumors, local alteration of  bone growth, and intramedullary hemorrhage10. Among these hypotheses, intramedullary hemorrhage is cur-rently the most accepted. It is caused by trauma, which results in the formation of  an intraosseous hematoma and blood supply failure, subsequently resulting in ne-crosis and bone reabsorption, and finally the formation of  a bone cavity9.Some studies have investigated possible etiopatho-genic correlations between SBC, Aneurysmal Bone Cyst (ABC), and Central Giant Cell Lesion (CGCL). These Figure 2. Photomicrographs of excisional biopsy. A) Well circumscribed pro-liferation recovered by stratified epithelium (HE, 4x). B) Multiple giant cell dispersed in a fibrous connective tissue (HE, 20x). C) Intra-osseous material after curettage: fibrous connective tissue and vital normal bone fragments. 4Journal of oral Diagnosis 2019Figure 3. Follow-up after one year. A) Oral mucosa without signals of recurrence. B) Panoramic radiography showing complete bone healing.hematoma. If  the hematoma is connected to a vascular enlargement, blood pressure could result in expansion and ABC development. If  the hematoma is supplied by small blood vessels, a CGCL composed of  soft tissue and endothelial-lined capillaries, proliferating fibroblasts, and multinucleated giant cells can develop. If  the blood supply to the hematoma is interrupted or blocked, it may result in the development of  a SBC9,13.Moreover, transformations from one lesion to another have already been reported in the literature and appear to occur in several ways. In 2002, Chiba et al. published a case report of  SBC that transformed to a CGCL 8 months after intervention10. Biesecker et al. reported two cases of  ABCs that formed after curettage of  a preexisting lesion; one developed after a CGCL and one evolved from a SBC14. Therefore, it is appealing to consider that all these pathological entities may be related, as different manifestations of  the same disease. These lesions could be caused by an intramedullary hematoma, and ABCs and CGCLs might be formed from the connective tissue as part of  hematoma repair; however, a failure of  hematoma repair results in a SBC. On the basis of  these findings, we proposed the hypothesis that our patient could have had a CGCL, which perforated the cortical bone and externalized dur-ing its progression. Subsequently, the local blood supply would have been compromised, thereby causing the de-generation or involution of  the intraosseous lesion and resulting in an empty cavity, which was diagnosed as a SBC (Figure 4). The features that support this hypothesis are the proximity of  both lesions, the characteristics of  tooth displacement that are uncommon in PGCL and more frequent in CGCL, and previous reports of  total spontaneous regression of  CGCLs15.In conclusion, when a lesion is detected in the gingiva or alveolar ridge, complementary imaging ex-amination is imperative to evaluate bone involvement. The diagnostic process underlying lesions of  the gnathic bones should consider the presence of  simultaneous le-sions, and the combination of  SBC and PGCL should be listed among the possible differential diagnoses.ACKNOWLEDGMENTSThis work was supported by CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, Ministry of  Education, Brazil).REFERENCES 1. Chaparro Avendaño AV, Berini Aytés L, Gay Escoda C. Granuloma periférico de células gigantes: A propósito de 5 casos y revisión de la literatura. Med Oral Patol Oral Cir Bucal. 2005;10:41-7. 2. Katsikeris N, Kakarantza-Angelopoulou E, Angelopoulos AP. Peripheral giant cell granuloma. Clinicopathologic study of 224 new cases and review of 956 reported cases. Int J Oral Maxillofac Surg. 1988;17:94-9. 3. Chrcanovic BR, Gomes CC, Gomez RS. Peripheral giant cell granuloma: An updated analysis of 2824 cases reported in the literature. J Oral Pathol Med. 2018;47:454-9.Figure 4. Etiopathogenic correlations between the Simple Bone Cyst (SBC), Aneurysmal Bone Cyst (ABC), and Central Giant Cell Lesion (CGCL). Hypothe-tical theory to the presented case.5Journal of oral Diagnosis 2019 4. Kumar LKS, Kurien N, Thaha KA. Traumatic Bone Cyst of Mandible. J Maxillofac Oral Surg. 2015;14:466-9. 5. Nelson BL. Solitary bone cyst. Head Neck Pathol. 2010;4:208-9. 6. Xindi J, Gang L, Xinhong W, Linlin C, Xing K, Zhen T, et al. Simple bone cyst of the jaw: a retrospective study of 11 cases. Hua Xi Kou Qiang Yi Xue Za Zhi. 2016;34:272-6. 7. Martini MZ, Rocha AC, Lemos CA Jr, Alves FA. Fibro-osseus lesions associated with simple bone cysts: three case reports and review of the literature. Minerva Stomatol. 2010;59:671-6.  8. Sarmento DJS, Carvalho SHG, Araújo JCWP Filho, Carvalho MV, Silveira EJDD. Florid cemento-osseous dysplasia and peripheral giant cell granuloma in a patient with neurofibro-matosis 1. An Bras Dermatol. 2017;92:249-52. 9. Stimson PG, McDaniel RK. Traumatic bone cyst, aneurysmal bone cyst, and central giant cell granuloma--pathogenetically related lesions? J Endod. 1989;15:164-7.10. Chiba I, Teh BG, Iizuka T, Fukuda H. Conversion of a trau-matic bone cyst into central giant cell granuloma: implica-tions for pathogenesis--a case report. J Oral Maxillofac Surg. 2002;60:222-5.11. Homem de Carvalho AL, Carrard VC, Martins MD, Rados PV, Sant’Ana Filho M. Simple bone cyst: Report of cases and proposal for a minimal surgical intervention. Int J Pediatr Otorhinolaryngol. 2010;74:1449-51.12. Bodner L, Peist M, Gatot A, Fliss DM. Growth potential of peripheral giant cell granuloma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2017;83:548-51.13. Hillerup S, Hjørting-Hansen E. Aneurysmal bone cyst--simple bone cyst, two aspects of the same pathologic entity? Int J Oral Surg. 1978;7:16-22.14. Biesecker JL, Marcove RC, Huvos AG, Miké V. Aneurysmal bone cysts. A clinicopathologic study of 66 cases. Cancer. 1970;26:615-25.15. Vieira Rda R, Biasoli ER, Crivelini MM, Miyahara GI. Total spontaneous regression of a central giant cell granuloma after incisional biopsy: a four-year follow-up case report. J Oral Maxillofac Surg. 2014;72:730-6.

Giant cell lesion and traumatic bone cyst : pathologically related lesions?

https://lume.ufrgs.br/bitstream/10183/217138/1/001114729.pdf

Giant cell lesion and traumatic bone cyst : pathologically related lesions?

Abstract

Similar works

Full text

Available Versions

Lume 5.8