vol 10 ppt
TRANSCRIPT
Giant cell tumor of bone-------Case 207-213 & 1040-1093
Volume 10
Giant Cell Tumors
Giant Cell Tumor of Bone
There are numerous primary tumors of bone with giant cell or
or macrophage activity seen within the tumor under the microscope.
These include the aneurysmal bone cyst, chondroblastoma, solitary
bone cyst, osteoid osteoma, osteoblastoma, fibrous dysplasia and
osteogenic sarcoma, hemorrhagic type. Some pathologists classify
these tumors as variants of the true giant cell tumor making it almost
a diagnosis of exclusion if none of the above diagnoses can be
established histologically. The clinical entity known as the benign
giant cell tumor of bone is seen typically in young adult females
between the ages of 20 and 40 years. It is less common in males. The
lesion is usually found in the ends of long bones, most commonly
about the knee joint where 50% of the lesions will be seen. The next
most common locations are the sacrum and distal radius. The other
epiphyseal tumor seen in children is the chondroblastoma that also
has giant cell activity in the tumor. Even the so-called brown tumor
of hyperparathyroidism has excessive macrophage activity but is a
pseudotumor induced by parathormone producing lesions such as
parathyroid adenomas and secondary hyperparathyroidism seen in
renal failure disease.
Currently most experts feel that the giant cell tumor is a low-grade,
benign mesenchymal tumor with a fibro-osteoblastic stem cell with a
molecular genetic defect similar to the stem cell of the osteosarcoma
but with a greater degree of molecular genetic stability. The giant cell
seen in this tumor is simply an immune response by the host in an
attempt to remove the neoplastic fibro-osseous tissue. Giant cell
tumors account for between 5-10 per cent of all benign tumors of the
skeletal system. They are usually associated with pain in the adjacent
joint involved, such as the knee joint, which may cause an effusion.
radiographically, the lesion is very characteristic because of its purely
lytic nature that can be very geographic in nature, located in the
epiphyseal-metaphyseal location of a long bone, frequently coming in
direct contact with the subchondral bone of the adjacent joint. In more
aggressive cases, the lesion can break through the adjacent metaphyseal
cortex and gain access to the subperiosteal space and take on the
appearance of a more malignant process, such as a hemorrhagic
osteosarcoma.
Even though this condition is considered benign with a very low
mitotic index seen in the stromal cells, one or two per cent of the
tumors can metastasize to the lung as a benign process. There is an
excellent prognosis for cure with simple surgical resection in 80% of
the cases. Treatment usually consists of an aggressive curettement
of the tumor followed by a packing of the defect with either bone
graft, in smaller lesions, or more typically with bone cement in
larger lesions which gives a better chance of a permanent cure with
about a 5 to 10% recurrence rate with the cementation technique. In
more aggressive lesions located in the sacrum or anterior portion
of the spinal column, surgical resection is very difficult because of
the adjacent nerve roots or spinal cord, in which case occasionally
local radiation is used. However, in about 5% of cases, this can
convert the tumor into a high-grade tumor sarcoma at a much later
date. The tumor also has the potential for spontaneous conversion
to a high grade tumor, such as an osteosarcoma or a malignant
fibrous histiocytoma, in about 1% of cases.
Giant cell tumors that have a local recurrence have a greater
potential for pulmonary metastasis, running as high as 6% and, for
this reason, chest x-rays should be obtained periodically for a
period of approximately three years after the primary treatment of
the tumor.
CLASSIC
Case #207
23 year female with
GCT proximal tibia
Rapid progression
5 months later
Tumor breaking thru periostium of tibia
Curettement of tumor thru cortical window
Photomic showing giant cells
Appearance of tumor cavity following curettement
femoral
condyle
Light coming thru tibial plateau articular cartilage
Cleaning up tumor cavity with high-speed burr
Further clean up with waterpic lavage
Lysis of remaining
tumor cells with
3% hydrogen peroxide
Washing tumor cavity with peroxide
Tumor cavity clean ready for cementation
Placement of large threaded Steinman pins
2 stage cementation completed
cement
Placement of autogenous cancellous graft
Immediate post op
radiograph
18 months later
without recurrence
bone
graft
16 years later came
to a routine TKA
old cement
AP view
Case #207.1
43 year old male with knee pain for 4 months
GCT tibia
CT scan
Cor T-1 T-2 Gad
Sag T-1 T-2 Gad
Axial T-1 T-2
Gad
Two stage cementation procedure
Post op x-ray
Case #208
28 year male
GCT distal radius
Coronal T-1 MRI
Axial T-2 MRI showing multiple hemorrhagic cysts
X-ray following wide resection and transpostion of the distal ulna with it’s blood supply and fixed with plates
and fused to carpus
ulna radius
Case #208.1 GCT radius
67 year old female with wrist pain 6 months
Coronal T-1 T-2 Gad C+
Sagittal T-1 T-2 Gad C+
Axial T-1 T-2
Gad
Axial T-1 T-2
Gad
Post op x-ray following curettage and cementation
Case #209
59 year female with GCT sacrum
CT scan
Bone scan
9 years post curettement and radiation
Lateral view at 9 years and no recurrence
Case #209.1 CT scan
Bone scan
47 year old male with LBP 3 months
GCT sacrum
Axial T-1
T-2
Case #210
49 year male 10 yrs
post op bone graft
plus radiation therapy
for GCT with current
radiation sarcoma
old
graft
Coronal T-2 MRI
showing high signal
sarcoma
Amputation specimen cut in path lab
graft
Photomic showing pleomorphic sarcoma cells
Case #211
45 year male with spontaneous conversion of GCT
to OGS 15 yrs post curettement without RT
radius
Sagittal T-1 MRI
Axial T-1 MRI
Case #212
25 year male
aggressive GCT
proximal humerus
Case #212.1
22 year old female with
shoulder pain for 3 months
GCT
Cor T-1 T-2
Gad
PO #1 PO #2
PO #2
3 mos
PO #3
Case #213
Sagittal proton density
MRI of a 19 year
female with GCT T-1
Biopsy photomic
Sagittal T-1 MRI
2 years post op anterior
interbody fusion
without recurrence
Sagittal proton density
MRI one year later
showing recurrence and
cord compression
Coronal post gad contrast MRI
Surgical decompression and reconstruction
Anterior reconstruction
with bone cement and
titanium screw
Post op sagittal T-1 MRI showing cord decompression
cement
CT scan of chest shortly after spinal surgery
showing multiple pulmonary mets
Photomic showing benign GCT met in lung
tumor
lung tissue
Sagittal T-1 MRI
1 year later showing
recurrent tumor and
cord compression
Biopsy photomic showing OGS
osteoid
Case #1040
35 year male with
path fracture lateral
femoral condyle thru
GCT
Lateral view
Coronal T-1 MRI
Axial T-1 MRI
Sagittal T-1 MRI
Sagittal T-2 MRI
Coronal gad contrast MRI
Surgical specimen with resection distal femur
fracture
Tumor breaking thru the back of lat fem condyle
Photomic
Compress system used for reconstruction
anchor
spindle
taper
Disarticulated Compress device
Anchor plug Belleville washers
spindle
Belleville washers
compression nut spindle
Placement of anchor plug pins thru guide
Cementing tibial
component
Completed rotating hinge TKA
2 months post op
anchor
Lateral view
Case #1041
20 year female with
path fracture thru GCT
lateral femoral condyle
Oblique view
Lateral view
Photomic
Photomic showing foam cells
Fracture reduced and fixed with 1st batch of cement
Steinman pins
Second batch of cement
fracture line
1 year post op with
normal knee function
Lateral view
Case #1042
35 year male with GCT
distal femur
Surgical exposure of tumor
Curetted specimen
Photomic showing neoplastic osteoid formation
Tumor cavity following aggressive curettement
Completion of a 2 stage cementation
cement
4 years post op showing
radiolucent cement and
Steinman pins
12 years and working
full time as electrician
26 years and shows
early signs of DOA
Lateral view
Case #1043
32 year male with GCT distal femur
Sagittal T-1 MRI
Axial T-2 MRI
Case #1044
17 year female with
GCT lateral femoral
condyle
Lateral view
CT scan
1 year PO excisional
arthrodesis with titanium
spacer & cancellous
allograft
Case #1045
20 year female with
GCT distal femur
1 year after cementation
procedure
4 years later with normal
function of knee
6 mos following a traumatic
fracture of tibia and again
normal knee function
Case #1046
37 year female with prior
cementation procedure for
GCT followed later with
a recent removal of cement
and replacement with present
cancellous allograft
1 year later with collapse of
patellofemoral joint and loss
of active knee extension
Lateral view showing
patella collapsed into
tumor cavity
Patellar-femoral view
Sagittal T-1 MRI
Axial T-1 MRI
showing anterior
collapse of lateral
femoral condyle
Surgical exposure at time of patellofemoral reconstruction
with early findings of degenerative osteoarthritis
Removal of cancellous allograft placed over one year ago
Placement of Steinman pins ready for cementation
Completion of patellofemoral arthroplasty
One year later with
near normal ROM
of knee
Lateral view
Case #1047
45 year female with
GCT lateral femoral
condyle
Lateral view
CT scan
Immediate post op
X-ray following
cementation procedure
4.5 years later with signs
of recurrent tumor at
upper pole of cement
Lateral view
CT scan showing recurrence of GCT
Bone scan shows
recurrence also
1 year following a redo
cementation procedure
with no recurrence
Lateral view
Case #1048
23 year male with recurrent
GCT following a prior
curettement and cementation
AP view
cement
Cut specimen in path
lab following wide
resection and rotating
hinge arthroplasty cement
recurrent
tumor
Photomic
Case #1048.1
29 year male with
knee pain 3 months
GCT 9/07
Cor T-2 Gad 10/07
Axial T-1 PD
Gad
Sag T-2 Post op
10/07
12/08
Recurrence 1 yr
later
12/08
Axial T-1 T-2
Recementation 12/08
T-1 MRI showing soft tissue recurrence 2/2010
Axial T-1 Sag
Wide resection and Compress reconstruction 2/10
Case #1048.2
23 yr female with pain
R knee for 3 months
GCT
Cor T-1 T-2
Gad
Sag T-1 PD FS
Axial T-2 Gad
Post op x-ray
Case #1049
50 year male with pain L knee 2 mos but normal x-ray
L R
Lateral view shows questionable lysis distal femur
4 months later with
obvious lytic changes
Lateral view
Coronal PD MRI
Axial PD MRI
1 year post op
with cementation
and side plate
Case #1050
16 year female with
GCT distal femur
2 mos post op bone
graft with recurrence
4 mos post op and
even more signs of
recurrence
Surgical curettement of recurrent tumor
Photomic of recurrent tumor
Higher power with osteoid formation
Surgical appearance following curettement
Placement of Steinman pins prior to cementation
Cementation completed
9 months post radiolucent
cementation and 6500
rads of RT
13 years post op with
multiple path fractures
thru radiated bone with
multiple surgeries to fix
these fractures
20 years after 1st surgery with continued stress fractures
Shortly after last x-ray she developed pulmonary mets
2nd to radiation OGS seen in this photomic of lung biopsy
Case #1051
19 year female with
GCT distal femur and
ABC proximal tibia
GCT
ABC
Lateral view
Coronal T-1 MRI
Coronal T-2 MRI GCT
ABC
Photomic from femoral biopsy showing GCT
Case #1052
69 year male with prior
history of GCT distal
femur treated with curettement
and bone graft 35 years ago.
Now has a path fracture thru
OGS at the same site
old bone graft
Biopsy photomic shows OGS
CT scan shows metastatic OGS to inguinal lymph node
Case #1053
31 year male with GCT
femoral neck
Coronal T-1 MRI
Axial T-2 MRI
Axial T-2 MRI
at lower level
Bone scan
Biopsy photomic
Post op curettement with cementation and pins
Case #1054
34 year female with GCT
femoral neck 2 mos. PO
DHS fixation but no
removal of tumor
3 months PO complete
curettement thru anterior
approach and cementation
with DHS screw
5 years later with good
calcar hypertrophy and
normal hip function
Lateral view
Case #1055
39 year male with early GCT femoral head
5 months later without treatment
Coronal T-1 MRI
Coronal T-2 MRI
Post op x-ray showing bipolar prosthesis
Case #1056
44 year male with GCT
proximal femur
Coronal T-1 MRI
Photomic
14 months post op
cementation and pins
Case #1057
tumor
46 year female with GCT pelvis
CT scan
Photomic
6 months post op cementation with pins
Lateral view
Two years post op
Case #1058
29 year female with GCT
supra acetabular area
1 year later with central
fracture dislocation hip
4 years post op Tronzo
THA
Case #1059
73 year female with prior
GCT tibia treated with
curettage and cementation
Shortly after she
developed this second
GCT in ilium
CT scan
tumor
Photomic showing tumor osteoid
More tumor osteoid
Later she developed a
recurrence in the tibia
which led to an AK amp
and then developed the
path fracture in femoral
stump seen here thru yet
another multifocal GCT
Later on she developed
benign pulmonary mets
and died 6 mos later while
on chemotherapy
Case #1060
31 year male with GCT patella
17 months following
curettage with recurrent
tumor
Photomic
Case #1061
30 year female with
path fracture thru GCT
lateral tibial plateau
Lateral view
Surgical specimen from prox tibial resection
Surgical specimen showing lateral plateau fracture
Cut specimen in path
lab showing plateau
fracture into tumor
Photomic
Reconstructed with cemented
long stem single axial long
stem Guepar knee prosthesis
placed upside down
cement
Post op x-ray with
hinge prosthesis and
radiolucent cement
Case #1062
35 year male with GCT
proximal tibia
6 months post op
cementation with
painful chondrolysis
medial joint space
Post op revision to a
unicondylar prosthesis
Lateral view
Case #1063
17 year female with
GCT proximal tibia
Surgical curettement of tumor
Curetted specimen
Yellow portion of specimen showing foam cells
Tumor cavity following aggressive curettement
and use of a high speed bur
burr
Cementation completed
cement radiolucent
2 year post op with
radiolucent cement
Case #1064
27 year female with
GCT proximal tibia
Lateral view
Sagittal T-1 MRI
Coronal T-2 MRI
Case #1064.1
14 yr female with knee pain for 3 months
Axial T-1 T-2 FS
Gad
Sag T-1 STIR
Gad
Cor Gad
52 yr female with pain in knee for 1 yr
Case #1064.1 Geode in DOA GCT pseudotumor
Cor T-1 T-2
Sag T-1
Axial T-2
Case #1064.2
61 year male with increasing pain in knee for 5 years
GCT pseudotumor - geode
CT scan
Cor T-1 T-2 Gad
Sag T-1 T-2 Gad
Axial T-1 T-2
Gad
64 yr male with primary THA 15 yrs ago
Case #1064.3 Giant Cell Pseudotumor of Hip
Periarticular biopsy
69 yr male
TKA
Similar case
Pseudo tumor
of fibula
Fibular head biopsy
Polarized microscope
Case #1065
25 year female with
aggressive GCT
proximal tibia
Lateral view prior to
wide resection and
Compress TKA recon
Proximal tibial resection specimen
Photomic
Case #1066
28 year male with GCT
distal tibia
Lateral view
Immediate post op
cementation procedure
9 months later with
tumor recurrence
Post op cementation
revision procedure
Case #1067
27 year female with
GCT distal tibia
Lateral view
Sagittal T-1 MRI
Sagittal T-2 MRI
Case #1068
42 year female with
GCT distal radius
Post op cementation
with pins
Lateral view
Case #1069
19 year female with GCT distal radius
Lateral view
3 years later showing recurrent tumor
Surgical resection specimen
tumor
Allograft replacement fixed to side plate
Allograft reconstruction completed
Early post op x-ray
allograft
4 years later showing collapse of allograft
Case #1070
74 year female with
path fracture thru
GCT distal radius
Resection of distal radius and ulna
Distal face of radius engulfed with tumor
Macro section of distal radius
Photomic
Surgical appearance prior to reconstruction
carpus
Completion of cemented Volz total wrist arthroplasty
Post op x-ray
Lateral view
Case #1070.1
X-ray of 40 year
male with wrist pain
for 4 months
Axial T-1 Axial T-2
Gad C.
hemorrhagic
cysts
Sagittal T-1
Sagittal T-2
Post op x-ray
following curettment
and cementation with
a single Steinman pin
Case #1071
22 year female with
GCT distal ulna
Post op Darrach
resection distal ulna
Case #1072
29 year female with
GCT distal ulna
Case #1073
31 year male with GCT
distal humerus and
proximal ulna
Lateral view
Axial T-2 MRI
Coronal T-2 MRI
Post op x-ray with
Compress total elbow
arthroplasty
Case #1074
42 year female with large aneurysmal GCT prox radius
AP view
This huge benign tumor required an AE amputation
Case #1075
31 year male with
prior history of GCT
prox ulna treated 5
years ago with bone
graft and radiation
Now we see x-ray
evidence of OGS
2nd to the radiation
Photomic of benign GCT 5 yrs ago
osteoid
Photomic of present biopsy showing OGS
Numerous large
pulmonary mets seen
following AE amp
and chemotherapy
Case #1076
62 year male with GCT proximal humerus
Coronal T-1 MRI
Axial T-1 MRI
Coronal T-2 MRI
Photomic
Post op cementation
with pins one year later
Case #1077
23 year female with
ABC arising from a
GCT of distal humerus
Lateral view showing
aneurysmal appearance
Sagittal T-1 MRI
Sagittal T-2 MRI showing large hemorrhagic cysts
Axial T-2 MRI showing fluid-fluid levels
Post op cementation
with single pin
Lateral view
Case #1078
57 year male with GCT body of scapula
Case #1079
33 year female with GCT 3rd metatarsal
Case #1080
33 year female with
GCT 1st metatarsal
Case #1081
10 year male with
path fracture thru a
giant cell reparative
granuloma of the
2nd metatarsal
Case #1082
21 year male with
large GCT mid foot
Laminogram x-ray
Case#1083
26 year male with GCT great toe
Case #1084
23 year female with GCT os calcis
CT scan
Case #1084.1
AP and lat x-ray of a 43 yr. female with GCT talus
T-1 MRI
sagittal
coronal axial
Sagittal T-2 MRI
Sagittal & coronal Gad MRI
Post op curettement and cementation
Case #1085
31 year male with GCT 2nd metacarpal
Case #1086
25 year female with
GCT middle finger
Lateral view
Case #1087
28 year male with GCT 5th metacarpal
Case #1088
44 year male with GCT hamate bone
Oblique view
Coronal T-1 MRI
Axial T-2 MRI
Case #1089
35 year female with aggressive GCT finger
photomic
Pulmonary metastasis
Photomic from pulmonary met
Case #1090
26 year male with GCT body od L-2
AP view
Photomic
Post op spine fusion
Lateral view with posterior
Harrington rods and
anterior bone graft
Case #1091
27 year male with
GCT lumbar spine
treated with anterior
bone graft and post
Harrington rods 6
years ago
AP view
Case #1092
52 year male with GCT T-1 vertebra
R
Bone scan
CT scan
Case #1093
24 year female with GCT
C-spine 3 years post op
curettement and combined
anterior and posterior
spinal fusion