PMC5322443_01
Initial clinical manifestation. A small radiolucent area (arrow) is revealed near mobile dental element 34. Chronic periodontitis is present.
CRID2017-9604570.001.jpg
PMC5322443_01_CRID2017-9604570.001.jpg
fig1
The orthopantomogram only showed a small radiolucent area adjacent to the dental element (Figure 1).
Relapse of the lesion. (a) The next examination, three months later, revealed the presence of a radiolucent cyst-like lesion in the mandible with mildly defined and irregular borders. (b) The CT radial view showed lingual cortical plate with a polylobate appearance and erosion of the buccal cortical plate (arrow). (c) The CT axial view highlighted the buccal erosion of the cortical plate (arrow).
CRID2017-9604570.002.jpg
PMC5322443_01_CRID2017-9604570.002.jpg
fig2
The CT scan revealed the presence of a radiolucent cyst-like lesion in the mandible with thin expanded buccal cortical plate and localized erosion and a polylobate appearance on the lingual aspect of the cortical plate (Figures 2(a)-2(c)).
Central giant-cell granuloma (CGCG). (a) A lobulated mass of proliferating connective tissue containing many giant cells. (b) A larger view of the giant cell containing more than ten nuclei each. (c) Ki-67 indicates a low mitotic index. The lesion is defined as locally aggressive but cannot be considered as a true neoplasm. (d) CD68 antibody indicates the giant cells deriving from the monocytic-macrophagic line. (e) The so-called "cannibal cells" (arrows) indicate an aggressive CGCG and could suggest likely recurrence. (f) A larger view of the monocytic-derived cannibal giant cells highlighted with CD68.
CRID2017-9604570.003.jpg
PMC5322443_01_CRID2017-9604570.003.jpg
fig3
The histological description of the sample reported the presence of an aggressive lesion with widely distributed giant cells (Figures 3(a)-3(d)). Moreover, several giant cells displayed scattered cannibalistic processes, in the absence of bizarre figures like those reported in complex cannibalism of OSCC (Figures 3(e) and 3(f)).
Radiographic appearance after six months. (a) Multiple osteolytic areas involving the mandible bilaterally revealed by another orthopantomogram (b-d) and CT scan six months after.
CRID2017-9604570.004.jpg
PMC5322443_01_CRID2017-9604570.004.jpg
fig4
There was no sign of neurological involvement, although the nerves appeared to be dislocated (Figures 4(a)-4(d)). The multiple lesions described in Figures 4(a)-4(d) required maxillofacial evaluation for surgery, but a decision was made to verify whether the pathology was limited to the mandible or whether other body areas were involved.
Systemic correlation. (a and b) A CT scan of the left knee highlighted the presence of an osteolytic, cyst-like, polylobate lesion which resembles those encountered in the mandible. (c) "Salt-and-pepper" appearance of the cranial vault.
CRID2017-9604570.005.jpg
PMC5322443_01_CRID2017-9604570.005.jpg
fig5
MRI and CT scans of the patient's left knee revealed the presence of a cyst-like, polylobate lesion in the kneecap, with regular borders, cortical thinning, and localized erosion (Figures 5(a) and 5(b)). It was advisable to complete the head examination by prescribing an X-ray of the cranial vault, which showed multiple osteolytic areas with a salt-and-pepper appearance (Figure 5(c)).
Parathyroid adenoma. (a) The patient underwent minimally invasive video-assisted parathyroidectomy (MIVAP) with intraoperative PTH determinations (baseline and 20 minutes after tumor removal) and continuous intraoperative nerve monitoring. A left inferior parathyroid adenoma was successfully removed. The baseline PTH measurement was 678 pg, and 20 minutes after excision the PTH serum level was 47 pg. Postoperative progress was uneventful. The patient was discharged the day after the operation with the appropriate prescriptions. (b and c) Parathyroid adenoma with clear cells at a low and high grade of amplification; a thin fibrous capsule is present. (d) CD34 endothelial staining showed no evidence of angioinvasion. (e) PTH staining confirmed the functional activity of the tumor. (f) Ki-67 expression was low, confirming the benign nature of the tumor.
CRID2017-9604570.006.jpg
PMC5322443_01_CRID2017-9604570.006.jpg
fig6
Radiographic appearance after four months and two years. (a) Signs of bone healing after four months after surgical excision of the parathyroid adenoma. (b) Complete recovery of the bony tissue two years after the operation.
CRID2017-9604570.007.jpg
PMC5322443_01_CRID2017-9604570.007.jpg
fig7
Another two orthopantomograms carried out 4 months and 2 years later, respectively, showed advanced and complete healing of the bony lesions in the mandible (Figure 7).