giant cell tumour and osteosarcoma

GIANT CELL TUMOUR ANDOSTEOSARCOMA

GIANT CELL TUMOUR AND

OSTEOSARCOMA

GIANT CELL TUMOUR• Common bone tumour

PATHOLOGY• Cell of origin is uncertain.

• Microscopically,– Undifferentiated spindle cells

interspersed with multinucleate giant cells.

• Tumour stroma is highly vascular.

• Giant cells mistaken as osteoclasts- OSTEOCLASTOMA.

CLINICAL FEATURES• Age Group

– 20-40 years(after epiphyseal fusion).

• Bones affected– Around knee joint.– Lower end of radius.

• Tumour at epiphysis, may reach upto joint surface.

• Common presenting complaints:

– Swelling and vague pain

– Pathological fracture

EXAMINATION• Eccentrically located bony

swelling at the end of the bone.

• Smooth surface.• May be tender on firm

palpation.• ‘Egg-shell crackling’ may be

elicited.• Limb deformity(pathological

fracture).

DIAGNOSIS

• Solitary lytic lesion of bone.

Features Giant cell tumour

Simple bone cyst

Aneurysmal bone cyst

Fiibrous dysplasia

Age 20-40 yrs <20 yrs 10-40 yrs 20-30 yrs

Common bones

Lower femurUpper tibia

Lower radius

Upper humerus

Upper femur

TibiaHumerus

Neck of femurTibia

Location Epiphysis Metaphysis Metaphysis Metaphysis

X-raySoap bubble appearance,Eccentrically

placed

Maximum width less

than width of the growth

plate

Distending lesion,

‘ballooning’ the bone

Multi-loculated

Ground-glass appearance

Trabeculations++

Treatment Excision Curettage and bone graft

Curettage and bone graft

Curettage and bone graft

RADIOLOGICAL FEATURES

• Solitary- loculated or lytic.

• Eccentric location, often subchondral.

• Expansion of the overlying cortex(expansile lesion)

• ‘Soap-bubble appearance’-– Tumour homogenously lytic

with trabeculae of the remnants of bone traversing it – loculated appearance.

• No calcification within the tumour

• None or minimal reactive sclerosis

• Cortex thinned out or perforated at places.

• Usually does not enter the adjacent joint.

TREATMENT• Best treatment- EXCISION• If not possible(spine)-

Radiotherapy• Commonly used treatment

methods:a) Excisionb) Excision with reconstructionc) Curettage with or without

supplementary procedures.d) Amputatione) Radiotherapy

Excision• When tumour affects a bone

whose removal does not hamper with functions.

• Eg: FibulaLower end of ulna…

Excision with reconstruction

• When excision results in significant functional impairment.

• Defect created is made up, usually partially, by some reconstructive procedure.

• Eg: tumours affecting lower end of femur, affected part is excised, and defect created made up by:

Arthrodesis by the Turn-o-Plasty procedure• Tibia split into two.• One half turned upside down• Fixed with the stump of the

femur.

Arthrodesis by bridging the gapBy double fibulae

Arthroplasty:ExcisedAutograft(patella to substitute

articular defect)Allograft(Using a preserved

bone)Artificial joint(prosthesis)

Curettage With Or Without Supplementary Procedures

• Supplementary procedures to reduce recurrence.

• Cryotherapy and thermal burning.

• Thermal effect of bone cement.

Amputation

• Aggressive tumours

• Following recurrence

Radiotherapy

• GCT affecting vertebrae.

Site Treatment of choice

Lower end of femur Excision with Turn-o-Plasty

Upper end of tibia Excision with Turn-o-Plasty

Lower end of radius Excision with fibular grafting

Lower end of ulna Excision

Upper end of fibula Excision

PROGNOSIS

• Recurrence – a serious problem

OSTEOSARCOMA(OSTEOGENIC SARCOMA)

Highly malignant primary bone tumour.

PATHOLOGY• Malignant tumor of

mesenchymal cells.

• Osteoid or bone formation by tumor cells

CLASSIFICATION• Based on clinical setting:

a) Primary osteosarcoma 15-25 years No known pre-malignant

conditionsb) Secondary osteosarcoma

Older age(>45yrs) Paget’s disease, fibrous

dysplasia…

• Based on dominant histo-morphology:

a) Osteoblastic

b) Chondroid

c) Fibroblastic

d) Telengiectatic or osteolytic type

FEATURES• Age of onset:

– 15-25yrs

• Sites of origin:– Any bone– Lower end of femur– Upper end of tibia– Upper end of humerus

• Gross appearance

Osteoblastic tumour: Greyish white, hard and gritty feeling when cut.

Chondroid type: Opalescent and bluish grey.

Fibroblastic: Typical fish flesh sarcomatous appearance.

Telengiectatic: Tumour necrosis and blood filled spaces

• Histologically,Basically anaplastic

mesenchymal parenchyma with tumour cells surrounded by osteoid.

CLINICAL FEATURES

• Pain- constant and boring

• Swelling

• Pathological fracture

EXAMINATION• Swelling in the region of

metaphysis.• Skin over the swelling: Shiny

with prominent veins.• Swelling warm and tender.• Margins: Not well defined.• Mechanical block of the swelling.• Compression• Regional lymph node

enlargement, usually reactive

INVESTIGATIONSRADIOLOGICAL EXAMINATION:

• Area of irregular destruction in the metaphysis. Cortex overlying lesion eroded.

– New bone formation in the matrix.

• Irregular periosteal reaction

• Codman’s triangle: – Triangular area of subperiosteal new bone– At tumour-host junction at tumour end.

• Sun-ray appearance:– Tumour grows to overlying

soft tissues.– New bone laid down along

the blood vessels within the tumour growing centrifugally.

SERUM ALKALINE PHOSPHATASE

(SAP):

– Generally elevated

– No diagnostic significance.

– Useful for follow-up

– Rise after tumor removal- Indicator of recurrence or metastasis.

BIOPSY

–Open biopsy

TREATMENT• Aims:

– Confirm diagnosis

– Evaluate spread

– Adequate treatment

• Confirmation of diagnosis:

– Histologically, Tumour new bone formation- pathognomonic of osteosarcoma.

– Or Clinical and radiological picture

• Evaluation of spread of tumour:– Lung-Earliest site.– Chest X-ray.– CT scan

• Extent of involvement need to be known to:

– Plan amputation surgery

– Plan limb saving operation

• Treatment of the tumour:

– Local control:

• Surgical ablation.

• Amputation remains the mainstay.

• ROLE OF RADIOTHERAPY:– Surgically inaccessible sites.

–Control of distant macro or micro-metastasis

• ROLE OF CHEMOTHERAPY:– Drug used: high dose

Methotrexate, Endoxan…

• ROLE OF IMMUNOTHERAPY

FOLLOW UP• Patient is checked up every

6-8 weeks.

• Recurrence needs to be diagnosed early and treated.

PROGNOSIS• Without treatment: death

within 2 years.• 5 year survival with surgery

alone(20%).• Primarily lytic

type(telengiectatic) osteosarcoma-worst prognosis.