giant cell tumor of bone
TRANSCRIPT
Giant Cell Tumor of Bone
Overview
Definition Epidemiology Hx Presentation/Exam Radiology Dx Tx Outcomes
Definition
10 bone neoplasmFirst described Cooper 1818Lebert microscopic description 1845Generally benignPotential for : Recurrence Pulmonary metastasis Frank malignancy
Epidemiology
5-10% 10 bone tumors
20% benign bone tumors
F : M 1.5 : 1
70-80% age 20-40
Rare skeletally immature
Epiphyseal
Monostotic
Incidence
Ends of long bones
>50% about knee
High recurrence rate
1-2% benign pulm. Mets
10 malignant GCT <1%
Rare polyostotic form <1%
Location
Presentation
Pain x wks. – mos.
Swelling
Mass
Pathologic #
Neuro deficit (spine / sacrum)
incidental
Radiology
Lytic lesion
Epipyseal
Eccentric or central
Narrow zone transition
Cortical thinning
expansile
No sclerotic margin
Imaging
Occ. Cortical breakthrough +/- soft tissue mass
Extend to subarticular cortex
Typically no host response
Often large @ presentation
Other modalities
CT Integrity cortical rim
MRI Assess subchondral breakthrough
Bone Scan Suspect multicentri loci ie. HAND
DDx
Consider: Age & Location Fibrogenic/Telangiectatic Osteosarcoma MFH Brown tumor Chondroblastoma ABC Chondromyxoid fibroma (rare) Mets / Myeloma
Histology
Fibrohistiocytic origin
Multinucleated giant cells
Mononuclear stroma Round / ovoid / spindle
Indistinct cell membrane
Mitoses
Giant cells 20 fusion stromal cells
Gross
Enneking Staging
Stage 1 Stage 2 Stage 3
Pt % 10-15% ~70% 10-15%
Symptoms asymp pain pain
Radiograph sclerotic rim
expanded cortex
cortical
perforation
Histology benign benign benign
Biopsy
Necessary for Dx
Tumor principles
Histologic grade not helpful
R/O 10 malignant GCT
Occ assoc. ABC Pagets
Curettings
Tx
ControversialTraditionally: Intralesional curettage / resection & bone graft Recurrence 35-42%
En Bloc resection Recurrence ~10% Multiple complications
Adjuvant
Curettage
Wide decortication (windowing)
Curettage / high speed burr
Aggressive
Choice of adjuvant
Adjuvant Tx
Radiation - ~10% sarcomatous degeneration
PMMA, Liquid N2, Phenol, CO2 laser, Electrocautery Local extension of margin Kill residual foci
PMMA
Fill tumor cavity
Heat kill of tumor cells?
Effect size dependent
8-26% recurrence
Easy recurrence detection
Degenerative changes
Recurrence
Subchondral bone grafting
Cryotherapy
3 freeze thaw cycles
Irrigate cartilage with cool saline
Circumferential necrosis
“difficult”
Complications Soft tissue injury Late fractures
Cryotherapy
Phenol
Wash cavity
Alcohol rinse
10-20% recurrence
Enbloc Resection
Expendable bones Prox fibula / Distal ulna
High recurrence with other Tx Hand / Distal radius
RecurrencePathologic #Joint involvementOsteochondral allograft reconstruction
Reconstruction
Spine
< 3% vertebrae above sacrumAll levels affected equallyAffects vertebral body c ext. pedicleResection with stabilizationOften incomplete?radiation as adjuvant (low dose 3000 Gyc) Incomplete excision Local recurrence
Sacrum / Pelvis
Intalesional excision
Adjuvant
+/- radiation
Pelvis
GCT often vascular Pre-op angiography ? embolization
Angiography
Outcome