gct radius
DESCRIPTION
gct distal radiusntrreated by extended curettage.newer modalities of treatment as per the literature.recent advsncses un ythe fiewld.bone c2wment,graft and ghelfoam were used to reconstruct the defectTRANSCRIPT
DEPARTMENT OF ORTHOPAEDICS
GOVT.MEDICAL COLLEGETHRISSUR
CASE 1
42yrs old patient Ref from Ottappalam Govt. hospital Pain (L)wrist of 1/12 duration Fullness of the (L)wrist Range of movements: mild restriction
of palmar flexion, ulnar deviation & pronation
Mild weakness of the grip
42yrs old male patient
X-RAY
DIFFERENTIAL DIAGNOSIS
1. GCT2. Infection 3. ABC4. Brown tumour5. Chondroblastoma 6. Unicameral bone cyst7. Chondromyxoid fibroma
OTHER INVESTIGATIONS
Hb -12g% ESR – 8 Chest X-ray-normal Ca ,P – normal S.ALP – 54 S.acid phosphatase – 35u T3,T4,TSH – normal
FNAC - giant cell, spindle cell lesion possibly GCT
MRI
Moderate sized expansile lesion in the distal epiphyseometaphyseal region of (L)radius, eccentrically located, medial exophytic lobulation, no significant enhancement, lesion extends upto the subarticular region of the radius, exophytic component abuts the lateral margin of the ulna causing mild mass effect on the pronator quadratus muscle with mild oedema, no periosteal reaction - suggestive of giant cell tumour
CASE 2
41yr old male patient Pain and swelling (L)wrist > 2/12 Went for massage initially Pain and swelling increased after
massage Range of movements: all movements
painful and restricted Weakness of grip and severe pain
X-RAY
OTHER INVESTIGATIONS
Hb – 10.2g% ESR – 12 Chest X-ray - normal S.Ca, P – normal S.ALP – 80 S.acid phosphatase – 41u Thyroid function – normal
FNAC – suggestive of GCT
MRI
Moderate sized expansile lesion in the distal epimetapahyseal radius(L) eccentrically located , volar and lateral exophytic lobulation, extends upto the subarticular region of the radius, no periosteal reaction- suggestive of GCT
ENNEKING STAGING(PRE-OP)
Stage 1 (latent)-asymptomatic(intracompartmental)
Stage 2(active)-symptomatic(intracompartmental)
Stage 3(aggressive)-extracompartmental
CAMPANACCI GRADING
Campanacci radiological grades (cortical breach)
Grade 1 – intact cortex
Grade 2 – well-defined margins, no radio-opaque rim
Grade 3 – fuzzy borders
Campanacci histological grades(post-op)
Grade 1(typical) Grade 2(aggressive) Grade 3(malignant)
Compactness of stromaMitotic figuresHyperchromatism Giant cells
RECURRENCE AFTER SURGERY
Is there any absolutely predictable correlation between the grading systems and the incidence of local recurrence or metastasis of the giant cell tumour ?
No !!
TREATMENT OPTIONS
Curettage & bone grafting Extended curettage Resection(wide excision) & wrist
arthrodesis(vascularised/nonvascularised fibula)
Resection,Ulnar transposition(one-bone forearm)&wrist arthrodesis
Resection & reconstruction of the wrist with fibular head(fibular head arthroplasty)
JOURNAL OF ORTHO. SUR
Click icon to add picture
2012;4:76-82Dr.Dominic Puthur&Dr.Kishore Puthezhath
EXTENDED CURETTAGE
Curettage supplemented by power burrs & local adjuvants
Local adjuvants: phenol hydrogen peroxide bone cement zinc chloride argon beam cauterization
Dominic puthur,Wilson Iype:GCT-curettage&bone grafting:IJO,41,apr-jun 2007;121-23
MOST AUTHORS AGREE THAT THE COMPLETENESS OF THE CURETTAGE&EXCISION IS THE SINGLE MOST IMPORTANT FACTOR TO PREVENT RECURRENCE.
WHAT DID WE DO?Follows…….
EXPOSURE
EXCISION WITH PQ ENMASSE
CAVITY IN THE DISTAL RADIUS, MOPS SOAKED IN HYDROGEN PEROXIDE
SANDWITCH TECHNIQUE : ILIAC CREST GRAFT + GELFOAM
BONE CEMENTING
RECONSTRUCTION OF GCT WITH MINIMAL SUBCHONDRAL BONE
Sandwitch technique
CLOSURE WITHOUT DRAIN
POST-OP X-RAYS
HISTOPATHOLOGY
Stromal cells - neoplastic Osteoclast like giant cells – cells
responsible for bone destruction Aggressive lesions – compact
stroma,atypism,heterochromatism Benign lesions – more giant cells with
multiple nuclei Malignant cells in plenty - ?
GCT(pathologist)
HISTOPATHOLOGY
CASE 1: GCT WITH MILD ATYPISMCASE 2 : GCT WITH MODERATE ATYPISM
LITERATURE SUPPORT
Cheng etal treated grade 3 lesions with curettage when the tumour did not invade the wrist, >50% cortexinact,extraosseous mass only in one plane
Cheng CY,shih HN-treatment of GCT of distal radius:clin ortho&rel research 2001;383:221-8
Khan etal showed that curettage alone is sufficient for most of the distal radius GCTs
Khan MT,Gray JM-management of distal radius GCTs. Ann R coll surgery Engl 2004;86:18-24
COMPARATIVE TRIAL BY AK GUPTA ETAL. FROM GSVM MEDICAL COLLEGE,KANPUR
YOGESH,AJAY PURI ETAL. TATA MEMORIAL HOSPITAL,MUMBAI
ROLE OF BISPHOSPHONATES
Novel adjuvant therapy for GCTChang,Suratwala etal clin.ortho& relat res 2004;426:103-9
topical/systemic pamidronate or Zoledronate Induce apoptosis of the giant cells Limit tumour progression & prevent bone
destruction Rinsing morsellized bone grafts with
bisphosphonates prevents resorption and reduce the risk of mechanical failure
Kesteris&Aspenberg JBJS(Br)2006;88:993-96
TARTRATE RESISTANT ACID PHOSPAHATASE AS A TUMOUR-MARKER(?!)
Total serum acid phosphatase - tumour size
Akhane T,Isobe K acta ortho 2005;76:1231-3
High preoperative values , normalized after surgery, reappeared with local recurrence
Tartrate resistant acid phosphatase - more specific
IN OUR PATIENTS
Case 1 preoperative acid phosphatase – 35u 5th post-op day - 4.6u
Case 2 preoperative acid phosphatase - 41u 5th post-op day - 5.1u
CONCLUSION
Curettage&graft still a good option
Average recurrence rate of GCT - 32%(whatever be the mode of treatment)
Extended curettage - less recurrence rate
Bisphonates – medical management of GCT
Tumour marker – acid phosphatase
THANK YOU