Oral and maxillofacial pathology
Clinically aggressive central giant cell granulomas in two patients with neurofibromatosis 1

https://doi.org/10.1016/j.tripleo.2005.10.038Get rights and content

Background

Neurofibromatosis 1 (NF1) is an autosomal dominantly inherited disorder caused by a spectrum of mutations affecting the Nf1 gene. Affected patients develop benign and malignant tumors at an increased frequency. Clinical findings include multiple cutaneous café-au-lait pigmentations, neurofibromas, axillary freckling, optic gliomas, benign iris hamartomas (Lisch nodules), scoliosis, and poorly defined soft tissue lesions of the skeleton. Kerl first reported an association of NF1 with multiple central giant cell granulomas (CGCGs) of the jaws. There have since been 4 additional published cases of NF1 patients with CGCGs of the jaws.

Clinical cases

We report on 2 patients who presented with NF1 and aggressive CGCGs of the jaws. In both cases, the clinical course was characterized by numerous recurrences despite mechanical curettage and surgical resection.

Conclusions

We review proposed mechanisms to explain the apparent association between NF1 and an increased incidence of CGCGs of the jaws. While the presence of CGCGs of the jaws in patients with NF1 could represent either a coincidental association or a true genetic linkage, we propose that this phenomenon is most likely related to NF1-mediated osseous dysplasia. Compared to normal bone, the Nf1-haploinsufficient bone in a patient with NF1 may be less able to remodel in response to as of yet unidentified stimuli (e.g. excessive mechanical stress and/or vascular fragility), and consequently may be more susceptible to developing CGCG-like lesions. Alternatively, the CGCG in NF1 patients could represent a true neoplasm, resulting from additional, as of yet unidentified, genetic alterations to Nf1-haploinsufficient bone.

Section snippets

Case 1

In 1996, a 12-year-old boy presented with a large mass of the right palate. Intra-oral examination revealed significant palatal expansion (Fig. 1). The lesion crossed the midline, and extended to both the soft palate and the buccal vestibule. The extent of maxillary destruction was evident on coronal (Fig. 2, A) and axial (Fig. 2, B) CT scans.

The patient’s past medical history was significant for NF1, diagnosed when the patient was 3 years old. Besides multiple café-au-lait macules, axillary

Discussion

Central giant cell granuloma (CGCG) is a benign central lesion of bone, primarily involving the jaws, of variably aggressive nature characterized by aggregates of multinucleated giant cells in a background of cellular vascular fibrous connective tissue and spindle-shaped mononuclear stromal cells, often with extravasation of red blood cells.8 Currently there are no reliable criteria for correlating clinical aggressiveness with histological presentation.9 Recurrences are not uncommon, with an

Conclusion

We report 2 patients with NF1 who presented with central giant cell granulomas (CGCGs) of the jaws. In both cases, the clinical course was characterized by significant osseous destruction and recurrence.

Although the presence of CGCGs of the jaws in patients with NF1 could represent a coincidental association or a genetic linkage, we propose that this phenomenon is most likely related to NF1-mediated osseous dysplasia. Compared to normal bone, the Nf1-haploinsufficient bone in a patient with

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