"GIANT CELL TUMOR" : CASE PRESENTATION- At Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh

2. Prepared By-
Dr. Md Nazrul Islam
MBBS, M . sc. (BME).

3. Contents
 Overview
 Epidemiology
 Incidence
 Presentation
 Radiology
 Diagnosis
 Treatment
 Outcomes

4. 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

5. 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

6. 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%

7. Location
 Common sites:
 Distal femur
 Proximal tibia
 Distal radius
 Proximal humerus
 Other sites:
 Fibula , distal tibia
 Bones of pelvis, sacrum
 Vertebral body

8. 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

9. Radiology
 Lytic lesion
 Epiphyseal , Eccentric, Expansile
 Narrow zone transition
 Soap bubble appearance
 Cortical thinning
 Non sclerotic , sharply defined
margin

10. Radiology(con…)
• Occ. Cortical breakthrough
• +/- soft tissue mass
• Extend to subarticular cortex
• Often large presentation

11. Other modalities
 CT
 Integrity of cortical rim
 MRI
 Assess subchondral breakthrough
 Bone Scan
 Decreased radioisotope
uptake in the center of lesion
(Multicentric GCT)

12. Biopsy
 Needle(accuracy >90%) &
excisional
 Tumor principles , histologic
grade
 Necessary for Dx.
 Occ assoc.
 ABC
 Pagets

13. Gross
 Soft,brown mass
 Area of
haemorrhage (dark
red)
 Area of collagen
(gray)

14. Histology
 Fibrohistiocytic origin
 Multinucleated giant cells
Fusion of stromal cells
Uniformly distributed
 Mononuclear stromal cell
 Round / ovoid / spindle
 Indistinct cell membrane
 Prominent mitotic activity

15. Enneking Staging
Stage 1 Stage 2 Stage 3
(latent) (active) (aggressi
ve)
Pt % 10-15% ~70% 10-15%
Symptoms Asymptom Pain Pain
atic
Radiograph Non Expanded Cortical
sclerotic cortex Break
rim
Histology Benign Benign Benign

16. Angiography
 Neovascularity with
intense, inhomogen
eous capillary blush
 Intra & extra
osseous extent

17. Sacrum / Pelvis

18. Differential Diagnosis
 Aneurismal bone cyst (ABC)
 Simple/solitary bone cyst
 Chondroblastoma
 Brown
tumor(hyperparathyroidism)

19. 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

20. Curettage,
electrocautery & bone graft
 Wide decortication
(windowing)
 Curettage / high
speed burr
 Recurrence 10-
20%%

21. Curettage,
chemical cautery & bone graft
Phenol
 5-80% phenol
 Wash cavity with 70% Alcohol
 10-20% recurrence
Disadvantages
 Systemically toxic
 Chemical burn

22. Adjuvants
 Liquid N2, Phenol, CO2
laser,H2O2
Electrocautery
 Local extension of
margin
 Kill residual foci

23. PMMA
 Fill tumor cavity
 Heat kill of tumor cells
 8-26% recurrence
 Easy recurrence detection
 Degenerative osteoarthritis
 Difficulty in removing

24. Recurrence

25. Subchondral bone grafting

26. Enbloc Resection
 Expendable bones
 Prox fibula / Distal ulna
 High recurrence with
other Tx
 Hand / Distal radius
 Pathologic #
 Joint involvement
 Recurrence ~10%

27. Cryotherapy
 3 freeze thaw cycles
 Irrigate cartilage with cool saline
 Circumferential necrosis
 “difficult”
 Recurrence 2-12%
 Complications
 Soft tissue injury
 Late fractures

28. Excision & reconstruction
 Turn-O-plasty
 Arthrodesis
 Arthroplasty

29. Excision & reconstruction(Con..)

30. Amputation
Widespread
aggressive tumour
Last resort

31. 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

32. Metastasis
 Lung, Lymph node(rare)
 After 3-5 years
 Spontaneously regress,static,grow slowly
or rapidly
 Mortality 15-25%
 Rx- wide resection,iradiation,interferon

33. Follow-up
 Observation at least 5 years
 Physical examination & radiology
– affected site, lung
 Relapse – pain, swelling

34. 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

35. Sacrum / Pelvis
 GCT often vascular
 Pre-op angiography
 Embolization, Intalesional
excision or radiation

36. 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%.