Improvement of Giant Cell Lesions of the Jaw Treated With High and Low Doses of Denosumab: A Case Series

Abstract

Giant cell tumors (GCTs) and central giant cell granulomas (CGCGs) are aggressive lesions that appear in the jaw. These lesions occur in the second and third decades of life and often arise in the mandible. Clinical manifestations of these lesions vary from asymptomatic to symptomatic tooth displacement with cortical perforation. GCTs, which are characterized by multinucleated osteoclast-type giant cells that express receptor activator of nuclear factor-κB (RANK) ligand, rarely present in the jaw and have overlapping histopathologic features with CGCGs, which are composed of fibroblastic stromal cell lesions. GCTs and CGCGs have overlying histopathologic features that make distinction between the two challenging. There is a real controversy as to whether giant cell tumors and central giant cell granulomas are in fact, one and the same lesion. The majority of GCTs occur in the long bone, with surgery being the typical therapeutic option. Denosumab as a treatment modality is a fairly new concept that has been used effectively in GCTs affecting long bones. There is less experience, however, with its use for jaw lesions. This seven-case series describes the effective use of both low-dose and high-dose denosumab in the treatment of GCTs and CGCGs affecting the jaw and special dosing considerations for younger patients who present with disease. © 2017 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

Keywords: ANTIRESORPTIVES; CANCER; CELLS OF BONE; DENTAL BIOLOGY; STROMAL/STEM CELLS; THERAPEUTICS; TUMOR‐INDUCED BONE DISEASE.

Figure 1

(A) Jaw X‐ray showing an expansive mandibular lesion with irregular borders. (B) Biopsy showing central lesion (solid arrow) with perivascular hyalinization (dashed arrow). (C) Panoramic X‐ray 1 year on treatment shows resolution of the lesion. (D) Biopsy confirmed viable lamellar and trabecular bone with fibrous connective tissue. No giant cell lesion observed.

Figure 2

(A) X‐ray showing a 25 mm × 15 mm radiolucent lesion in the right posterior mandible. (B) Surveillance image after 1 year of treatment, which shows a denser lesion without regression in size.

Figure 3

(A) Large expansile lesion with ill‐defined borders and a moth eaten permeative pattern. The lesion protrudes into dental roots. (B) One‐year image illustrates improvement in bone quality with mild reduction in size.

Figure 4

(A, B) Lytic lesion measuring 25 mm × 25 mm × 22 mm. (C, D) Surveillance imaging with 7 months of treatment showed calcification and stabilization of the lesion.