Central Giant Cell Granuloma: A Decade of Institutional Experience and Curative Potential of Neoadjuvant Denosumab

Central giant cell granuloma (CGCG) is a rare lesion of the maxilla and/or mandible affecting young adults. Traditionally, first-line management includes surgery, however surgery portends significant associated risks, including risk of disfigurement, especially given the young age of patients affected and the facial placement of the lesion. Medical therapy has been previously described, however there is uncertainty regarding choice, duration of medical therapy, and risk of recurrence. RANKL inhibition through denosumab has previously been described in a related condition, giant cell tumor of bone, and has been used in central giant cell granuloma in other small case series. Here, we propose the usage of denosumab as a neo-adjuvant treatment prior to surgical resection. We describe a denosumab regimen of 120 mg monthly subcutaneously with a stepwise increase in dosing interval depending on individual clinical, biochemical, and radiological response to treatment, to 2-monthly, 3-monthly, and 6-monthly. Twelve patients were included in this longitudinal study, and clinical and radiologic response was seen in all patients after a mean of 3 and 6 denosumab doses, respectively. Neoadjuvant denosumab use led to complete remission in the majority of cases. Adverse events included hypocalcemia and hypercalcemia, with no cases of medication related osteonecrosis of the jaw. This study demonstrates efficacy of denosumab in the treatment of CGCG both as initial and final treatment and as neo-adjuvant treatment prior to surgical resection.