case report gct

7/28/2019 Case Report Gct

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Multiple skeletal metastases

from a giant cell tumour of

the distal fibula with fataloucome

CASE REPORT


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Giant Cell Tumor of Bone


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Definitionrare aggressive non-cancerous (benign) tumor

potential for : recurrence metastasis

Statistically :

80% benign course, with a local rate ofrecurrence of

20% to 50%.

10% undergo malignant transformation atrecurrence

1% to 4% give pulmonary metastases even incases of


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Epidemiology

5- 10% primary bone tumors

20 % benign bone tumors

F : M 1,5 : 1

70- 80 % age 20 40

higher incidence rates in Asia,

20% of all primary bone

tumors in China


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Location

usually prefers the

epiphyses of long bones. half of the cases knee joint

distal femur, proximal tibia,

distal radius & proximal

humerus.

other sites: fibula, sacrum,

& distal tibia


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Diagnose

History

age

progessivity of tumor

pain swelling


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Clinical symptom:

hard and painfull mass

swelling

joint effusion

tenderness, muscle atrofi

patologic fractur (11-37%)

neurogical deficit (sacrum)


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Radiography :

o lytic lession

o radiolucent area at the end

of the bone with no firmboundaries.

o transition zone between

normal and pathological

bone


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CT Scan :

o improves detection

of cortical thinning fracture,

pathological, andperiosteal reaction.

o to accurately determine

the location and softtissue mass.


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MRI

o help determine extent of

tumor destruction

o indicated when the tumorhas eroded thorugh

the cortex and allows

determination of whether

neurovascular structures

are involved

o help evaluate subchondral penetration


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Angiography


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Histology

macroscopic : brown mass and soft

haemorrhage and

necrosis


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microscopic :

multinucleatedgiant cells

mononuclear

stroma (round /ovoid / spindle),

large nuclei and

indistinctnucleoli

mitoses
http://www.kumc.edu/instruction/medicine/pathology/ed/ch_26/c26_s41.jpg


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Classification

Enneking (radiological, histological and clinical

classification) : stage I benign latent GCT (15%)

stage II benign active GCT (70%)

stage III

locally aggressive tumors (15%) malignant sarcomatous lesion contiguous

with benign

GCT ( very rare)


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Treatment

Principal :

Excise the lesion

Sterilize the cavity

Reconstruct the defect


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Traditional

Intralesional curettage & bone grafting

Local recurrence rates 40-60%


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Modern Adjuvant Treatment

(Polymethylmethacrylate) PMMA

Liquid N2

Phenol

Cryotherapy Irrigate cartilage

Liquid nitrogen is a

chemical reagent

used in cryotherapy


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Enbloc Resection reserved for expendable

bones :

prox fibula / distal ulna high recurrence with

other Tx

stage III lesions


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Reconstruction


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CASE REPORT in 1997

A 25-year-old woman with no significant past medical historyunderwent curettage and grafting with spongiosa for a lesion at the

lateral malleolus.

Histological presence of a giant cell tumour.

Malignancy was not suspected and recovery was uneventful.

in April 2002

the tumour recurred locally

treated again with curettage and grafting.

pathology laboratory : recurrent giant cell tumour


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In Feb 2003

recurrent pain in the lateral aspect of her right ankle

radiographs progressive destruction of the distal fibula

recurrence of the giant cell tumour.

MRI a lesion in the distal fibula, 4 cm long and 3 cm wide.Extensive

destruction of bone was localised to the area of the lateral malleolus.

Tx : EN BLOCK RESECTION

histology : giant cell tumor with mononucleal cell (spindle) with mild

to moderat nuclear atypia and some mitosis

3 month normal ankle and chest


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in Nov 2003

severe pain around the right iliac crest

radiographs of the pelvic region, a whole body scan and a whole

body CT scan, revealed multiple bony metastases.

no abnormality was detected in the viscera or the lungs


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Histology : recurrence of the giant cell tumour.

Tx : chemotherapy with radiotherapy

she developed signs and symptoms of raised

intracranial pressure. Her condition deteriorated

and she died in a state of epileptic shock.

In the absence of a post-mortem examination it is

not possible to be certain that there was no lunginvolvement.


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DISSCUSSION

In this case, the mechanism of tumour spread is unclear,

particularly considering the lack of pulmonary metastases.

One possible explanation might be retrograde embolisation via

superficial veins.

Vessel destruction within the tumour does not necessarily indicate

a higher risk of metastases. About 40% of all GCT exhibit vessel

destruction but very few of them develop metastases.


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In this case, metastasis via the blood stream as

seen in other malignant tumours has to be assumed.

In this patient, passage through the lung without

pulmonary cell colonisation may have occurred.

giant cell tumours show a tendency to local

recurrence

Recurrences after the treatment mostly caused by

curettage and can reach up to 85%.

To suppress recurrence rate, curettage thermal

cautery using 5% phenol, bone cement or with liquid

nitrogen are recommended.

In this way, the number recurrence after curettage

action can be suppressed up to 20%.

The most frequent recurrence occurred within a

period of 2-3 years post surgery.


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THANK YOU

case report gct

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