Bansal SK et al. Granular cell Ameloblastoma of the Jaw.

Case Report
Granular cell Ameloblastoma of the Jaw: A Case Report and
Review of Literature
Satish Kumar Bansal1, Gopal Singal2, Umesh Chhabra3, Sandeep Kumar Goyal3,Yudhvir Singh4
Geetanjali Gupta5
1
Associate Professor, 2Professor, 3Assistant Professor, 4Senior Resident, Department of General
Surgery, 5Junior Resident, Department of Dentistry, MAMC, Agroha, Hisar, India
Abstract:
Ameloblastoma is a neoplasm of odontogenic epithelium, especially of enamel organ-type tissue that has not
undergone differentiation to the point of hard tissue formation. It accounts for approximately 10% of all
tumors originating from gnathic bones. It exhibits diverse microscopic patterns which occurs either singly or
in combination with other patterns. Granular cell ameloblastoma is a rare condition, accounting for 3.5% of
all ameloblastoma cases that shows marked transformation in the cytoplasm of tumor cells, which are
usually stellate reticulum like cells. It is also considered an aggressive variant of ameloblastoma with
potential recurrence and malignant transformation. This article describes a case of granular cell variant of
ameloblastoma affecting a 50-year old male.
Key Words: Ameloblastoma, Granular Cell, Odontogenic Tumor
Corresponding Author: Dr. Satish Kumar Bansal, Associate Professor, Department of General
Surgery, MAMC, Agroha, Hisar, India, E mail: [email protected]
This article may be cited as: Bansal SK, Singal G, Chhabra U,Goyal SK,Singh Y,Gupta G.
Granular cell Ameloblastoma of the Jaw: A Case Report and Review of Literature. J Adv Med
Dent Scie Res 2015;3(1):140-142.
INTRODUCTION article is to present a case of unusual variant
Ameloblastoma is a neoplasm of odontogenic of ameloblastoma highlighting its unique
epithelium, especially of enamel organ-type microscopic features that allow its distinction
tissue that has not undergone differentiation from other jaw tumors with a granular cell
to the point of hard tissue formation.1 It often consistency.
presents as a slow growing, painless CASE REPORT
swelling, causing expansion of the cortical A 50-year old male reported with a swelling
bone, perforation of the lingual and buccal in the lower left back tooth region since 2
plates and infiltration of soft tissue.2 It occurs years. Patient noticed small swelling which
in three different clinical‑radiographic was initially pea-nut in size and progressed to
patterns: conventional intraosseous solid and present size. There was no significant past
multicystic (86%), unicystic (13%) and medical history. Extraorally, facial
peripheral (1%). The common histological asymmetry was noted on left side of face.
patterns include the follicular (32.5%) and The swelling was 4x2cm in size extending
plexiform (28.2%) ones, less common being antero-posteriorly from parasymphysis to
the acanthomatous (12.1%), granular, angle of mandible and supero-inferiorly 2 cm
desmoplastic (8.6‑13%) and basal (2%) from angle of mouth to inferior border of
forms.3 Granular cell ameloblastoma (GCA), mandible on left side (Figure 1). Tender on
a relatively rare histologic subtype, palpation and was firm in consistency.
representing 3‑5%, is characterised by large Intraoral examination revealed a diffuse
round/cuboidal eosionophillic cells with swelling in the mandibular posterior region
granular cytoplasm and, in most instances, it on left side extending along the buccal
is blended with a follicular subtype.4 Only vestibule extending from 34 to 37 which was
few cases of granular ameloblastomas are irregular in shape, pale pink in color, stony
reported in the literature. The purpose of this hard and tender. Obliteration of the buccal
vestibule was seen in relation to 36. Missing

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 Bansal SK et al. Granular cell Ameloblastoma of the Jaw.

teeth in relation to 36, 37. Aspiration of the Reichart et al. reviewed all available
lesion revealed reddish brown fluid. literature on ameloblastoma of the jaws from
Orthopantamograph revealed an ill-defined 1960 to 1993 and reported that out of a total
radiolucent area extending from 33 to angle of 1593 cases with available data on
of mandible with a discontinuity in lower histologic subtypes; there were only 56
body of mandible on left side. Lesion (3.5%) cases of the granular cell variant3.
exhibited a compartmented appearance with Granular cells are just a transitional or
septa of bone extending into the radiolucent matured phase in the lifecycle of
tumour mass (Figure 2). A provisional ameloblastomas, starting with normal stellate
diagnosis of ameloblastoma, calcifying reticulum like cells leading to production of
epithelial odontogenic tumor, or a fibro- granules and finally leading to degeneration
osseous lesion was made and a biopsy was and formation of cystic areas.5
performed. The selected treatment planning Numerous theories have been put forward on
was enucleation and reconstruction with non- the origin and nature of these granular cells
vascularised iliac bone graft, and in ameloblastomas, with an epithelial origin,
osteosynthesis by plate and screws. HE several ultrastructural and histochemical
stained sections revealed ameloblastic studies have described them as lysosomes
epithelium arranged in follicles consisting of and many authors have reported the
stellate reticulum-like cells in the mature immunohistochemical (IHC) findings of
fibrous connective tissue stroma. Follicles GCA, yet the actual contents within the
show palisaded, peripheral tall columnar granular cells remains largely undefined6. It
cells with nuclear hyperchromatism and was speculated that, with age, the
reverse polarity. Few epithelial islands unnecessary aged components progressively
enclosing eosinophilic granular cells were increase in the cytoplasm of some of the
evident (Figure 3). The final diagnosis of tumor cells, while the ability of lysosomes to
Granular Cell Ameloblastoma was made. eliminate these materials decreases; hence,
The postoperative period went without their cytoplasm becomes packed with
complications, with good aesthetic and lysosomal granules.7
functional final results. At 1.5 years follow A recent IHC and ultrastructural study
up, there are no signs of recurrence. suggests that the cytoplasmic granularity
DISCUSSION might be attributed to the increased apoptotic
GCA represents a rare variant of cell death of the neoplasic granular cells, and
ameloblastoma only 1 out of 77 to their subsequent phagocytosis by the
ameloblastoma cases was classified as the adjacent granular cells.8
granular cell subtype.

Figures: 1): Clinical picture showing facial

asymmetry on left side of face; 2): Tumour
exhibits a compartmented appearance with
septa of bone extending into the radiolucent
tumour mass. 3): Low power view shows
islands of enamel organ like tissue
consisting of stellate reticulum like cells in
the mature fibrous connective tissue stroma;
4): High power view shows peripherically
placed ameloblast like cells with nuclear
hyperchromatism reverse polarity.
Eosinophilic granular cells are also evident.

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 Bansal SK et al. Granular cell Ameloblastoma of the Jaw.

The most recent studies suggested that the 2. Adeyeme WL, Bamgbose BO, Ladeinde
synthesis of signalling molecules, such as AL, Ogunlewe MO. Surgical management
beta‑catenin and Wnt‑5a, is upregulated in of ameloblastomas: conservative or
the granular cells of GCA, but their radical approach? A critical review of the
transportation or secretion is impaired, their literature. Oral Surgery 2008; 22-27.
accumulation within granular cells, as 3. Reichart PA, Philipsen HP, Sonner S.
autophagosomes, thus resulting. Also, the Ameloblastoma: biological profile of 3677
heparinase enzyme, which is associated with cases. Eur J Cancer B Oral Oncol
invasiveness, fails to be activated, being 1995;31:86-99.
accumulated within these cells, in its latent 4. Vijaykumar G, Latturiya GR, Biradar S.
form.9 Of the odontogenic tumors, granular Granular cell ameloblastoma: A diagnostic
cells have been described in the granular cell dilemma for histopathologist. Eur J of Gen
ameloblastoma and the granular cell Dent 2012; 1(2): 109‑11.
ameloblastic fibroma.10 Similar cells occur in 5. Gupta S, Grewal H, Saha K. Granular cell
the congenital epulis, a lesion regarded by ameloblastoma showing desmoplasia. Ann
some as a product of dental epithelium and Saudi Med. 2012;32:537-40.
more specifically of ameloblastic. The 6. Vinuth DP, Aggrawal P, Dhirwani R,
striking morphological and tinctorial Gunjan, Haranal S, Naresh N. A giant cystic
resemblance of the granular cells in these granular ameloblastoma of the mandible. Int
three lesions to those of the granular cell J of Medical Dent 2013;3(3):238-42.
myoblastoma have led some authors to 7. Nasu M, Tagaki M, Yamamoto H.
conceive congenital epulis as a granular cell Ultrastructural and histochemical studies of
myoblastoma and of the GCA as a granular cell ameloblastoma. J Oral Pathol
coincidential mixture of ameloblastoma and 1984;13:448-56.
granular cell myoblastoma. The origin of the, 8. Kumamoto H, Ooya K.
granular cells has been a matter of great Immunohistochemical and ultrastructural
speculation as concerning histogenesis, the investigation of apoptotic cell death in
GCA's are of epithelial nature, and arise from granular cell ameloblastoma. J Oral Pathol
ameloblasts. Conversely, the granular cells Med 2001;30:245-50.
found in other lesions of the oral cavity are of 9. Ara SG, Han PP, Tamamura R, Nagatsuka
mesenchymal derivation.11 H, Hu H, Katase et al. Immunolocalisation
CONCLUSION of cell signalling molecules in the granular
Early diagnosis and prompt surgical cell ameloblastoma. J Oral Pathol Med
treatment in granular cell ameloblastoma is 2007;36:609-14.
of prime importance. Noteworthy is that 10. Couch DR, Morris EE, Vellios, F. Granular
granular cell ameloblastoma 's may rarely cell ameloblastic fibroma. Report of 2 cases
behave in a malignant fashion giving rise to in adults, with observations on its similarity
metastasis. Patients should be kept under to congenital epulis. Amer J Clin Path
periodic observation because of reports of 1996;37:398-404.
recurrences even up to 8 years after initial 11. Saigal S, Bhargava A, Chalishazar M.
treatment. Granular cell ameloblastoma- a case report.
Oral & Maxillofac Pathol J 2011;2:170-74.
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