giant

Giant Cell Tumor of Bone

An examination of benign and malignant tumors of bone and a

case study involving the foot

Giant Cell Tumor of Bone•

Comprises 5% of bone tumors.•

3% present in the lower extremity.•

Seen in 20-40 year old patient, with a predisposition of 1:1 male to female.

•

Pain is the most common presentation, followed by local swelling and limitation of motion.

•

Usually epiphyseal involvement in mature bone and metaphyseal in immature bone.

•

An eccentric,

osteolytic

lesion, extending to subchondral bone causing cortical thinning and expansion with a delicate trabecular pattern.

•

Neither a sclerotic rim nor a

periosteal

reaction is usually seen.


Associated with

Paget’s

disease, but then only

appears in the skull. Rare to find in the skull when not assoc. with

Paget’s

disease

•

Diagnosis is complicated by the similar

appearence

of a lesion known as a giant cell reparative granuloma

•

Can be transformed in

Paget’s

to metastatic

carcinoma to the lung•

Other neoplastic involvement in

Paget’s

includes

sarcomatous

degeneration


Considered a benign, but

aggresive

tumor of bone

•

Aggresive

nature demonstrated by the violation of

the cortex and

involvent

to adjacent soft tissue

•

Transformation to malignant tumor is 5% to 10%

•

Caused primarily by irradiation of the tumor

•

Will transform to a

fibrosarcoma,

osteosarcoma,

malignant fibrous

histiocytoma


Benign Tumors–

Osteochondroma–

Enchondroma–

Chondroblastoma–

Osteoblastoma–

Osteoid Osteoma–

Unicameral Bone Cyst–

Fibrous

Dysplasia–

Giant Cell–

Non-ossifying Fibroma–

Eosinophillic

Granuloma–

Chondromyxoid

Fibroma–

Aneurysmal

Bone Cyst

•

Malignant Tumors–

Osteosarcoma–

Osteosarcoma

Variants:•

Parosteal•

Periosteal•

Small Cell

–

Chondrosarcoma–

Malignant Fibrous

Histiocytoma–

Fibrosarcoma–

Ewing’s Sarcoma–

Metastatic Carcinoma–

Others:•

Lymphoma–

Non-Hodgkins–

Hodgkins

•

Multiple

Myeloma•

Leukemia


Differential Diagnosis would include:–

Metastatic Carcinoma (differentiate from brown cell tumor)

–

Chondroblastoma

(occurs in immature skeleton, calcifies)

–

Intraosseous

ganglion (usually at the medial malleolus, carpal bones or

periarticular

region of the hip. They are

multilocular

with a sclerotic margin and associated with soft tissue ganglions.)

–

Subchondral Cysts (occur in RA, Gout, CPPD, Hemophilia, Pigmented

Villonodular Synovitis. These cysts are usually multiple, communicate with the joint and are associated with additional articular abnormalities.)

–

Aneurysmal

Bone Cyst–

Fibrous

Dysplasia–

Eosinophilic

Granuloma–

Brown Tumors–

Giant Cell Reparative Granuloma (occur at facial bones, in females, the young and present with swelling, pain, headache,

diplopia, epistaxis)

–

Amelonotic

Melanoma

Giant Cell Tumor of BoneCommon tumors of bone

and where they occur


•

Treatment:–

Currettage•

associated with a high

recurrance

rate when used alone

–

En Bloc excision–

Amputation

(if the tumor has penetrated the joint)

–

It is recommended that

phenolization

or cryosurgery be used after

curretage

–

Bone chips or PMMA (polymethylmethacrylate) used to fill the defect left at site of excised tumor

–

Irradiation is contraindicated due to the high incidence of recurrence and possible transformation to

fibrosarcoma

or osteogenic sarcoma –

Rates of recurrence stands at 40%-60%, within 2 years and usually at original site of tumor

–

Transformation to malignant tumor is 5% to 10% and occurs after irradiation of tumor


•

Case Study•

24 year old White male•

Presents to F&A Institute for treatment of pain in right ankle of 4 months duration. Patient reports sprain of same ankle 2 years ago with

frequent turns afterwards. Pain is sharp, and without radiation. No other examination is contributory except for the orthopaedic exam which reveals crepitus at the right ankle upon ROM., and the dermatologic exam, which divulged a palpable, non-fluctuant mass at the inferior area of the right medial malleolus.

•

Pt. is scheduled to have an MRI study performed on the right ankle and foot.•

Diagnosis of giant cell tumor of bone made by radiologist and pathology. •

Pt. is operated and

excison

of bone tumor undertaken. Area is packed with bone chips.

•

After 6 months of casting treatment, patient undergoes physical therapy and is informed of future possibility of fusion to address pain.


Conclusions

•

Giant Cell tumor is an uncommon tumor presenting in the bones of the lower extremity

•

When occurring, the tumor must be treated by means which will allow total excision, as the recurrence rate is high

•

If seen in the facial bones, it is assumed to be secondary to

Paget’s

disease until proven otherwise. There is a high association of metastasis to the lung in these patients

•

Treatment should be en bloc, or if

curretage

is used, cryosurgical or phenol

ablatement

should be used•

Area can be packed with bone, or with PMMA

giant

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