Giant cell tumors of bone

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Giant cell tumors of bone

  1. 1. Giant cell tumour of bone Dr Abdul G Suhail MBBS,D.Ortho,MS (Ortho) Assistant Professor in Orthopaedics
  2. 2. History   First described in 1818 by Sir Astley Cooper Described in detail in 1940 by Jaffe and Litchenstein
  3. 3. GIANT CELL TUMOUR DEFINITION: Distinct neoplasm arising from non-bone forming supportive connective tissue of marrow with network of stromal cells regularly interspersed with giant cells. ( Jaffe & Liechtenstein )
  4. 4. AGE OF PRESENTATION 75-80% OF PATIENTS 20-50 YRS  10% 15-20 YRS   10% >60 yrs  <1.7% BELOW 15 YRS
  5. 5. SEX   Male:Female- 1:1.3 (Benign) -3:1 (Malignant)
  6. 6. SITE Epiphyseo-metaphyseal region of long bones  GCT –Described from all bones EXCEPT middle ear bones Axial skeleton- 8% UL:LL-1:3
  7. 7. Site  55% AROUND THE KNEE  10% in the distal radius  6% in the proximal humerus   SPINE rarely involved (commoner in the sacrum) In the head and neck region the maxilla and mandible are more commonly involved
  8. 8. GIANT CELL TUMOUR INTRA ARTICULAR EXTENSION- 10% TRANS OSSIOUS EXTENSION- 5% Common sites Wrist Ankle & foot Forearm Leg
  9. 9. MULTICENTRIC INVOLVEMENT    Incidence-0.5-5% Simultaneous Peculiar features  hand metaphyseal abundant spindle cells  GOLTZ syndrome ` occular defects skeletal anomaly multifocal GCT
  10. 10. GIANT CELL TUMOUR SIGNS&SYMPTOMS 1. PAIN 2. SWELLING 3. JOINT RESTRICTION 4. MUSCLE WASTING 5. NEUROLOGICAL SIGNS 6. PATHOLOGICAL #
  11. 11. Pathology GROSS End of bone is expanded.  Eccentric lesion at the epiphyseometaphyseal region.  Thin periosteum.  Fleshy dark brown, soft, friable mass.  Cystic spaces seen.
  12. 12. PATHOLOGY GROSS-
  13. 13. Pathology Microscopy Vascularized network of round,oval or spindle shaped stromal cells and multinucleated giant cells with numerous centrally placed nuclei
  14. 14. PATHOLOGY MICROSCOPY
  15. 15. Grading Jaffe,Lichenstein and Portis(1940) GRADE 1o Conventional GCT o Stroma is inconspicuous o Giant cells dominate the field o No atypism of stromal cells and are loosely arranged o Stromal cells are predominantly spindle shaped
  16. 16. Grading GRADE 2o Boderline tumours o Stromal cells are prominent and tightly packed o Giant cells are less in number compared to grade 1 and their nuclei may show atypism o Stromal cells show atypism o These tumours have a strong chance for recurrence and some may undergo malignant change
  17. 17. Grading GRADE 3o Sarcomatous type of stroma o Frequently metastase o Stromal cells abundant and closely compacted and present an irregular whorled arrangement o Nuclei are unusually large, irregular and atypical o Giant cells are few in number and atypical
  18. 18. Modified grading Sannerkin et al(1980)    Malignant GCT- with frank sarcomatous changes and full metastatic potential Borderline GCT- without sarcomatous changes but with abnormal mitoses or vascular permeation or both Conventional GCT- without features of any of the above two types
  19. 19. No correlation exists between histological grading and clinical behavior of the tumour. Hence grading not widely accepted.
  20. 20. GIANT CELLS in Giant cell tumor  Numerous nuclei(15-150)  Centrally placed uniform size nuclei Tuberculosis  Number of nuclei are less  Peripherally placed nuclei
  21. 21. Enneking staging for GCT Stage 1-(10-15%)       Patients asymptomatic Discovered incidentally May cause pathological fracture Has sclerotic rim on x-ray or CT Relatively inactive on bone scans Histologically benign
  22. 22. Enneking staging for GCT Stage 2-(70%)      Symptomatic Often associated with path: fracture Has expanded cortex but no break through Is active on bone scans Histologically benign
  23. 23. Enneking staging for GCT Stage 3-(10-15%)       Symptomatic Rapidly growing mass Has cortical perforation with accompanying soft tissue mass Activity on bone scan extends beyond the lesion in x ray Shows intense hypervascularity on angiogram Histologically benign
  24. 24. RADIOLOGY Type of Osteolysis  Geographic destruction (I) Lodwick 1A  1B Moth-eaten (II) 1C Permeative(III)
  25. 25. RADIOLOGY  Expansile
  26. 26. RADIOLOGY  TRABACULATION PURE LYTIC (60%) FINE TRABACULTION(40%)
  27. 27. RADIOLOGY AGGRESSIVENESS LARGE INTRAOSSEOUS CONTENT PURELY LYTIC CORTICAL BREACH SOFT TISSUE INVASION
  28. 28. INVESTIGATIONS SCINTI GRAPHY Less useful Inconsistent uptake “Doughnut sign” ANGIO GRAPHY Locate vessels type of feeders For embolisation C.T Intraossous content Intra articular spread Cortical breach Site of window M.R.I. Soft tissue spread Joint breach Locate N.V. bundle
  29. 29. GCT Ulna
  30. 30. GCT of Olecranon
  31. 31. GCT Radius
  32. 32. GCT distal femur
  33. 33. GCT lower end femur
  34. 34. GCT Fibula
  35. 35. GCT Calcaneum
  36. 36. GCT Ilium
  37. 37. GCT C7
  38. 38. DIFFERENTIAL DIAGNOSIS 1.ANEURYSMAL BONE CYST 2. GIANT CELL REPARATIVE GRANULOMA 3.CHONDROBLASTOMA 4.BROWN TUMOR 5.INTRA OSSEOUS GANGLION 6.BENIGN FIBROUS HISTEOCYTOMA
  39. 39. Bubbly lesions of bone Tumors  Aneurismal bone cyst  Unicameral bone cyst  Non ossifying fibroma  Osteoblastoma  Hyper parathyroidism  Chondromyxoid fibroma  Histiocytosis X  Myeloma  Metastasis(kidney,thyroid) Infection  Brodies abscess  Coccidioidomycosis  Ecchinococcus
  40. 40. BIOPSY CLOSED FINE NEEDLE TRUECUT TREPHINE OPEN INCISIONAL EXCISION
  41. 41. TREATMENT STAGE STAGE1 TYPE LATENT Lodwick2 STAGE 2 ACTIVE Lodwick3 STAGE 3 AGGRES. GRADE SITE METASTASIS G0 T0 M0 G0 T0 M0 G0 T1,2 M0,1
  42. 42. SURGICAL TREATMENT Stage1& Stage2 --- Intralesional or Marginal Excision Stage3 --- Wide resection with Reconstruction Radiation, Embolaisation
  43. 43. Curettage & Bone Grafting INDICATION STAGE-1&2 ADEQUATE WINDOW MOTORISED BURR
  44. 44. Extended Curettage PHENOL BONE CEMENT LIQUID NITROGEN CAUTERY CO 2 LASER
  45. 45. EN.BLOC EXCISION  Better result  Dispensable bone ---- Patella, head of Fibula  Sub articular lesion
  46. 46. RECONSTRUCTION     Auto graft Allograft Arthrodesis Custom made prosthesis
  47. 47. Reconstruction With Autograft
  48. 48. Reconstruction With Allograft
  49. 49. Reconstruction With Arthrodesis
  50. 50. Reconstruction With Prosthesis
  51. 51. Metastasis Benign pulmonary metastasis seen in 2% of patients unpredictable course Some spontaneously regress Others treated by pulmonary wedge resection 25% mortality Other sites Lymph nodes, mediastinum ,pelvis.
  52. 52. Pushpavally 32yrs
  53. 53. Pushpavally 32yrs
  54. 54. FEMALE 21YRS. 15-5-92
  55. 55. Lady 28yrs.
  56. 56. Recurrent GCT
  57. 57. Recurrent GCT
  58. 58. Recurrent GCT
  59. 59. Recurrent GCT
  60. 60. Recurrent GCT
  61. 61. Recurrent GCT

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