giant cell tumor of bone ( osteoclastoma )
DESCRIPTION
Giant Cell Tumor of Bone ( Osteoclastoma ). Dr. Hermansyah , SpOT. Bahagian Bedah Tulang Rs Dr M Djamil Padang / Fakultas kedokteran Unand. Pendahuluan. Tumor tulang pertama ditemukan Dijelaskan oleh Cooper 1818 Gambaran mikroskospik oleh Lebert 1845 Secara umum jinak (benign) - PowerPoint PPT PresentationTRANSCRIPT
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Giant Cell Tumor of Bone
(Osteoclastoma)
Dr. Hermansyah, SpOT
Bahagian Bedah Tulang Rs Dr M Djamil Padang
/ Fakultas kedokteran Unand
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PendahuluanTumor tulang pertama ditemukanDijelaskan oleh Cooper 1818Gambaran mikroskospik oleh Lebert 1845Secara umum jinak (benign)Potensial menjadi : Ganas Berulang Metastasis Pulmonal
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Epidemiologi
5-10% tumor tulang
20% tumor jinak tulang
F : M 1.5 : 1
70-80% umur20-40
Jarang pada sekeletal immature
Sekitar Epiphysis
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Insiden
Terutama ujung tulang panjang
Setelah penutupan ephyphisis
>50% sekitar lutut
Angka kambuh tinggi
Malignant GCT <1%
Kadang berbentuk polyostotic
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Klinis
Nyeri kalau sudah ada penekanan
Bengkak
Ganguan gerak sendi
Masa
Fraktur Pathologis
Gangguan Neuro (spine / sacrum)
Tidak sengaja
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Radiologik
Lesi litik
Sekitar epiphisis
Eksentrik atau sentral
Batas tegas
Penipisan kortek
Expansile
Tidak terdapat batas sklerotik
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Gross anatomiKerusakan kortek +/- Pembengkakan jaringan
lunak
Bisa terjadi fraktur intra artikular
Bisa terjadi perdarahan didalam rongga kista
Bisa terdapat fibrosis dan tumpukan kolesterol kandungan masa kuning kemerahan
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Imaging
CT Integritas dari kortek
MRI Menilai kerusakan sub kondral
Bone Scan Dugaan lesi multiple ie. HAND
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Diagnosis banding
Pertimbangkan: Umur dan lokasi Fibrogenic/Telangiectatic Osteosarcoma Chondroblastoma ABC (Aneurysma Bone Cyst Chondromyxoid fibroma (jarang) Mets / Myeloma
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HistologiFibrohistiocytic origin
Multinucleated giant cells
Mononuclear stroma Round / ovoid / spindle
Mitosis
Giant cells 20 fusion stromal cells
Fokus hemorrhage atau nekrosis
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Enneking Staging
Stage 1 Stage 2 Stage 3
Pt % 10-15% ~70% 10-15%
Symptoms asymp pain pain
Radiograph sclerotic rim
expanded cortex
corticalperforation
Histology benign benign benign
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Campanacci et.al
1-Batas tegas, penipisan kortek minimal
2-Penyebaran lebih luas, penipisan kortek sedang sampai brat
3-Sudah terjadi destruksi dari korteke
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Biopsi
Penting untuk diagnosis
Pemeriksaan tahap akhir
Histologic tidak mempengaruhi prognosis
R/O 10 malignant GCT
Bisa berhubungan/disertai ABC Pagets
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Pengobatan
KontroversiTradisional: Kuretase Intralesi / reseksi & bone graft Kekambuhan 35-42%
Reseksi En Bloc Recurrence ~10% Komplikasi multiple
Adjuvant
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Prinsip Dasar Pengobatan
Pengangkatan Tumor.
Suportiv
Rekonstruksi
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Pengobatan
1. Medical Therapy2. Surgical Therapy
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Pengobatan1. Medical Therapy• Juni 2013, FDA membolehkan
penggunaan denosumab (Xgeva) untuk unresectable giant cell tumor pada dewasa dan adolescent
• Metastasis Pulmonal• wide resection,• Chemotherapy, • Radiation therapy, • Interferon alpha.
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2. Surgical Therapy
Stage1& Stage2 --- Intralesional or Marginal Excision
Stage3 --- Wide resection with Reconstruction
Radiation, Embolisasi
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Complete removal of tumor mass
Intra-lesional Curettage
En-block Excision
Radiation pada tempat yang susah dicapai (spine)
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Adjuvant Therapy
Pulse Lavage
H2O2
Phenol
Alcohol
Liquid nitrogen
Electric cauterization
Laser
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Rekonstruksi/Restorasi
Bone grafts
Allografts
Semen
Semen diperkuat dg batang logam.҉� Not MRI computable – Follow up MRI deteksi dini sulit
Sandwich technique Kombinasi Bone Graft + semen tulang
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Kuretase
Dekortikasi luas (windowing)
Kuretase / high speed burr
Agresif
Choice of adjuvant
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Terapi Ajuvan
Radiasi - ~10% degenerasi sarkoma!!!!
PMMA, Liquid N2, Phenol, CO2 laser, Electrocautery Memperluas daerah steril tumor Membunuh fokus lokal
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Polymethylmethacrylate (PMMA)
Mengisi rongga tumor
Reaksi panas membunuh sel tumor
8-26% rekurensi
Mudah mendeteksi kalau ada rekurensi
Perubahan Degenerative
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Rekuren
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Subchondral bone grafting
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Cryotherapy
Irigasi rongga bekas curetase dg NaCl dingin
Nekrosis Circumferential
“Sulit”
Komplikasi Trauma jaringan lunak Fraktur terlambat
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Phenol
Mencuci luka
Alcohol rinse
Rekurnesi 10-20%
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Reseksi Enbloc
Expendable bones Prox fibula / Distal ulna
Rekurensi tinggi Hand / Distal radius
Pathologic #Terkena sendiMemerlukan allograft Osteochondral u rekonstruksi
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Rekonstruksi
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Spinal
< 3% vertebrae diatas sacrumBisa mengenai semua levelMengenai vertebral body dan meluas ke pedicleReseksi dan stabilisasiSering in komplitAjuvan radiasi (Dosis rendah3000 Gyc) Eksisi inkomplit Rekuren lokal
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Sacrum / Pelvis
Eksisi Intralesi
Adjuvant
+/- radiation
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Pelvis
GCT sering kobinasi dengan vaskular Pre-op angiography Embolization
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Kombinasi (Sandwich technique)
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Reconstruksi dengan Mega Prosthesis
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Pulse Lavage + H2O2
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