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