Long-Term Treatment Outcomes of Central Giant Cell Lesions of the Jaws

Title: Long-Term Treatment Outcomes of Central Giant Cell Lesions of the Jaws Authors: Naseem Ghazali, Surbhi Sehgal, Robert Ord Institution Oral & Maxillofacial Surgery, University of Maryland Dental School, 650 W. Baltimore Street, Suite 1401, Baltimore, MD 21201. Statement of the problem: Central giant cell lesions (CGCL) of the jaws are rare lesions composed of multinucleated giant cells lying within a background of vascular-rich connective tissue. Managing CGCL is challenging due to considerable variation in clinical behavior. CGCL classification into ÒaggressiveÓ or ÒnonaggressiveÓ lesions was proposed based on a combination of clinicopathological features [Chuong, 1986]. Aggressive lesions are characterized by pain, root resorption, rapid growth, cortical perforation, and recurrence post-surgery. However, this classification includes treatment response, which can only be made retrospectively. There is currently no predictive biomarker of the biological behavior that may aid treatment planning.

This study aims to evaluate long-term treatment outcomes of CGCL. The objectives are to (1) determine rates of complete resolution and of recurrence; and (2) evaluate potential predictors for recurrence.

Materials & method: A retrospective case review of CGCL treated at the Oral & Maxillofacial Surgery unit, University of Maryland was undertaken. Cases with definitive histological diagnosis of CGCL were included. Giant cell lesions with distinct histological entities, eg, cherubism, hyperparathyroidism, giant cell granuloma, traumatic bone cyst, were excluded. Eligible patients were identified via department registry. A case note review enabled data collection.

Data analysis: Data analysis included summary statistics and comparison of proportions. Univariate analysis was undertaken for predictive factors of outcomes.

Results: Forty-nine patients were identified. After excluding 6 with incomplete treatment data, 43 patients (87.8%) were included in this study. There were 14/43 males (32.6%) and 29/43 females (67.4%). The mean age at presentation was 25.7 years (range, 6-77). The frequency of CGCL across ethnic groups was 34 white (79.1%), 4 African American (9.3%), and 5 others (11.7%). At presentation, primary and recurrent CGCL accounted for 86% (37/43) and 14% (6/43) of referrals, respectively. The vast majority presented symptomatically (37/43, 86%), in particular, swelling (30/43, 69.8%). Almost three-quarters of lesions occurred in the mandible (32/43, 74.4%). Lesions appeared multilocular (24/43, 55.8%) and unilocular (17/43, 39.5%) on radiograph. Surgery (41/43, 97.7%) was the most common treatment rendered, which included enucleation and curettage (39/41, 95.1%) and major resection (2/39, 4.9%). Nonsurgical approach was undertaken with intralesional steroid injection in 2 patients (4.7%). Median length of follow up was 624 days (range, 37-5789). Based on the Òaggressive-nonaggressiveÓ classification, 27/43 lesions were considered ÒnonaggressiveÓ (62.8%), while 16/43 were ÒaggressiveÓ (37.2%). The mean score for aggressive lesions was 3.1 (range, 3-5). The most common aggressive features noted were swelling and cortical perforation.

Outcomes data: Complete resolution was achieved in 31/43 (72.1%), where 30/31 underwent surgery (97%). Recurrence ensued in 13/43 (30%). Multiple recurrences occurred uncommonly (2/43) as most recurrences occurred once (11/13). Mean time to first recurrence was 343 days (median, 231; range, 76-1266). Surgery was the modality of choice for managing recurrences (15/17, 88%). On univariate analysis, predictors of recurrence were multilocular radiographic appearance, cortical perforation and cortical expansion (p<0.05). Conclusions: This long-term follow-up study suggests that surgical treatment in CGCL is curative in 70% (30/43). Recurrences occurred in 30%, usually within the first year postsurgery but may present later. Recurrence was not predicted by Òaggressive-nonaggressiveÓ classification. Instead, bone-related clinical features may be more valuable in predicting post-treatment recurrence.

References

Chuong R, Kaban LB, Kozakewich H, Perez-Atayde A: Central giant cell lesions of the jaws: A clinicopathologic study. J Oral Maxillofac Surg 44:708-13, 1986 Edwards PC: Insight into the pathogenesis and nature of central giant cell lesions of the jaw. Med Oral Patol Oral Cir Bucal Mar 1;20 (2):e196-8, 2015