"giant cell tumor" : case presentation- at shaheed suhrawardy medical college hospital,...

Department Of Orthopaedics& Traumatology.Sheed Suhrawardy Medical College Hospital, Dhaka-1207, Bangladesh.

Giant Cell Tumor Of

Bone -Diagnosis & Management

Basic of

From -

CME on

Presenting By- Dr. Nabarun Biswas & Dr. Golam Mahamud Suhash,From Department of Orthopedic & Traumatology, Shaheed Suhrawardy Medical College Hospital, Dhaka-1207. Bangladesh.

Prepared By-Dr. Md Nazrul IslamMBBS, M . sc. (BME).

Giant Cell Tumor Of

Bone -Diagnosis & Management

Contents

Overview Epidemiology Incidence Presentation Radiology Diagnosis Treatment Outcomes

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

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

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%

Location

Common sites: Distal femur Proximal tibia Distal radius Proximal humerus

Other sites: Fibula , distal tibia Bones of pelvis, sacrum Vertebral body

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

Radiology Lytic lesion Epiphyseal , Eccentric,

Expansile Narrow zone transition Soap bubble appearance Cortical thinning Non sclerotic , sharply defined

margin

Radiology(con…)

• Occ. Cortical

breakthrough

• +/- soft tissue mass

• Extend to subarticular

cortex

• Often large presentation

Other modalities

CT Integrity of cortical rim

MRI Assess subchondral breakthrough

Bone Scan Decreased radioisotope uptake in the center of lesion (Multicentric GCT)

Biopsy

Needle(accuracy >90%) & excisional

Tumor principles , histologic grade

Necessary for Dx. Occ assoc.

ABC Pagets

Gross Soft,brown mass Area of haemorrhage

(dark red) Area of collagen

(gray)

Histology Fibrohistiocytic origin Multinucleated giant

cells Fusion of stromal cells

Uniformly distributed Mononuclear stromal

cell Round / ovoid / spindle

Indistinct cell membrane

Prominent mitotic activity

Enneking Staging

Stage 1 (latent)

Stage 2 (active)

Stage 3 (aggressive)

Pt % 10-15% ~70% 10-15%

Symptoms Asymptomatic

Pain Pain

Radiograph Non sclerotic rim

Expanded cortex

CorticalBreak

Histology Benign Benign Benign

Angiography

Neovascularity with intense, inhomogeneous capillary blush

Intra & extra osseous extent

Sacrum / Pelvis

Differential Diagnosis

Aneurismal bone cyst (ABC)

Simple/solitary bone cyst Chondroblastoma Brown tumor(hyperparathyroidism)

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

Curettage, electrocautery & bone graft

Wide decortication (windowing)

Curettage / high speed burr

Recurrence 10-20%%

Curettage, chemical cautery & bone graft

Phenol 5-80% phenol Wash cavity with 70%

Alcohol 10-20% recurrenceDisadvantages Systemically toxic Chemical burn

Adjuvants

Liquid N2, Phenol, CO2 laser,H2O2 ElectrocauteryLocal extension of margin

Kill residual foci

PMMA

Fill tumor cavityHeat kill of tumor cells8-26% recurrenceEasy recurrence detectionDegenerative osteoarthritisDifficulty in removing

Recurrence

Subchondral bone grafting

Enbloc Resection

Expendable bonesProx fibula / Distal

ulnaHigh recurrence with

other TxHand / Distal radius

Pathologic #Joint involvement Recurrence ~10%

Cryotherapy

3 freeze thaw cycles Irrigate cartilage with cool saline Circumferential necrosis “difficult” Recurrence 2-12% Complications

Soft tissue injury Late fractures

Excision & reconstruction

Turn-O-plasty Arthrodesis Arthroplasty

Excision & reconstruction(Con..)

Amputation

Widespread aggressive tumour

Last resort

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

Metastasis

Lung, Lymph node(rare) After 3-5 years Spontaneously regress,static,grow

slowly or rapidly Mortality 15-25% Rx- wide

resection,iradiation,interferon

Follow-up

Observation at least 5 yearsPhysical examination & radiology – affected site, lung

Relapse – pain, swelling

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

Sacrum / Pelvis

GCT often vascular Pre-op angiography Embolization, Intalesional

excision or radiation

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%.

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