gct of distal radius

Giant cell tumorGiant cell tumorofof

Distal RadiusDistal Radius

Sumroeng Neti, M.D. (1st class honors)Sumroeng Neti, M.D. (1st class honors)

Orthopedic CenterOrthopedic Center

Bumrungrad International HospitalBumrungrad International Hospital

EpidemiologyEpidemiology- 5% of bone tumors 5% of bone tumors- : : - 2040- 2040yyyyyyyyyy- Slightly female predominantSlightly female predominant

LocaIizationLocaIization- Epiphysis/metaphysisEpiphysis/metaphysis lesion lesion- eccentrically locatedeccentrically located

1.1. Distal femur : Distal femur : most common most common sitesite

2.2. Proximal tibiaProximal tibia

3.3. Distal radiusDistal radius

4.4. SacrumSacrum

Clinical presentationClinical presentation- Progressive pain with Progressive pain with

mass mass - : : most common 80%most common 80%- Pathologic fracture : 10-Pathologic fracture : 10-

30%30%- Joint effusionJoint effusion

Plain radiographPlain radiographTumor effect to bone

- Purely lytic : geographic pattern

- Eccentrically located in the epiphyses and abut the subchondral bone

Bone response to tumor

- Expansile

- Margin

: Distinct or poorly outlined

: Classically nonsclerotic

: Erosion through the cortex

ClassificationClassification

- 15 % latent

- bone maintain normal contour

- Sharply defined margin

- 70 % active lesion

- deformity and expansion of bone

- cortical erosion

- Limited endosteal response

- 15 % aggressive lesion

- poorly outlined margin

- cortical breakthrough and soft tissue mass

- pathologic fracture

MRIMRI- To determine the extent of lesion both within the bone and the soft tissue

- Usually dark on T1-weight images and bright on T2 - weight images

PathologyPathology- Multinucleated giant cells ( 40-60 nuclei per cell) in a sea of mononuclear stromal cell

- Area of storiform spindle cell formation

- Small amount of bone or osteoid

Goal of TreatmentGoal of Treatment

1.Tumor removal1.Tumor removal- - Extended curettage Extended curettage : latent, active: latent, active- - En Bloc resection : aggressiveEn Bloc resection : aggressive

““Prevent local recurrence”Prevent local recurrence” 2.Restore function : Reconstruction2.Restore function : Reconstruction

- Allograft – Osteochondral allograft- Allograft – Osteochondral allograft- Arthrodesis- Arthrodesis- Arthroplasty- Arthroplasty

ConventionalConventional Surgical Treatment Surgical Treatment

GCT of bone

Grade

En Bloc excision & Reconstruction

Grade 3

Extended curettageCement or Bone graft

Grade 1 & 2

TreatmentTreatment Local recurrence Local recurrence

• - - Almost happen within first Almost happen within first22 yea yearsrs

• - Simple c- Simple c urettage and bone graf urettage and bone graf -ting 30 40% -ting 30 40%

• - - Extended curettage < 10% Extended curettage < 10%• - - - Lung metastasis is 6 time high - Lung metastasis is 6 time high

er in recurrence case er in recurrence case Extended curettage = curettage + - high speed bur

r +

adjuvant agents (phenol, liquid nitrogen,etc.)

TreatmentTreatmentCurettageCurettage

: realize the importance of creating : realize the importance of creating a cortical window at least a cortical window at least as large as large as the lesionas the lesion to prevent leaving to prevent leaving residual tumor cells “ residual tumor cells “ around the around the cornercorner” ”

Filling materialsFilling materialsyyyy yyyyyy yyyy yyyyyy

AdvantageAdvantage

- - early limb using early limb using

- early- early recurrence detecti recurrence detectionon

- kill residual tumor cell - kill residual tumor cell by heat of by heat of polymerizationpolymerization

DisadvantageDisadvantage

- - - heat induced degenerat- heat induced degenerat ive joint disease ive joint disease

Bone graft Bone graftAdvantageAdvantage

- - biologic healing biologic healing

- - preserve bone stock preserve bone stock

DisadvantageDisadvantage - - delayed delayed rehabilitationrehabilitation

- - difficult tumor recurre difficult tumor recurre nce detection nce detection

TreatmentTreatment Adjuvant RxAdjuvant Rx

- 1. 1. PhenolPhenol - : : concentration should be limited in 5%concentration should be limited in 5%- 2. 2. Electrocautery or argon beam Electrocautery or argon beam

coagulatorcoagulator- 3. 3. Liquid nitrogenLiquid nitrogen- : Disadvantage: Disadvantage- - - Post – treatment fracture Post – treatment fracture - - Wound healing problem - Wound healing problem - - Nerve injury - Nerve injury - - Difficult to control depth of necrosis- Difficult to control depth of necrosis

TreatmentTreatmentIn the In the expendable bonesexpendable bones

- distal ulna- distal ulna

- proximal radius, fibula- proximal radius, fibula

En Bloc resectionEn Bloc resection reduce the risk of recurrence

TreatmentTreatmentInoperable lesionInoperable lesion

- Spine - Spine

- pelvis - pelvis

RadiationRadiation

A. Chakravarti MD et al JBJS 1999

: 20 patients underwent a single course of megavoltage radiation (40- 70 gray ) tumor had not progress 17/20  : no radiation-induced malignancy (Mean F/U 9.3 yrs)

Lung metastasisLung metastasis - 3- 3 % of patients % of patients - - Slowly grow, stationary or reso Slowly grow, stationary or reso

lve in some lesions lve in some lesions - - May be surgically resected May be surgically resected - - Mortality rate Mortality rate from pulmonary from pulmonary

metastasis : metastasis : -10 15%-10 15%

F/U planF/U plan- - y yyyyyyy yyy y-yyyy yy yyyyy yyyyy yyyyyyy yyy y-yyyy yy yyyyy yyyy

rrencerrence(3-20 yrs)(3-20 yrs) : :- - mass, painful area mass, painful area

- - CXR PA and lateral view CXR PA and lateral view

- - CT chest CT chest : : ++

DurationDuration

- - 11stst year q 3 months year q 3 months

- - 22ndnd q q qqqqqq6 q q qqqqqq6

- - - 612then q months - 612then q months

Case # 1Case # 1

Dx : GCT of Dx : GCT of Distal RadiusDistal Radius

stage III : Aggressivestage III : Aggressive

Rx : En Bloc resectionRx : En Bloc resection

+ osteochondral allograft+ osteochondral allograft

with good resultwith good result

Reconstruction of the distal Reconstruction of the distal radius with use of an radius with use of an

osteoarticular allograftosteoarticular allograft Mankin HJ et alMankin HJ et al – – JBJS(A)JBJS(A) 19981998

24 patients between 1974-199224 patients between 1974-1992 F/U 10.9 years (2.1-22.3) F/U 10.9 years (2.1-22.3) 8/24 need revision8/24 need revision

• 7/8 arthrodesis : 4 #’s, 1 recurrence 7/8 arthrodesis : 4 #’s, 1 recurrence • 1/8 amputation1/8 amputation

Average ROMAverage ROM• Dorsi/volar flexion : 36/21Dorsi/volar flexion : 36/21• Radial/ulnar deviation : 16/15Radial/ulnar deviation : 16/15• Supination/pronation : Supination/pronation : 5872/5872/

Reconstruction of the distal Reconstruction of the distal radius with use of an radius with use of an

osteoarticular allograftosteoarticular allograft Mankin HJ et alMankin HJ et al – – JBJS(A)JBJS(A)

19981998 associated with associated with

• a low rate of recurrence of the tumora low rate of recurrence of the tumor• moderately high rate of revisionmoderately high rate of revision• little pain in association with common activitieslittle pain in association with common activities• good function, and a moderate range of motiongood function, and a moderate range of motion

Osteoarticular allograftsOsteoarticular allografts are an option for are an option for reconstruction of the distal radiusreconstruction of the distal radius

Case # 2Case # 235 year – old Thai male35 year – old Thai male

4 months postop.4 months postop.

8 months postop.8 months postop.

1 year & 1 month postop.1 year & 1 month postop.

1 year & 6 month postop.1 year & 6 month postop.

1 year & 8 month postop.1 year & 8 month postop.

Dx : GCT of Dx : GCT of Distal RadiusDistal Radius

stage III : Aggressivestage III : Aggressive

Rx : En Bloc resectionRx : En Bloc resection

+ osteochondral allograft+ osteochondral allograft

with allograft collapsewith allograft collapse

Case # 3Case # 321 year – old female21 year – old female

S/P wide resection S/P wide resection

+ allograft arthrodesis+ allograft arthrodesis

1 year postop.1 year postop.

3 year postop.3 year postop.

Dx : GCT of Dx : GCT of Distal RadiusDistal Radius

stage III : Aggressivestage III : Aggressive

11stst Rx : En Bloc resection Rx : En Bloc resection

+ osteochondral allograft+ osteochondral allograft

with allograft fracture, nonunionwith allograft fracture, nonunion

22ndnd Rx : Free vascularized fibular Rx : Free vascularized fibular

bone graftbone graft

Vascularized fibular graft for Vascularized fibular graft for reconstruction of the wrist reconstruction of the wrist after excision of GCTafter excision of GCT

Ono H et alOno H et al – – Plast Reconstr Surg.Plast Reconstr Surg.19971997

7 patients of GCT of distal radius7 patients of GCT of distal radius radiographic evidence of bone radiographic evidence of bone

union at the host-graft junctions union at the host-graft junctions in all casesin all cases

No local recurrenceNo local recurrence There were six good and one There were six good and one

excellent functional results excellent functional results

Case # 4Case # 452 year – old female52 year – old female

After curettageAfter curettage

After burringAfter burring

After phenol & alcoholAfter phenol & alcohol

After cementingAfter cementing

1 year 2 months postop.1 year 2 months postop.

1 year 9 months postop.1 year 9 months postop.

1 year 9 months postop.1 year 9 months postop.

Dx : GCT of Dx : GCT of Distal RadiusDistal Radius

stage III : Aggressivestage III : Aggressive

Rx : Extended curettageRx : Extended curettage

(+ phenol) & bone cement(+ phenol) & bone cement

[ No recurrence within 2 years][ No recurrence within 2 years]

Treatment of GCT of boneTreatment of GCT of bone: a comparison of : a comparison of

curettage and wide resectioncurettage and wide resection Liu HS et alLiu HS et al – – Changgeng Yi Xue Za Zhi. 1998Changgeng Yi Xue Za Zhi. 1998 27 patients 27 patients 11 patients : extended curettage + cement11 patients : extended curettage + cement 16 patients : wide resection+ reconstruction16 patients : wide resection+ reconstruction F/U 50 months F/U 50 months Excellent functional resultsExcellent functional results

• extended curettage + cement = 80 %extended curettage + cement = 80 %• wide resection+ reconstruction = 13 %wide resection+ reconstruction = 13 %

Local control rateLocal control rate• extended curettage + cement = 90.9 %extended curettage + cement = 90.9 %• wide resection+ reconstruction = 93.75 %wide resection+ reconstruction = 93.75 %

Treatment of GCT of boneTreatment of GCT of bone: a comparison of : a comparison of

curettage and wide resectioncurettage and wide resection Liu HS et alLiu HS et al – – Changgeng Yi Xue Za Zhi. 1998Changgeng Yi Xue Za Zhi. 1998 Infection rateInfection rate

• extended curettage + cement = 0/11extended curettage + cement = 0/11• wide resection+ reconstruction = 3/16wide resection+ reconstruction = 3/16

CONCLUSION:CONCLUSION: • better functional result after curettage better functional result after curettage

and packing with cement than following and packing with cement than following wide resectionwide resection

• recommend curettage and cement recommend curettage and cement packing for giant cell tumor of bone packing for giant cell tumor of bone whenever it is technically feasiblewhenever it is technically feasible

Currently recommended Currently recommended Surgical TreatmentSurgical Treatment

GCT of bone

Grade

En Bloc excision & Reconstruction

Grade 3

c marked destruction

Extended curettageCement or Bone graft

-Grade 1, 2, 3

s marked destruction-

Reconstruction forReconstruction for

Distal RadiusDistal Radius

Reconstruction forReconstruction forDistal RadiusDistal Radius

Preserve RC & DRUJPreserve RC & DRUJ

Preserve DRUJPreserve DRUJ

No motion preservedNo motion preserved

Osteochondral Osteochondral allograft allograft or or autograftautograft

Fusion wristFusion wrist + +• AllograftAllograft• AutograftAutograft

VascularizedVascularized Non – vascularizedNon – vascularized

One bone forearmOne bone forearm

Thank you Thank you for for

your attentionyour attention