Abstract
The typical management of central giant cell granuloma (CGCG) of the jaws involves curettage or resection; however, in selected cases, medical therapies such as denosumab have emerged as potential alternatives. We present the case of a 22-year-old patient who presented with a right mandibular expansile lesion. Imaging and biopsy confirmed mandibular CGCG. The patient was managed non-surgically with denosumab, and follow-up imaging demonstrated lesion stabilisation and radiographic maturation. Denosumab may represent an alternative to surgery when operative management carries significant morbidity.
Introduction
Central giant cell granuloma (CGCG) is an uncommon benign intraosseous lesion, accounting for approximately 7% of benign jaw tumours. Its behaviour ranges from indolent to locally aggressive, with potential for pain, cortical expansion, root resorption, and pathological fracture, but no documented risk of malignant change. ,, Several reports describe its unpredictable biological behaviour and management challenges. ,,,,
Traditionally, treatment involves surgical curettage or resection. ,,, However, medical therapies have gained attention, including intralesional steroids, calcitonin, interferon-α and, more recently, denosumab, a monoclonal antibody against RANK-L with a half-life of 32 days. ,, Evidence for denosumab largely arises from studies of giant cell tumours of long bones (GCTB), a biologically related entity. ,, Its application in CGCG remains off-label but has shown potential in reducing surgical morbidity or serving as an alternative when surgery is contraindicated.
This report describes a case of mandibular CGCG managed with denosumab.
Case report
This case report was conducted in accordance with CARE guidelines. Clinical examination, radiographic imaging, and incisional biopsy were performed with histopathological confirmation as part of routine clinical care. Denosumab (120 mg) was administered following local approval using a schedule extrapolated from GCTB literature (120 mg loading doses on days 1, 8, and 15, followed by monthly 120 mg doses for six months). Follow-up imaging was undertaken at intervals using computed tomography (CT). The patient provided informed consent for case reporting.
Case presentation
A 22-year-old female was referred with a three-month history of a painless, enlarging swelling of the right mandible. Clinical examination revealed a firm, non-tender expansion of the right posterior mandibular buccal cortex. CT revealed a 7 cm, well-defined, multilocular, expansile radiolucency involving the right mandibular ramus and angle. No perforation or pathological fracture was evident.
Incisional biopsy confirmed CGCG, and differential diagnoses, such as brown tumour of hyperparathyroidism, were excluded with normal serum calcium and parathyroid hormone (PTH) levels.
During consultation, a significant history of depression, anxiety, and previous self-harm was disclosed. Given the patient’s age and psychosocial background, the potential psychological burden of major reconstructive surgery (hemimandibulectomy and fibular free flap) was carefully considered. The case was therefore presented at a multidisciplinary team (MDT) meeting to discuss management strategies used in GCTB in comparable clinical contexts. After discussion with the patient and her family, a consensus was reached to carry out non-surgical management with denosumab.
Six months of subcutaneous denosumab therapy was administered by rheumatology colleagues, with monthly calcium monitoring. This approach avoided the immediate psychosocial impact, recovery time, and risks associated with resection and reconstruction.
Follow-up CT at six months demonstrated good internal mineralisation and no increase in lesion size. Ground-glass attenuation was noted within the lesion, improving visualisation of the right inferior alveolar nerve ( Fig. 1 ), which was clinically functioning after treatment. Mild side effects (headaches and fatigue), which were experienced during treatment, resolved after cessation of therapy, and the patient was satisfied with lesion stabilisation.
