GIANT CELL LESIONS

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Published on July 12, 2014

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GIANT CELL LESIONS: GIANT CELL LESIONS PRESENTED BY Dr.Neha Upadhyaya (M.D.S IIND YEAR) GUIDED BY Dr.Shubhangi Khandekar (Professor & Guide) Dr.Alka Dive (Professor & H.O.D) 1 GIANT CELLS: GIANT CELLS Very large cells. Cytoplasm similar to endothelial cells. Diameter of 40-50 mic.m. 100 or even more nuclei. Seen when macrophages are not able to engulf the foreign material in extravascular tissue. 2 ORIGIN: ORIGIN Depends upon intimate contact of freshly migrated monocyte simultaneously with other monocyte and macrophages. Combination of high cell density and simultaneous endocytosis of same material by two or more macrophages. 3 ORIGIN: ORIGIN Either by fusion of macrophages or division of nuclei without accompanying cytoplasmic fusion. Fusion of mononuclear phagocytes. ( Spector and Mariano,1975…, Chambers,1978…). 4 ORIGIN: ORIGIN Fusion results from the simultaneous attachment of fusing cells to an endogenous substrate.( Chambers). Early workers considered that giant cell formation represented an adaptation of improved phagocytosis. 5 ORIGIN: ORIGIN Recent studies show giant cells to be much less phagocytic than an equivalent mononuclear phagocytic population. Giant cells secrete enzymes and other materials in surrounding tissue. ( Papalimitriou and Robertson, 1980…) 6 ORIGIN: ORIGIN No special function peculiar to giant cell has been attributed. They are seen much more often in high turnover granulomatous disorders than in low turn over granulomatous disorders. 7 CLASSIFICATION OF GIANT CELLS: CLASSIFICATION OF GIANT CELLS Name of giant cell Commonly asso.dis. Key word Langhan’s cell Tuberculosis Horse shoe shaped nuclei. Foreign body giant cell Foreign body Central nuclei. Touton giant cell xanthomatosis Lipid vacuoles. 8 CLASSIFICATION OF GIANT CELLS: CLASSIFICATION OF GIANT CELLS Warthin Finkeldey cells Measles Lymph nodes Aschoff’s cells Rheumatic fever In heart usually Reed stenberg cell Hodgkins disease Mirror image nuclei. Floret type giant cell Pleomorphic lipoma Marginally placed. 9 CLASSIFICATION OF GIANT CELLS: CLASSIFICATION OF GIANT CELLS The above classification was on the basis of the giant cells thought to arise from macrophages. The following classification is based on the giant cells not arising from macrophages. 10 CLASSIFICATION OF GIANT CELLS: CLASSIFICATION OF GIANT CELLS Name of the giant cell Commonly associated disease Key words Tumor giant cell Associated with many tumors Often with abnormal nuclei Placental giant cell normal (syncytial knots) From syncytial cells 11 CLASSIFICATION OF GIANT CELLS: CLASSIFICATION OF GIANT CELLS Epulis giant cells Epulis, oral cavity Arises from blood vessels. osteoclast HPTH Tumor of bone megakayocyte Myeloid metaplasia Normal in bone marrow (from platelet) 12 FOREIGN BODY GIANT CELL: FOREIGN BODY GIANT CELL Multinucleated cell with 50-100 nuclei. Regular in size. Scattered in cytoplasm. Seen at site of hemorrhage or necrosis. Associated with atheroma in an attempt to remove cholesterol crystals. 13 LANGHAN’S GIANT CELL: LANGHAN’S GIANT CELL Multinucleated cell. Nuclei arranged towards the periphery of the in a characteristic horse shoe shaped arrangement. Seen in tuberculosis. 14 TOUTON GIANT CELL: TOUTON GIANT CELL Seen in Xanthomatosis . Peripheral cytoplasm has a foamy appearance and is vacuolated due to its lipid content. Nuclei surround central area of eosinophilic cytoplasm. Nuclei arranged in a circular manner to form a wreath. 15 WARTHIN FINKELDEY CELL: WARTHIN FINKELDEY CELL Seen in Measles,lymphoid tissue of appendix, throat, naso-pharynx and GIT. Characteristic giant cell formation in germinal centres of lymphoid foliicles of the regional lymphnodes and mucosa of pharynx. 16 WARTHIN FINKELDEY CELL: WARTHIN FINKELDEY CELL 100 mic.m in diameter and 50-100 nuclei. Described by Warthin and hence the name. Represent reaction to measles virus. 17 ASCHOFF’S CELL: ASCHOFF’S CELL Seen in rheumatic fever. They probably represent cardiac histiocytes. Contain 6-7 vesicular nuclei. Basophilic granular cytoplasm. 18 REED-STERNBERG CELL: REED-STERNBERG CELL 15-45 mic.m in diameter. Binucleated or bi lobed with two halves appearing as mirror images of each other. Nucleus is enclosed in abundant amphophilic cytoplasm. 19 REED-STERNBERG CELL: REED-STERNBERG CELL Within the nuclei are large, inclusion like “owl eye” inclusions surrounded by clear halo. Nucleoli are acidophilic or atleast amphophilic and react strongly with RNA stain. 20 LACUNAR TYPE: LACUNAR TYPE 21 CLASSICAL TYPE: CLASSICAL TYPE 22 PowerPoint Presentation: 23 PowerPoint Presentation: Figure 1b (right, above). Mononuclear Reed-Sternberg cell (1) with deeply hyperlobated nucleus, hypertrophic nucleoli, and surrounding lymphocytes (2), some of which orient themselves to the circumference of the neoplastic cell. Neoplastic cell shows a minimal degree of cytotoxic change (slight nuclear edema); surrounding lymphocytes are in moderately tight apposition. (X 3,000).  24 TUMOR GIANT CELL: TUMOR GIANT CELL Seen in osteogenic sarcoma and widely other different tumors. Exm. Glioblastoma multiforme, rhabdo myosarcoma. Large,nuclei are hyperchromatic,oval or indented, joined together, stained darkly and few in number. Considerable variation in size and shape. 25 OSTEOCLASTIC GIANT CELL: OSTEOCLASTIC GIANT CELL 10-20 nuclei occupying a central position like a rosette. Intensely basophilic. Seen in osteoclastoma, chronic osteitis, osteitis fibrosa cystica. 26 MEGAKARYOCYTES: MEGAKARYOCYTES Blood platelets are derived from megakaryocytes. Abundant, finely stippled, light blue to pink cytoplasm. Irregular, multilobed, basket work nucleus which is densely chromatic. Derived from primitive stem cell. 27 FLORET TYPE GIANT CELL: FLORET TYPE GIANT CELL Eosinophilic cytoplasm. Multiple marginally placed and often overlapping nuclei resembling petals of a flower. Seen in pleomorphic lipoma. 28 ULTRASTRUCTURE: ULTRASTRUCTURE Characteristic ultra structure. Irregular outline with projections in the surrounding tissue. Some areas exhibit microvilli. 29 ULTRASTRUCTURE: ULTRASTRUCTURE Varied size and shape of nuclei with condensation of electron dense material at the periphery. Usually single nucleolus but occasionally may be two or three. Large number of densely packed mitochondria. Small with varying shape and size. 30 ULTRASTRUCTURE: ULTRASTRUCTURE Giant cells contain large amounts of acid phosphatase…Miller and Monteleone et al, pepler (1985). Metabolically active cell with potential for protein synthesis. Large golgi apparatus compatible with secretary activity. 31 ULTRASTRUCTURE: ULTRASTRUCTURE Association with areas of hemorrhage with giant cells. Hemorrhage resulting from giant cells. Secretion of substance damaging the walls of the blood vessels. Ultra structure lends support to his hypothesis. 32 ULTRASTRUCTURE: ULTRASTRUCTURE Origin of giant cells from endothelial cells. Groups of fine fibrils in their cytoplasm as well as numerous pinocytic vesicles lacking in giant cells. Greater similarity between undifferentiated cell of stroma and giant cell. 33 CLASSIFICATION OF GIANT CELL LESIONS: CLASSIFICATION OF GIANT CELL LESIONS 34 PREDOMINANT GIANT CELL LESIONS: PREDOMINANT GIANT CELL LESIONS BENIGN GIANT CELL LESIONS Extra osseous lesions PGCG Foreign body GCG Hyaline ring granuloma Giant cell fibroma. Giant cell angiofibroma 35 PREDOMINANT GIANT CELL LESIONS: PREDOMINANT GIANT CELL LESIONS Giant cell arteritis Giant cell hepatitis Giant cell tumor of tendon sheath. Giant cell myocarditis. 36 PREDOMINANT GIANT CELL LESIONS: PREDOMINANT GIANT CELL LESIONS Intra osseous lesions CGCG. Osteoblastoma. Osteoclastoma. Cherubism. 37 PREDOMINANT GIANT CELL LESIONS: PREDOMINANT GIANT CELL LESIONS MALIGNANT GIANT CELL LESIONS Extra osseous lesions Giant cell sarcoma. Giant cell carcinoma of liver. Giant cell carcinoma of lung. Giant cell carcinoma of thyroid. Hodgkins lymphoma. 38 PREDOMINANT GIANT CELL LESIONS: PREDOMINANT GIANT CELL LESIONS Intra osseous lesions malignant osteoblastoma. 39 PREDOMINANT GIANT CELL LESIONS: PREDOMINANT GIANT CELL LESIONS INFECTIVE DISEASES Tuberculosis. Giant cell hepatitis. Giant cell pneumonia. 40 OCCASIONAL GIANT CELL LESIONS: OCCASIONAL GIANT CELL LESIONS BENIGN GIANT CELL LESIONS Extra osseous lesions Eosinophilic granuloma. Ameloblastoma. Pleomorphic adenoma. Juv active ossifying fibroma. Crohn’s disease. 41 OCCASIONAL GIANT CELL LESIONS: OCCASIONAL GIANT CELL LESIONS Intra osseous lesions Fibrous dysplasia. Focal cemento-oseeous dysplasia. Radicular cyst. 42 OCCASIONAL GIANT CELL LESIONS: OCCASIONAL GIANT CELL LESIONS MALIGNANT GIANT CELL LESIONS Mucoepidermoid carcinoma. 43 OCCASIONAL GIANT CELL LESIONS: OCCASIONAL GIANT CELL LESIONS INFECTIONS Sarcoidosis. Actinomycosis. Fungal infection. Herpes simplex. 44 CLASSIFICATION OF GIANT CELL LESIONS 2: CLASSIFICATION OF GIANT CELL LESIONS 2 45 PHYSIOLOGICAL CONDITIONS: PHYSIOLOGICAL CONDITIONS Resorption of deciduous teeth. Healing of extraction teeth. Orthodontic tooth movement. Synctiotrophoblasts of placenta. 46 NON NEOPLASTIC GROWTH: NON NEOPLASTIC GROWTH Soft tissue PGCG. Giant cell fibroma. Epulis fissuratum. Traumatic granuloma. 47 NON NEOPLASTIC GROWTH: NON NEOPLASTIC GROWTH Bone CGCG. Browns tumor. Fibrous dysplasia. Pagets disease. Osteomalacia. Cherubism. 48 CYSTS AND NEOPLASMS: CYSTS AND NEOPLASMS Cysts ABC. CEOT. Solitary bone neoplasm. 49 CYSTS AND NEOPLASMS: CYSTS AND NEOPLASMS Benign neoplasms Giant cell tumor. Osteoid osteoma. Osteoblastoma. Central hemangioma. 50 CYSTS AND NEOPLASMS: CYSTS AND NEOPLASMS Malignant neoplasms Osteosarcoma. Hodgkins lymphoma. Reticular cell sarcoma. Lymphosarcoma. Oral squamous cell carcinoma. 51 INFECTIONS: INFECTIONS Bacterial Tuberculosis Syphilis Leprosy. Actinomycosis. Osteomyelitis. 52 INFECTIONS: INFECTIONS Viral Herpes simplex. Herpes zoster Mumps CMV Measles. 53 INFECTIONS: INFECTIONS Fungal Histoplasmosis. Candidiasis. Blastomycosis. Coccidiodomycosis. Rhinosporidosis. 54 INFECTIONS: INFECTIONS Protozoal Leishmoniasis. 55 INFECTIONS: INFECTIONS Chlamydial Lymphogranuloma venerum 56 NON-INFECTIVE GRANULOMA: NON-INFECTIVE GRANULOMA Midline lethal granuloma. Wegeners granulomatosis. Plasma cell granuloma. Sarcoidosis. 57 PERIODONTAL CONDITIONS: PERIODONTAL CONDITIONS Periodontitis. Periapical cyst. Periapical granuloma. Chronic periapical abscess. 58 MISCLLANEOUS: MISCLLANEOUS Internal resorption. External resorption. Massive osteolysis. Spindle or epithelial cell nevus. 59 CLASSIFICATION OF GIANT CELL LESIONS 3.: CLASSIFICATION OF GIANT CELL LESIONS 3. 60 DEBATABLE ORIGIN: DEBATABLE ORIGIN Peripheral giant cell granuloma (PGCG) Central giant cell granuloma (CGCG) Aneursymal bone cyst (ABC) Traumatic bone cyst (TBC) 61 INFECTIONS: INFECTIONS Tuberculosis Leprosy Actinomycosis Histoplasmosis Herpes Zoster 62 INFECTIONS: INFECTIONS HIV-1 Meningoencephalitis Measles Sporotrichosis cryptococcosis coccidiodomycosis 63 UNKNOWN ETIOLOGY: UNKNOWN ETIOLOGY Wegeners granulomatosis Chelitis granulomatosa Sarcoidosis 64 GENETIC: GENETIC Cherubism 65 METABOLIC/ENDOCRINAL: METABOLIC/ENDOCRINAL Browns tumor ( hyperparathyroidism ) 66 TUMOR CONDITIONS: TUMOR CONDITIONS Giant cell tumor Atypical fibroxanthoma 67 PERIPHERAL GIANT CELL GRANULOMA: PERIPHERAL GIANT CELL GRANULOMA Reactive rather than reparative lesion. Unknown etiology . Dental plaque and calculus. Poor dental restorations. Ill-fitting dental appliances. Dental extraction. 68 CLINICAL FEATURES: CLINICAL FEATURES Fourth to sixth decade. Mean age : 38-42 yrs. Dentulous as well as edentulous patients. Females affected more than males. Asymptomatic with rapid growth rate. Gingiva or the alveolar process anterior to molars. 69 CLINICAL FEATURES.: CLINICAL FEATURES . Pedunculated or sessile mass. Seen arising from the deeper tissues. 0.5-1.5 cms. in diameter. Appears to originate from the periosteum or PDL. Dark red, vascular or hemorrhagic in appearance with common surface ulceration. 70 .: . 71 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Nonencapsulated mass of tissue. Delicate reticular or fibrillar connective tissue stroma containing ovoid or spindle shaped young connective tissue cells and multinucleated giant cells. Giant cells resemblance to osteoclasts. 72 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Numerous capillaries seen around the periphery and sometimes giant cells are seen within the lumen. 73 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Foci of hemorrhage. Liberation of hemosiderin pigments. Inflammatory cell infiltration. 74 PowerPoint Presentation: 75 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES In a review of 720 cases Waldron and Giansanti found that giant cells in the lesion showed considerable variation. Number of mitoses in the stromal cells varied considerably. Lesion sometimes exhibited stratified squamous epithelium while sometimes it showed ulceration. 76 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES They also observed that some of the lesions exhibited calcification, osteoid or bone formation. 77 ORIGIN OF GIANT CELLS: ORIGIN OF GIANT CELLS Striking resemblance to osteoclasts but seldom do they carry normal resorptive function. 78 ORIGIN…: ORIGIN… According To Geshickter and Copeland, they may be derived from proliferating giant cells associated with the resorption of roots of deciduous teeth. No sufficient data to support this. 79 ORIGIN: ORIGIN Endothelial cells of the capillaries. They are commonly seen within the vascular channels, suggesting that they arise from the fusion of the endothelial cells. 80 STUDIES ON GIANT CELLS: STUDIES ON GIANT CELLS Histochemical Study of this lesion is reported by shklar and cataldo with distinct differences observed in different multinucleated giant cells with respect to sulfhydryl and tyrosine groups. 81 STUDIES…: STUDIES… Electron microscopic studies carried out by Sapp reported sufficient number of features in common with osteoclasts suggesting that they are modified form of that cell. Stromal cells compatible with various stages of differentiating osteoprogenitor cells. 82 RADIOGRAPHIC FEATURES: RADIOGRAPHIC FEATURES May or may not involve underlying bone. In edentulous areas, it exhibits superficial erosion of the bone with pathognomonic – peripheral cuffing of the bone. 83 RADIOGRAPHIC FEATURES…: RADIOGRAPHIC FEATURES… When in dentulous areas, it exhibits superficial destruction of the alveolar margin or crest of interdental bone, but this by no means is invariably present. 84 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Conservative excision. Lesion must be completely removed to prevent recurrence. Recurrences are seen with 10-15% but are managed with additional surgery. 85 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Recurrence of the peripheral giant cell granuloma after excision often is discussed in the literature but has not been documented frequently. 86 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Malignant change has not been demonstrated convincingly. Baxter in 1930 could find no report of malignant change in PGCG. Dunning in 1924 however described a transition into round cell sarcoma. 87 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Hayward in 1959 reported a malignant giant cell tumor of mandible which initially occurred with a prominent peripheral component. 88 CENTRAL GIANT CELL GRANULOMA: CENTRAL GIANT CELL GRANULOMA It was initially thought of as a sarcoma or to be of myeloid origin. This belief was changed in 1953 when Jaffe introduced the term giant cell reparative granuloma. It was convey that the lesion was not a neoplasm. 89 CGCG…: CGCG… Reparative term has been dropped these days since the lesion is typically destructive, sometimes aggressive and never reparative. Term granuloma is also a misnomer, the term giant cell lesion has been used occasionally. 90 PowerPoint Presentation: 91 CLINICAL FEATURES: CLINICAL FEATURES Nearly all published studies show a predilection for women, with 58% or more of the affected patients being female. Whitaker and Waldron found out that there was a male predilection in the first decade but female predilection therafter. 92 CLINICAL FEATURES: CLINICAL FEATURES Hormonal role in its initiation or promotion is unclear. According to Whitaker et al.. Estrogen and progesterone proteins were not demonstrated in an immunohistochemical study of 10 CGCG’s. 93 CLINICAL FEATURES: CLINICAL FEATURES Seen in first three decades of life with a mean age of occurrence in the twenties. Its presence in a patient more than 30 yrs of age should suspect a clinician of hyperparathyroidism and perform the necessary lab evaluation. 94 CLINICAL FEATURES: CLINICAL FEATURES It occurs more commonly in mandible than in the maxilla. Mostly seen anterior to the first molars. Nearly always solitary lesions; multifocal synchronous or metachronous disease is extremely unusual. 95 CLINICAL FEATURES: CLINICAL FEATURES Asymptomatic localized swelling that may be associated with tenderness or discomfort. Symptomatic patients show average duration of 3 months or less. Teeth may be nonvital and maxillary lesions may show nasal obstruction and epistaxis. 96 CLINICAL FEATURES: CLINICAL FEATURES Aggressive and non Aggressive types. Aggressive lesions : Younger age group. Grow more rapidly. Larger at the time of diagnosis. More likely to recur. 97 RADIOGRAPHIC FEATURES: RADIOGRAPHIC FEATURES Unilocular Or Multilocular XL. Multilocular XL may show radiographic evidence of expansion. Ill-defined or corticated. “fuzzy” densities and “wispy” calcifications. 98 RADIOGRAPHIC FEATURES: RADIOGRAPHIC FEATURES Loss of dental lamina dura. Resorption or cortical perforations in aggressive cases. Smooth or scalloped margins. Tendency to cross midline of either jaw. ( OKC and Ameloblastoma ). 99 PowerPoint Presentation: 100 HISTOPATHOLOGIC FEATURES.: HISTOPATHOLOGIC FEATURES. Presence Of Multinucleated Giant Cells in collagenous stroma having a variable cellularity. Giant cell vary in number, size, shape, number of nuclei they contain, but they have a eosinophilic or amphophilic cytoplasm. 101 HISTOPATHOLOGIC FEATURES: HISTOPATHOLOGIC FEATURES Limited to focal collections or diffusely scattered. Each cell contains 3-18 nuclei. More often patchy than even distribution. Electron microscopy shows that giant cells are rich in mitochondria, microvesicular fat and RER. 102 HISTOPATHOLOGIC FEATURES: HISTOPATHOLOGIC FEATURES stromal cells have uniform ovoid or spindle shaped nuclei with few mitoses, and pale indistinct cytoplasm. Arranged in a haphazard manner. Storiform or herringbone pattern. Extravasated erythrocytes and deposits of hemosiderin. 103 HISTOPATHOLOGIC FEATURES: HISTOPATHOLOGIC FEATURES Osteoid or thin trabaculae of bone are evident in one half of the cases. Most of the stromal cells show features of fibroblasts. Some are smooth muscle like while some are histiocytic. 104 PowerPoint Presentation: 105 TREATMENT AND PROGNOSIS.: TREATMENT AND PROGNOSIS. Curettage alone or combine with either resection with continuity loss or electrocoagulation. Aggressive lesions- resection with continuity loss followed by immediate reconstruction. 106 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Mandibular lesions- curretage and resection without continuity loss with a large round burr. For maxillary lesions- curretage alone. Recurrences may be multiple. Its more with aggressive lesions. 107 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Anterior Maxilla-least recurrence. Mandibular ramus-most recurrence. Non-surgical means : S.C. human calcitonin. Inj.corticosteroids. 108 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Mixture of equal parts of triamcinolone acetonide and local anesthetic with epinephrine was injected into the lesion under pressure ( weekly for 6 wks ). 2ml per estimated 2cm of XL. Large lesions- multiple penetrations. 109 ANEURYSMAL BONE CYST: ANEURYSMAL BONE CYST Jaffe and Lichtenstein first described ABC in 1940 Bernier and Bhaskar were the first to report lesions in the jaws under the term ABC. Distinctive lesion or one end of giant cell granuloma spectrum. 110 PATHOPHYSIOLOGY: PATHOPHYSIOLOGY According to Hillerup and Hjorrting-Hansen ABC,CGCG,TBC are different manifestations of same general process. Cause is vascular mishap resulting from trauma, primary bone disease, or malformation. 111 CLINICAL FEATURES: CLINICAL FEATURES Long bones and vertebral column- most common. Affects both membranous and intramembranous bones. Flat bones- away from joint to produce a full thickness symmetrical expansion. 112 CLINICAL FEATURES: CLINICAL FEATURES Its association with other lesions of the jaws. Fibrous dysplasias, osteosarcomas, gingival fibromatosis, and tooth resorption. Rapid expansion in fibrous dysplasias- clinician should suspect ABC. 113 CLINICAL FEATURES: CLINICAL FEATURES Seen at any age. Most common- second and third decades. Asymptomatic. Sometimes pain may be associated with it. 114 RADIOGRAPHIC FEATURES: RADIOGRAPHIC FEATURES Unilocular or multilocular XL usually multilocular. Soap bubble or honey-comb pattern. Thinning of cortices or destruction. If surgeon suspects possibility of vascular lesion on XG then angiography should be performed. 115 PowerPoint Presentation: 116 PowerPoint Presentation: 117 HISTOPATHOLOGIC FEATURES: HISTOPATHOLOGIC FEATURES Proliferation of spindle cells,which form a richly cellular stroma. Fibroblasts,myofibroblasts,osteoblasts and histiocytes. Giant cells resembling osteoclasts. Ovoid with eosinophilic cytoplasm. 118 HISTOPATHOLOGIC FEATURES: HISTOPATHOLOGIC FEATURES Giant cell nuclei scattered throughout the cytoplasm. Sometimes they may be centrally placed. Extravasated erythrocytes. Congested blood vessels. 119 HISTOPATHOLOGIC FEATURES: HISTOPATHOLOGIC FEATURES Pooled blood in extravascular spaces. Aggregates of erythrocytes displays areas of thrombosis with fibrotic organization. Deposition of hemosiderin pigment. Reddish brown, variegated appearance of gross specimen. 120 PowerPoint Presentation: 121 PowerPoint Presentation: Preoperative photograph showing a thin walled cyst with brownish serous fluid coming out of it. (P = pinna, Z = arch of zygoma, C = aneurysmal bone cyst) 122 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Surgical Entry Into The Lesion Shows The Presence Of Blood. Sometimes clear fluid in long standing lesions. 123 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Enucleation Cryotherapy- low recurrence rates. Radiation resection. Amputation. Contraindication for cryotherapy- late surgery, decreased vascularity. 124 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Radiation t/t may lead to sarcoma. Hence it is reserved when other forms are non amenable. Reserved for vertebral lesions around the spinal canal. Bleeding-wide exposure, hemostats, liberal use of gauze. 125 CHERUBISM: CHERUBISM First Described by Jones in 1933. Children looked similar to renaissance cherubs, hence the name. 126 CLINICAL FEATURES: CLINICAL FEATURES Autosomal dominant transmission with 100% male penetration and 50-70% female penetration. Affected children show normal intelligence and stature and the karyotype of the entire family appears normal. 127 CLINICAL FEATURES: CLINICAL FEATURES Painless bilateral jaw enlargements. Between the ages of 2-3 yrs. Lesion growth greatest during 3 to 4 yrs. They undergo resolution in second decade of life. Relative symmetric enlargements of mandible. 128 CLINICAL FEATURES: CLINICAL FEATURES Maxillary involvement must be extensive for cherubic appearance to be evident. Apparent upward gaze. Maxillary involvement- furrowed palate. Mandibular expansion-decrease in the lingual space and malocclusion. 129 CLINICAL FEATURES: CLINICAL FEATURES Displaced, malposed, impacted and unerupted teeth. Supernumerary and missing teeth. Premature loss of deciduous dentition. Delayed eruption of permanent dentition. Multiple dentigerous cysts. 130 CLINICAL FEATURES: CLINICAL FEATURES In severe cases there may be significant affects on speech, respiration, mastication, deglutition and esthetic concerns. Cervical lymphadenopathy seen which gradually regresses. 131 PowerPoint Presentation: 132 SYNDROMES IN CHERUBISM: SYNDROMES IN CHERUBISM Noonan’s syndrome. Ramon’s syndrome. Jaffe-campanacci syndrome. 133 RADIOGRAPHIC FEATURES: RADIOGRAPHIC FEATURES Bilateral Multilocular XL lesions of mandible. Paper thin cortices. Involvement of coronoid process to produce a blunted appearance. Extragnathic bone involvement- ribs. 134 RADIOGRAPHIC FEATURES: RADIOGRAPHIC FEATURES When lesions resolve the bone returns to a near normal appearance with some areas displaying a granular pattern with focal sclerosis. 135 PowerPoint Presentation: 136 PowerPoint Presentation: 137 HISTOPATHOLOGIC FEATURES: HISTOPATHOLOGIC FEATURES Identical to CGCG. Eosinophilic material cuff around blood vessels. Dense collagen deposits. 138 HISTOPATHOLOGIC FEATURES: HISTOPATHOLOGIC FEATURES Increased erythrocytes- increased numbers of giant cells and decreased collagen. Vice versa with decreased erythrocytes. 139 HISTOPATHOLOGIC FEATURES: HISTOPATHOLOGIC FEATURES Replacement of the giant cell component with fibrous connective tissue and eventually bone occurs with lesional regression. 140 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Surgical intervention may not be needed. Restoration of cosmesis and function with osseous recontouring. Decortication and curretage. Delay treatment till active growth phase is completed. 141 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Radiation is contraindicated because of the risk of malignant transformation and growth asymmetry. 142 BROWNS TUMOR OF HYPERPARATHYROIDISM: BROWNS TUMOR OF HYPERPARATHYROIDISM First account published by Sylvanus Bevan . Recklinghausen- osteitis fibrosa cystica. Red brown appearance due to abundant hemosiderin pigment. 143 ETIOLOGY: ETIOLOGY Parathyroid gland dysfunction : Primary Secondary Tertiary Occult neoplasms. 144 CLINICAL FEATURES: CLINICAL FEATURES Primary HPT- 50 to 80 yrs of age. More common in perimenopausal women. Stones Bones Moans groans 145 CLINICAL FEATURES: CLINICAL FEATURES Bone fractures and bending of long bones. Neuromuscular weakness. Fatigue. Polydipsia and HTN secondary to renal damage. GIT symptoms. CNS symptoms. 146 CLINICAL FEATURES: CLINICAL FEATURES Ophthalmologic changes. Metastatic calcifications in the walls of the blood vessels. Bony swelling in more than one quadrant. Reduction in the height of the edentulous ridge. 147 PowerPoint Presentation: 148 RADIOLOGIC FEATURES: RADIOLOGIC FEATURES Well demarcated circumscribed osteolytic lesions. Usually multilocular. But can be unilocular and focal. Salt and pepper appearance. Root resorption. Space occupying mass in sinus. 149 RADIOLOGIC FEATURES: RADIOLOGIC FEATURES Subperioteal resorption of bone. Poor definations of inner and outer skull tables. Granular demineralizations. Loss of lamina dura. 150 PowerPoint Presentation: 151 PowerPoint Presentation: 152 PowerPoint Presentation: 153 HISTOPTHOLOGIC FEATURES: HISTOPTHOLOGIC FEATURES Osteoclastic and osteolytic bone resorption. Irregular bone and enlarged lacunae. Cortical “cuting cones”. “dissecting osteitis”. Depositions of woven bone and osteoid. 154 HISTOPTHOLOGIC FEATURES: HISTOPTHOLOGIC FEATURES Positive staining for aluminium at the bone osteoid interface. Giant cells in fibrovascular stroma. Cyst like spaces. Foci of hemorrhages. Accumulation of hemosiderophages. 155 HISTOPTHOLOGIC FEATURES: HISTOPTHOLOGIC FEATURES Filling of osteoclast induced burrows with fibrous tissue, peritrabecular and marrow fibrosis. Pulpal calcifications. 156 LABORATORY EVALUATION: LABORATORY EVALUATION Elevated levels of serum calcium. Alkaline phosphatase. PTH. Urinary cyclic AMP. Low levels of serum phosphorus. 157 LABORATORY EVALUATION: LABORATORY EVALUATION For patients with renal osteodystrophy : Elevated serum phosphorus. Low levels of vitamin D metabolites. 158 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Primary HPT : Removal of the adenomas. Renal osteodystrophy : Increasing the levels of serum calcium to suppress the hyperplastic parathyroid tissue. 159 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Refractory patients : Total parathyroidectomy. Presence of Al deposits : Prognosis is worse. 160 GIANT CELL TUMOR OF BONE: GIANT CELL TUMOR OF BONE Neoplasm of undifferentiated cells. Giant cells result from the fusion of mononuclear cells. Malignant giant cell tumor cannot be diagnosed unless previous evidence of benign counterpart. 161 CLINICAL FEATURES: CLINICAL FEATURES Female predominance. Most of the cases- third decade. Pain of variable severity. Swelling. Weakness and limitation of motion. 162 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Basic proliferating cell has oval to spindle shaped nuclei. Numerous mitotic figures. Scattered giant cells with 40-60 nuclei. Infarct like necrosis. Collection of foam cells. 163 PowerPoint Presentation: 164 PowerPoint Presentation: 165 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Removal of the tumor by curettage. Recurrence may be as late as seven yrs. Malignant change to fibrosarcoma or steosarcoma. 166 PowerPoint Presentation: 167 GIANT CELL FIBROMA: GIANT CELL FIBROMA First described in 1974 by Weathers and Callihan. 168 CLINICAL FEATURES: CLINICAL FEATURES Asymptomatic sessile or pedunculated nodule. Papillary surface. 10-30 yrs with no gender predilection. Most common- mandibular gingiva. 169 DIFFERENTIAL DIAGNOSIS: DIFFERENTIAL DIAGNOSIS Squamous Papilloma. Irritation fibroma. Pyogenic granuloma. PGCG. 170 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Unencpsulated mass of loose fibrous connective tissue. Large, plump, spindle shaped, stellate fibroblasts. Central areas show fusiform fibroblasts. Some of the fibroblasts are multinucleated. 171 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Corrugated, atrophic epithelium with thin elongated rete ridges. 172 TREATMENT AND PROGNOSIS: TREATMENT AND PROGNOSIS Conservative excision. Recurrence is rare. 173 HYALINE RING GRANULOMA: HYALINE RING GRANULOMA Variety of names. Chronic periosteitis. Granuloma in edentulous jaws. Giant cell hyaline angiopathy. Pulse granuloma. Oral vegetable granuloma. 174 HYALINE RING GRANULOMA: HYALINE RING GRANULOMA Lewars(1971)-response to food particles driven into mucosa. Adkins reported number of cases with histological picture of rings of palely stained structure less material and giant cells in and around rings. 175 HYALINE RING GRANULOMA: HYALINE RING GRANULOMA In 1975, Rannie described similar cases. In 1977, Dunlop reported 7 cases and noted histologically similar changes in hye wall on naso palatine duct. They suggested the term giant cell hyaline cell angiopathy. In 1978, Kings suggested the term pulse granuloma. 176 HISTOPATHOLOGY: HISTOPATHOLOGY Dense fibrous connective tisue. Numerous multinucleated giant cells associated with the rings of pale staining hyaline material. Some of the rings were completely filled with one or two giant cells others contained hemosiderin particle. 177 HISTOPATHOLOGY: HISTOPATHOLOGY Horse shoe shaped rings were also found. They were positive for PAS stain. Calcific foci were also seen. 178 DIFFERENTIAL DIAGNOSIS: DIFFERENTIAL DIAGNOSIS T.Globrata infection. Chen et al..found such bodies in the wall of odontogenic cysts. Harrison and Martin supported vegetable nature of hyaline rings. They stated that hyaline rings were mainly compose of vegetable cell wall, hence the name. 179 GIANT CELL ANGIOFIBROMA: GIANT CELL ANGIOFIBROMA Rare soft tissue neoplasm which was first described by Dei Tos Et al in 1995 as an orbital tumor occurring in adult. 180 CLINICAL FEATURES: CLINICAL FEATURES Benign tumor with rare local recurrence and no metastatic potential. Wide age distribution with mean age of 59 yrs. Men predominantly affected. Painless mass or nodule. Back, thigh, inguinal area and chest wall. 181 HISTOLOGICAL FEATURES: HISTOLOGICAL FEATURES Pseudovascular spaces. Well circumscribed but unencapsulated mass of moderately cellular spindle cells. Centrally thin walled pseudovascular spaces seen. Some filled with lymph. 182 HISTOLOGICAL FEATURES: HISTOLOGICAL FEATURES Spaces lined by floret type multinucleated giant cells with large hyperchromatic nuclei. Giant cells scattered in spindle cell area also seen. Few adipocytes. 183 GIANT CELL TUMOR OF SALIVARY GLAND.: GIANT CELL TUMOR OF SALIVARY GLAND. Giant cells are found in: Pleomorphic adenoma. Mucoepidermoid carcinoma. 184 TYPES OF GIANT CELLS: TYPES OF GIANT CELLS Foreign body giant cells Fibroblast like giant cells- uncommon in salivary gland tumors. Osteoclast like giant cells- seen in salivary gland carcinomas. 185 GIANT CELL SARCOMA: GIANT CELL SARCOMA This term was used by the authors to describe a rather pleomorphic, destructive, non osteogenic tumor which contained numerous tumor giant cells scattered among a population of obviously malignant cells. 186 BENIGN OSTEOBLASTOMA: BENIGN OSTEOBLASTOMA Was first described under the name giant osteoid Osteoma by Dahlin and Johnson in 1954. It is believed to represent longer version of osteoid osteoma. Uncommon primary lesion of the bone that occasionally arises in mandible or maxilla. 187 ETIOPATHOLOGY: ETIOPATHOLOGY Unknown. Chromosomal translocation. 188 CLINICAL FEATURES: CLINICAL FEATURES Arises in various vertebrae and long bones of the body. Less commonly involves jaws and other craniofacial bones. Posterior tooth bearing regions of mandible and maxilla most commonly involved. Mandible more commonly involved. 189 CLINICAL FEATURES: CLINICAL FEATURES Most commonly in second decade. Pain often quite severe. Localized swelling with or without pain. Expanded cortices and tender to palpation. Mobility of adjacent teeth. Pain not relieved by aspirin or other NSAIDS. 190 RADIOLOGIC FEATURES: RADIOLOGIC FEATURES Combination of radiolucent and radiopaque pattern. Lesions greater than 2cms in diameter. A thin radiolucency surrounding a central calcified tumor mass. Sclerosis of perilesional bone is absent. A sun ray pattern of new bone production may be evident. 191 HISTOPATHOLOGY: HISTOPATHOLOGY Irregular trabaculae of osteoid and immature bone in a stroma containing prominent vascular network. Bony trabaculae exhibit various degrees of calcification. Remodeling of osseous tissue. Trabaculae lined by osteoblasts. Small and slender stromal cells. 192 PowerPoint Presentation: 193 PowerPoint Presentation: Histological studies of osteoblastoma. Upper: Photomicrograph showing packed, small, irregular trabeculae composed of pure woven bone and osteoid. A shell of ossification ( arrows ), (expanded and thinned cortex) is seen at the periphery of the osteoblastoma. Intertrabecular stroma is abundant and cellular. Lower: Photomicrograph showing that intense proliferation of cells occurs between irregularly serrated, thick woven bone trabeculae. The cells consist of osteoblasts ( small arrows ), osteoclasts ( large arrows ), and spindly stromal cells. This field also shows numerous dilated capillaries (C) and foci of hemorrhage (H). H & E, original magnifications × 40 ( upper ) and × 200 ( lower ). 194 HISTOPATHOLOGY: HISTOPATHOLOGY Numerous scattered multinucleated giant cells. 195 DIFFERENTIAL DIAGNOSIS: DIFFERENTIAL DIAGNOSIS Osteoid osteoma. Fibrous dysplasia. Ossifying fibroma. Osteosarcoma. 196 TREATMENT: TREATMENT Surgical excision. Recurrence is rare after adequate surgical intervention. 197 PowerPoint Presentation: 198 PowerPoint Presentation: Diagnostic images of C-2 osteoblastoma. This 10-year-old boy presented with neck pain, and on physical examination local swelling was found on right cervical region. Lateral x-ray films (a) showed a soft-tissue swelling in the retropharyngeal space. Lateral (b) and coronal (c) MR images demonstrating tumor in the C-2 body and a soft-tissue mass from C1–6. Axial CT scan (d) demonstrating a typical osteoid nidus with peritumoral sclerotic rim on the right side of the C-2 body. Technetium bone scan (e) also displays pronounced uptake in this region. We performed tumor excision via an anterolateral retropharyngeal approach (f) occipitocervical fixation by using two axis plates and titanium wires (g). Lateral x-ray films obtained immediately after (h) and 2 years postsurgery (i) showing solid fusion. 199 MALIGNANT OSTEOBLASTOMA: MALIGNANT OSTEOBLASTOMA Histologically more bizzare pattern of cells. Abundant and often plump hyperchromatic nuclei. Greater nuclear atypia. Numerous giant cells. Locally more aggressive but better prognosis than osteosarcoma. 200 GIANT CELLS IN AMELOBLASTOMA: GIANT CELLS IN AMELOBLASTOMA Foreign body giant cell reaction in the supporting connective tissue of an ameloblastoma has been described. Three different types of giant cell reactions: Foreign body. A reparative granulomatous. Osteoclastic reaction. 201 GIANT CELLS IN AMELOBLASTOMA: GIANT CELLS IN AMELOBLASTOMA The derivation of multinucleated giant cells of giant cell reparative granuloma is unknown. Five hypothesis have been put forward: Integral part of the lesion developing through fusion of number of stromal cells. Differentiation from multipotent endosteal or periosteal cells. 202 GIANT CELLS IN AMELOBLASTOMA: GIANT CELLS IN AMELOBLASTOMA Reactive to initial hemorrhage commonly seen in these lesions. Endosteal origin. Giant cells are osteoclasts. 203 RADICULAR CYST: RADICULAR CYST Most common cysts in the jaws. The inflammatory cysts derive their epithelial lining from proliferation of small odontogenic epithelial residues within the periodontal ligament. 204 HISTOPATHOLOGICAL FEATURES: HISTOPATHOLOGICAL FEATURES Archading and forking of rete ridges. Foci of dystrophic calcifications. Cholesterol clefts. Multinucleated giant cells. 205 TUBERCULOSIS: TUBERCULOSIS Specific Infectious Granulomatous disease caused by Mycobacterium Tuberculosis. 206 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Do not differ from the tuberculous lesions of the body. Cell mediated hypersensitivity reaction. Formation of granuloma. Foci of caseous necrosis surrounded by epitheloid cells, lymphocytes and giant cells. 207 PowerPoint Presentation: 208 PowerPoint Presentation: 209 PowerPoint Presentation: Higher power: This section shows a duct and a giant cell tubercle; a round nodule with a large Langhans giant cell in the center surrounded by fibroblasts; and occasional lymphocytes. 210 LEPROSY: LEPROSY Also called as Hansens disease. Chronic granulomatous infection caused by Mycobacterium Leprae . Slightly contagious disease. 211 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Granulomatous nodule shows the collections of epitheloid histiocytes and lymphocytes in a fibrous stroma. Langhans type of giant cells are invariably present. 212 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Sheets of lymphocytes with vacuolated macrophages called Lepra cells are scattered throughout the lesion. Tuberculoid type- paucity of micro organisms. Lepramatous type- abundance of micro organisms. 213 PowerPoint Presentation: 214 ACTINOMYCOSIS: ACTINOMYCOSIS Chronic granulomatous suppurative and fibrosing disease caused by anerobic gram positive non acid fast, branched filamentous bacteria. A.israelli, A.naselundi, A.viscosus, Odontolyticus and Propionica. 215 PowerPoint Presentation: 216 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Central abscess formation within which may be seen the characteristic colonies of microorganisms. Colonies float in a sea of polymorphonuclear leucocytes often associated with giant cells and macrophages around the periphery of the lesion. 217 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Colonies- round or lobulated. Meshwork of filaments staining with hematoxylin, but shows eosinophilia of the peripheral club shaped ends of filaments. Ray fungus. Methinamine silver. 218 PowerPoint Presentation: 219 HERPES SIMPLEX: HERPES SIMPLEX A viral infection. Attached mucosa. Inoculation by HSV 1 and occasionally HSV 2. 220 PowerPoint Presentation: 221 HISTOLOGICAL FEATURES: HISTOLOGICAL FEATURES Vesicles are lined by characteristic epithelial cells that show effects of HSV infection. These cells may contain single nucleus or may be multinucleated. 222 PowerPoint Presentation: 223 MEASLES: MEASLES Acute, contagious dermatropic viral infection, primarily affecting children and occurring many times in epidemic form. Caused by paramyxovirus which is RNA virus. 224 PowerPoint Presentation: 225 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Characteristic multinucleated giant cells called Warthin Finkeldey cells. Intranuclear inclusions. Multinucleated giant cells seen in the lymphoid tissues of patients with measles. 226 PowerPoint Presentation: 227 SARCOIDOSIS: SARCOIDOSIS Multisystem granulomatous disease. Young adults. Hilar lymphadenopathy, pulmonary infiltration, skin and eye lesions. Raised or abnormal serum immunoglobulins. 228 PowerPoint Presentation: 229 CLINICAL FEATURES: CLINICAL FEATURES Mild malaise and cough. Involvement of the specific organ followed by the dysfunction of that organ. Multiple, raised red patches that occur in groups grow slowly and do not tend to ulcerate or crust. 230 PowerPoint Presentation: 231 PowerPoint Presentation: 232 HISTOLOGICAL FEATURES: HISTOLOGICAL FEATURES Closely resemble proliferating non caseating nodule of tuberculosis. Nests of epitheloid cells and multinucleated giant cells are one of the chief microscopic features. 233 PowerPoint Presentation: 234 COCCIDIODOMYCOSIS: COCCIDIODOMYCOSIS Inhalation of dust contaminated by the spores of causative organism, Coccidiodes Immitis. 235 PowerPoint Presentation: 236 PowerPoint Presentation: Coccidioidomycosis . Histopathologic features of coccidioidomycosis of lung showing spherule with endospores of Coccidioides immitis. Endospores, not spherule wall, are stained (fluorescent antibody stain). 237 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Large mononuclear cells, lymphocytes and plasma cells predominate. Foci of coagulation necrosis. Multinucleated giant cells scattered throughout the lesion. 238 PowerPoint Presentation: 239 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Organisms are found within the cytoplasm of giant cells as well as lying free in the tissue. Organisms vary greatly in size and generally show budding. 240 CRYPTOCOCOSIS: CRYPTOCOCOSIS Fungal infection caused by Cryptococcus Neoformans and C.Bacillispora. Inhalation of the air borne organisms. Often an opportunistic infection. 241 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Causative organism is gram positive, budding, yeastlike cell with an extremely thick gelatinous capsule. Tissue microcyst. PAS and Sabourauds glucose agar. Granulomatous reaction. Multinucleated giant cells. 242 PowerPoint Presentation: 243 SPOROTRICHOSIS: SPOROTRICHOSIS Fungal infection caused by Sporotrichum Schenckii. Exposure to animals. Accidental injury from thorns of some plants. Accidental lab or clinical inoculation of hospital workers. 244 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Small, ovoid branching fungus with septate hyphae showing budding forms. Cultured on Sabouraud’s medium. Granulomatous reaction. Langhan’s type of giant cells and lymphocytes. 245 PowerPoint Presentation: 246 PowerPoint Presentation: 247 HISTOLOGIC FEATURES: HISTOLOGIC FEATURES Polymorphonuclear leukocytes. Asteroid bodies. Pseudoepitheliomatous hyperplasia of the overlying epithelium. 248 THANK YOU…: THANK YOU … 249

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