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Department Of Orthopaedics& Traumatology.Sheed Suhrawardy Medical College Hospital, Dhaka-1207, Bangladesh.
Giant Cell Tumor Of
Bone -Diagnosis & Management
Basic of
From -
CME on
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Presenting By- Dr. Nabarun Biswas & Dr. Golam Mahamud Suhash,From Department of Orthopedic & Traumatology, Shaheed Suhrawardy Medical College Hospital, Dhaka-1207. Bangladesh.
Prepared By-Dr. Md Nazrul IslamMBBS, M . sc. (BME).
Giant Cell Tumor Of
Bone -Diagnosis & Management
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Contents
Overview Epidemiology Incidence Presentation Radiology Diagnosis Treatment Outcomes
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Overview
Giant cell myeloma or Osteoclastoma
Primary bone neoplasm Generally benign, locally invasive Presence of multinucleated giant
cell Potential for :
Recurrence Pulmonary metastasis Frank malignancy
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Epidemiology
5-10% of primary bone tumors 20% of benign F : M = 1.5 : 1 70-80% occurs at age 20-40 Epiphyseal Monostotic Rare in skeletally immature
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Incidence Affects Ends of long
bones >50% around knee High recurrence rate 1-2% benign pulm. Mets Primary malignant
GCT<1% Rare polyostotic form
<1%
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Location
Common sites: Distal femur Proximal tibia Distal radius Proximal humerus
Other sites: Fibula , distal tibia Bones of pelvis, sacrum Vertebral body
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Presentation Pain – ends of long bone Swelling - mild to moderate Visible Mass Pathologic # (10-15%) Limited range of motion Fluid accumulation in
adjacent joint Rarely Neuro deficit if spine / sacrum involved
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Radiology Lytic lesion Epiphyseal , Eccentric,
Expansile Narrow zone transition Soap bubble appearance Cortical thinning Non sclerotic , sharply defined
margin
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Radiology(con…)
• Occ. Cortical
breakthrough
• +/- soft tissue mass
• Extend to subarticular
cortex
• Often large presentation
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Other modalities
CT Integrity of cortical rim
MRI Assess subchondral breakthrough
Bone Scan Decreased radioisotope uptake in the center of lesion (Multicentric GCT)
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Biopsy
Needle(accuracy >90%) & excisional
Tumor principles , histologic grade
Necessary for Dx. Occ assoc.
ABC Pagets
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Gross Soft,brown mass Area of haemorrhage
(dark red) Area of collagen
(gray)
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Histology Fibrohistiocytic origin Multinucleated giant
cells Fusion of stromal cells
Uniformly distributed Mononuclear stromal
cell Round / ovoid / spindle
Indistinct cell membrane
Prominent mitotic activity
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Enneking Staging
Stage 1 (latent)
Stage 2 (active)
Stage 3 (aggressive)
Pt % 10-15% ~70% 10-15%
Symptoms Asymptomatic
Pain Pain
Radiograph Non sclerotic rim
Expanded cortex
CorticalBreak
Histology Benign Benign Benign
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Angiography
Neovascularity with intense, inhomogeneous capillary blush
Intra & extra osseous extent
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Sacrum / Pelvis
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Differential Diagnosis
Aneurismal bone cyst (ABC)
Simple/solitary bone cyst Chondroblastoma Brown tumor(hyperparathyroidism)
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Treatment Surgical Intralesional curettage / resection
& bone graft (Rec.35-42%) En Bloc resection Curettage & bone
cementation(PMMA) Curettage & cryosurgery Excision & reconstruction Amputation Non surgical Irradiation therapy Embolization of feeding vessels
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Curettage, electrocautery & bone graft
Wide decortication (windowing)
Curettage / high speed burr
Recurrence 10-20%%
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Curettage, chemical cautery & bone graft
Phenol 5-80% phenol Wash cavity with 70%
Alcohol 10-20% recurrenceDisadvantages Systemically toxic Chemical burn
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Adjuvants
Liquid N2, Phenol, CO2 laser,H2O2 ElectrocauteryLocal extension of margin
Kill residual foci
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PMMA
Fill tumor cavityHeat kill of tumor cells8-26% recurrenceEasy recurrence detectionDegenerative osteoarthritisDifficulty in removing
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Recurrence
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Subchondral bone grafting
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Enbloc Resection
Expendable bonesProx fibula / Distal
ulnaHigh recurrence with
other TxHand / Distal radius
Pathologic #Joint involvement Recurrence ~10%
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Cryotherapy
3 freeze thaw cycles Irrigate cartilage with cool saline Circumferential necrosis “difficult” Recurrence 2-12% Complications
Soft tissue injury Late fractures
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Excision & reconstruction
Turn-O-plasty Arthrodesis Arthroplasty
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Excision & reconstruction(Con..)
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Amputation
Widespread aggressive tumour
Last resort
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Non surgical Rx
Irradiation therapy is for cases where surgery not performed safely or effectively
Malignant change 15% Embolization of feeding vessels by
catheter – shrink/disappearance of tumour
Drugs e,g interferon – shrink/disappearance of tumour
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Metastasis
Lung, Lymph node(rare) After 3-5 years Spontaneously regress,static,grow
slowly or rapidly Mortality 15-25% Rx- wide
resection,iradiation,interferon
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Follow-up
Observation at least 5 yearsPhysical examination & radiology – affected site, lung
Relapse – pain, swelling
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Spine
< 3% vertebrae above sacrum All levels affected equally Affects vertebral body Resection with stabilization Resection often incomplete Radiation as adjuvant (low dose 3000
Gyc) Incomplete excision Local recurrence
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Sacrum / Pelvis
GCT often vascular Pre-op angiography Embolization, Intalesional
excision or radiation
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Outcome
Prognosis is good, despite of recurrences and pulmonary metastases
Depends on surgical technique and expertise and the histological grade of this tumour
Angiovascular invasion does not have any significant influence on its prognosis
The mortality rate is about 4%.
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