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Vol 10 ppt

  1. 1. Volume 10Giant cell tumor of bone-------Case 207-213 & 1040-1093
  2. 2. Giant Cell Tumors
  3. 3. Giant Cell Tumor of Bone There are numerous primary tumors of bone with giant cell oror macrophage activity seen within the tumor under the microscope.These include the aneurysmal bone cyst, chondroblastoma, solitarybone cyst, osteoid osteoma, osteoblastoma, fibrous dysplasia andosteogenic sarcoma, hemorrhagic type. Some pathologists classifythese tumors as variants of the true giant cell tumor making it almosta diagnosis of exclusion if none of the above diagnoses can beestablished histologically. The clinical entity known as the benigngiant cell tumor of bone is seen typically in young adult femalesbetween the ages of 20 and 40 years. It is less common in males. Thelesion is usually found in the ends of long bones, most commonlyabout the knee joint where 50% of the lesions will be seen. The nextmost common locations are the sacrum and distal radius. The otherepiphyseal tumor seen in children is the chondroblastoma that alsohas giant cell activity in the tumor. Even the so-called brown tumorof hyperparathyroidism has excessive macrophage activity but is a
  4. 4. pseudotumor induced by parathormone producing lesions such asparathyroid adenomas and secondary hyperparathyroidism seen inrenal 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 amolecular genetic defect similar to the stem cell of the osteosarcomabut with a greater degree of molecular genetic stability. The giant cellseen in this tumor is simply an immune response by the host in anattempt to remove the neoplastic fibro-osseous tissue. Giant celltumors account for between 5-10 per cent of all benign tumors of theskeletal system. They are usually associated with pain in the adjacentjoint involved, such as the knee joint, which may cause an effusion.radiographically, the lesion is very characteristic because of its purelylytic nature that can be very geographic in nature, located in theepiphyseal-metaphyseal location of a long bone, frequently coming indirect contact with the subchondral bone of the adjacent joint. In moreaggressive cases, the lesion can break through the adjacent metaphyseal
  5. 5. cortex and gain access to the subperiosteal space and take on theappearance of a more malignant process, such as a hemorrhagicosteosarcoma. Even though this condition is considered benign with a very lowmitotic index seen in the stromal cells, one or two per cent of thetumors can metastasize to the lung as a benign process. There is anexcellent prognosis for cure with simple surgical resection in 80% ofthe cases. Treatment usually consists of an aggressive curettementof the tumor followed by a packing of the defect with either bonegraft, in smaller lesions, or more typically with bone cement inlarger lesions which gives a better chance of a permanent cure withabout a 5 to 10% recurrence rate with the cementation technique. Inmore aggressive lesions located in the sacrum or anterior portionof the spinal column, surgical resection is very difficult because ofthe adjacent nerve roots or spinal cord, in which case occasionallylocal radiation is used. However, in about 5% of cases, this canconvert the tumor into a high-grade tumor sarcoma at a much later
  6. 6. date. The tumor also has the potential for spontaneous conversionto a high grade tumor, such as an osteosarcoma or a malignantfibrous histiocytoma, in about 1% of cases. Giant cell tumors that have a local recurrence have a greaterpotential for pulmonary metastasis, running as high as 6% and, forthis reason, chest x-rays should be obtained periodically for aperiod of approximately three years after the primary treatment ofthe tumor.
  7. 7. CLASSICCase #20723 year female withGCT proximal tibia
  8. 8. Rapid progression5 months later
  9. 9. Tumor breaking thru periostium of tibia
  10. 10. Curettement of tumor thru cortical window
  11. 11. Photomic showing giant cells
  12. 12. femoral condyleAppearance of tumor cavity following curettement
  13. 13. Light coming thru tibial plateau articular cartilage
  14. 14. Cleaning up tumor cavity with high-speed burr
  15. 15. Further clean up with waterpic lavage
  16. 16. Lysis of remainingtumor cells with3% hydrogen peroxide
  17. 17. Washing tumor cavity with peroxide
  18. 18. Tumor cavity clean ready for cementation
  19. 19. Placement of large threaded Steinman pins
  20. 20. cement2 stage cementation completed
  21. 21. Placement of autogenous cancellous graft
  22. 22. Immediate post opradiograph
  23. 23. 18 months laterwithout recurrence bone graft
  24. 24. 16 years later cameto a routine TKA old cement
  25. 25. AP view
  26. 26. Case #207.1 GCT tibia 43 year old male with knee pain for 4 months
  27. 27. CT scan
  28. 28. Cor T-1 T-2 Gad
  29. 29. Sag T-1 T-2 Gad
  30. 30. Axial T-1 T-2 Gad
  31. 31. Two stage cementation procedure
  32. 32. Post op x-ray
  33. 33. Case #20828 year maleGCT distal radius
  34. 34. Coronal T-1 MRI
  35. 35. Axial T-2 MRI showing multiple hemorrhagic cysts
  36. 36. ulna radiusX-ray following wide resection and transpostion of thedistal ulna with it’s blood supply and fixed with plates and fused to carpus
  37. 37. Case #208.1 GCT radius 67 year old female with wrist pain 6 months
  38. 38. Coronal T-1 T-2 Gad C+
  39. 39. Sagittal T-1 T-2 Gad C+
  40. 40. Axial T-1 T-2 Gad
  41. 41. T-1 Axial T-2 Gad
  42. 42. Post op x-ray following curettage and cementation
  43. 43. Case #209 59 year female with GCT sacrum
  44. 44. CT scan
  45. 45. Bone scan
  46. 46. 9 years post curettement and radiation
  47. 47. Lateral view at 9 years and no recurrence
  48. 48. Case #209.1 CT scan GCT sacrum Bone scan47 year old male with LBP 3 months
  49. 49. T-2Axial T-1
  50. 50. Case #21049 year male 10 yrspost op bone graft oldplus radiation therapy graftfor GCT with currentradiation sarcoma
  51. 51. Coronal T-2 MRIshowing high signalsarcoma
  52. 52. graftAmputation specimen cut in path lab
  53. 53. Photomic showing pleomorphic sarcoma cells
  54. 54. Case #211 radius 45 year male with spontaneous conversion of GCT to OGS 15 yrs post curettement without RT
  55. 55. Sagittal T-1 MRI
  56. 56. Axial T-1 MRI
  57. 57. Case #21225 year maleaggressive GCTproximal humerus
  58. 58. Case #212.1 GCT 22 year old female with shoulder pain for 3 months
  59. 59. Cor T-1 T-2Gad
  60. 60. PO #1 PO #2PO #2 PO #33 mos
  61. 61. Case #213Sagittal proton densityMRI of a 19 yearfemale with GCT T-1
  62. 62. Biopsy photomic
  63. 63. Sagittal T-1 MRI2 years post op anteriorinterbody fusionwithout recurrence
  64. 64. Sagittal proton densityMRI one year latershowing recurrence andcord compression
  65. 65. Coronal post gad contrast MRI
  66. 66. Surgical decompression and reconstruction
  67. 67. Anterior reconstructionwith bone cement andtitanium screw
  68. 68. cementPost op sagittal T-1 MRI showing cord decompression
  69. 69. CT scan of chest shortly after spinal surgery showing multiple pulmonary mets
  70. 70. tumorlung tissue Photomic showing benign GCT met in lung
  71. 71. Sagittal T-1 MRI1 year later showingrecurrent tumor andcord compression
  72. 72. osteoidBiopsy photomic showing OGS
  73. 73. Case #104035 year male withpath fracture lateralfemoral condyle thruGCT
  74. 74. Lateral view
  75. 75. Coronal T-1 MRI
  76. 76. Axial T-1 MRI
  77. 77. Sagittal T-1 MRI
  78. 78. Sagittal T-2 MRI
  79. 79. Coronal gad contrast MRI
  80. 80. fractureSurgical specimen with resection distal femur
  81. 81. Tumor breaking thru the back of lat fem condyle
  82. 82. Photomic
  83. 83. taper spindleanchor Compress system used for reconstruction
  84. 84. spindle Belleville washersAnchor plug Disarticulated Compress device
  85. 85. spindle compression nut Belleville washers
  86. 86. Placement of anchor plug pins thru guide
  87. 87. Cementing tibialcomponent
  88. 88. Completed rotating hinge TKA
  89. 89. anchor2 months post op
  90. 90. Lateral view
  91. 91. Case #104120 year female withpath fracture thru GCTlateral femoral condyle
  92. 92. Oblique view
  93. 93. Lateral view
  94. 94. Photomic
  95. 95. Photomic showing foam cells
  96. 96. Steinman pinsFracture reduced and fixed with 1st batch of cement
  97. 97. fracture lineSecond batch of cement
  98. 98. 1 year post op withnormal knee function
  99. 99. Lateral view
  100. 100. Case #104235 year male with GCTdistal femur
  101. 101. Surgical exposure of tumor
  102. 102. Curetted specimen
  103. 103. Photomic showing neoplastic osteoid formation
  104. 104. Tumor cavity following aggressive curettement
  105. 105. cementCompletion of a 2 stage cementation
  106. 106. 4 years post op showingradiolucent cement andSteinman pins
  107. 107. 12 years and workingfull time as electrician
  108. 108. 26 years and showsearly signs of DOA
  109. 109. Lateral view
  110. 110. Case #1043 32 year male with GCT distal femur
  111. 111. Sagittal T-1 MRI
  112. 112. Axial T-2 MRI
  113. 113. Case #104417 year female withGCT lateral femoralcondyle
  114. 114. Lateral view
  115. 115. CT scan
  116. 116. 1 year PO excisionalarthrodesis with titaniumspacer & cancellousallograft
  117. 117. Case #104520 year female withGCT distal femur
  118. 118. 1 year after cementationprocedure
  119. 119. 4 years later with normalfunction of knee
  120. 120. 6 mos following a traumaticfracture of tibia and againnormal knee function
  121. 121. Case #104637 year female with priorcementation procedure forGCT followed later witha recent removal of cementand replacement with presentcancellous allograft
  122. 122. 1 year later with collapse ofpatellofemoral joint and lossof active knee extension
  123. 123. Lateral view showingpatella collapsed intotumor cavity
  124. 124. Patellar-femoral view
  125. 125. Sagittal T-1 MRI
  126. 126. Axial T-1 MRIshowing anteriorcollapse of lateralfemoral condyle
  127. 127. Surgical exposure at time of patellofemoral reconstruction with early findings of degenerative osteoarthritis
  128. 128. Removal of cancellous allograft placed over one year ago
  129. 129. Placement of Steinman pins ready for cementation
  130. 130. Completion of patellofemoral arthroplasty
  131. 131. One year later withnear normal ROMof knee
  132. 132. Lateral view
  133. 133. Case #104745 year female withGCT lateral femoralcondyle
  134. 134. Lateral view
  135. 135. CT scan
  136. 136. Immediate post opX-ray followingcementation procedure
  137. 137. 4.5 years later with signsof recurrent tumor atupper pole of cement
  138. 138. Lateral view
  139. 139. CT scan showing recurrence of GCT
  140. 140. Bone scan showsrecurrence also
  141. 141. 1 year following a redocementation procedurewith no recurrence
  142. 142. Lateral view
  143. 143. Case #104823 year male with recurrentGCT following a priorcurettement and cementation
  144. 144. AP view cement
  145. 145. recurrent tumorCut specimen in pathlab following wideresection and rotatinghinge arthroplasty cement
  146. 146. Photomic
  147. 147. GCT 9/07Case #1048.129 year male withknee pain 3 months
  148. 148. 10/07Cor T-2 Gad
  149. 149. Axial T-1 PDGad
  150. 150. 10/07Sag T-2 Post op
  151. 151. 12/08Recurrence 1 yr later
  152. 152. 12/08Axial T-1 T-2
  153. 153. Recementation 12/08
  154. 154. Axial T-1 SagT-1 MRI showing soft tissue recurrence 2/2010
  155. 155. Wide resection and Compress reconstruction 2/10
  156. 156. Case #1048.2 GCT23 yr female with painR knee for 3 months
  157. 157. Cor T-1 T-2 Gad
  158. 158. Sag T-1 PD FS
  159. 159. Axial T-2 Gad
  160. 160. Post op x-ray
  161. 161. Case #1049 R L 50 year male with pain L knee 2 mos but normal x-ray
  162. 162. Lateral view shows questionable lysis distal femur
  163. 163. 4 months later withobvious lytic changes
  164. 164. Lateral view
  165. 165. Coronal PD MRI
  166. 166. Axial PD MRI
  167. 167. 1 year post opwith cementationand side plate
  168. 168. Case #105016 year female withGCT distal femur
  169. 169. 2 mos post op bonegraft with recurrence
  170. 170. 4 mos post op andeven more signs ofrecurrence
  171. 171. Surgical curettement of recurrent tumor
  172. 172. Photomic of recurrent tumor
  173. 173. Higher power with osteoid formation
  174. 174. Surgical appearance following curettement
  175. 175. Placement of Steinman pins prior to cementation
  176. 176. Cementation completed
  177. 177. 9 months post radiolucentcementation and 6500rads of RT
  178. 178. 13 years post op withmultiple path fracturesthru radiated bone withmultiple surgeries to fixthese fractures
  179. 179. 20 years after 1st surgery with continued stress fractures
  180. 180. Shortly after last x-ray she developed pulmonary mets2nd to radiation OGS seen in this photomic of lung biopsy
  181. 181. Case #1051 GCT19 year female withGCT distal femur andABC proximal tibia ABC
  182. 182. Lateral view
  183. 183. Coronal T-1 MRI
  184. 184. GCTCoronal T-2 MRI ABC
  185. 185. Photomic from femoral biopsy showing GCT
  186. 186. Case #105269 year male with priorhistory of GCT distalfemur treated with curettementand bone graft 35 years ago.Now has a path fracture thruOGS at the same site old bone graft
  187. 187. Biopsy photomic shows OGS
  188. 188. CT scan shows metastatic OGS to inguinal lymph node
  189. 189. Case #105331 year male with GCTfemoral neck
  190. 190. Coronal T-1 MRI
  191. 191. Axial T-2 MRI
  192. 192. Axial T-2 MRIat lower level
  193. 193. Bone scan
  194. 194. Biopsy photomic
  195. 195. Post op curettement with cementation and pins
  196. 196. Case #105434 year female with GCTfemoral neck 2 mos. PODHS fixation but noremoval of tumor
  197. 197. 3 months PO completecurettement thru anteriorapproach and cementationwith DHS screw
  198. 198. 5 years later with goodcalcar hypertrophy andnormal hip function
  199. 199. Lateral view
  200. 200. Case #1055 39 year male with early GCT femoral head
  201. 201. 5 months later without treatment
  202. 202. Coronal T-1 MRI
  203. 203. Coronal T-2 MRI
  204. 204. Post op x-ray showing bipolar prosthesis
  205. 205. Case #105644 year male with GCTproximal femur
  206. 206. Coronal T-1 MRI
  207. 207. Photomic
  208. 208. 14 months post opcementation and pins
  209. 209. Case #1057 tumor 46 year female with GCT pelvis
  210. 210. CT scan
  211. 211. Photomic
  212. 212. 6 months post op cementation with pins
  213. 213. Lateral view
  214. 214. Two years post op
  215. 215. Case #105829 year female with GCTsupra acetabular area
  216. 216. 1 year later with centralfracture dislocation hip
  217. 217. 4 years post op TronzoTHA
  218. 218. Case #105973 year female with priorGCT tibia treated withcurettage and cementation
  219. 219. Shortly after shedeveloped this secondGCT in ilium
  220. 220. tumorCT scan
  221. 221. Photomic showing tumor osteoid
  222. 222. More tumor osteoid
  223. 223. Later she developed arecurrence in the tibiawhich led to an AK ampand then developed thepath fracture in femoralstump seen here thru yetanother multifocal GCTLater on she developedbenign pulmonary metsand died 6 mos later whileon chemotherapy
  224. 224. Case #1060 31 year male with GCT patella
  225. 225. 17 months followingcurettage with recurrenttumor
  226. 226. Photomic
  227. 227. Case #106130 year female withpath fracture thru GCTlateral tibial plateau
  228. 228. Lateral view
  229. 229. Surgical specimen from prox tibial resection
  230. 230. Surgical specimen showing lateral plateau fracture
  231. 231. Cut specimen in pathlab showing plateaufracture into tumor
  232. 232. Photomic
  233. 233. Reconstructed with cementedlong stem single axial longstem Guepar knee prosthesisplaced upside down cement
  234. 234. Post op x-ray withhinge prosthesis andradiolucent cement
  235. 235. Case #106235 year male with GCTproximal tibia
  236. 236. 6 months post opcementation withpainful chondrolysismedial joint space
  237. 237. Post op revision to aunicondylar prosthesis
  238. 238. Lateral view
  239. 239. Case #106317 year female withGCT proximal tibia
  240. 240. Surgical curettement of tumor
  241. 241. Curetted specimen
  242. 242. Yellow portion of specimen showing foam cells
  243. 243. burrTumor cavity following aggressive curettement and use of a high speed bur
  244. 244. radiolucent cementCementation completed
  245. 245. 2 year post op withradiolucent cement
  246. 246. Case #106427 year female withGCT proximal tibia
  247. 247. Lateral view
  248. 248. Sagittal T-1 MRI
  249. 249. Coronal T-2 MRI
  250. 250. Case #1064.1 14 yr female with knee pain for 3 months
  251. 251. Axial T-1 T-2 FS Gad
  252. 252. Sag T-1 STIR Gad
  253. 253. Cor Gad
  254. 254. Case #1064.1 GCT pseudotumor Geode in DOA 52 yr female with pain in knee for 1 yr
  255. 255. Cor T-1 T-2
  256. 256. Axial T-2Sag T-1
  257. 257. Case #1064.2 GCT pseudotumor - geode 61 year male with increasing pain in knee for 5 years
  258. 258. CT scan
  259. 259. Cor T-1 T-2 Gad
  260. 260. Sag T-1 T-2 Gad
  261. 261. Axial T-1 T-2 Gad
  262. 262. Case #1064.3 Giant Cell Pseudotumor of Hip 64 yr male with primary THA 15 yrs ago
  263. 263. Periarticular biopsy
  264. 264. Similar case Pseudo tumor of fibula 69 yr male TKA
  265. 265. Fibular head biopsy
  266. 266. Polarized microscope
  267. 267. Case #106525 year female withaggressive GCTproximal tibia
  268. 268. Lateral view prior towide resection andCompress TKA recon
  269. 269. Proximal tibial resection specimen
  270. 270. Photomic
  271. 271. Case #106628 year male with GCTdistal tibia
  272. 272. Lateral view
  273. 273. Immediate post opcementation procedure
  274. 274. 9 months later withtumor recurrence
  275. 275. Post op cementationrevision procedure
  276. 276. Case #106727 year female withGCT distal tibia
  277. 277. Lateral view
  278. 278. Sagittal T-1 MRI
  279. 279. Sagittal T-2 MRI
  280. 280. Case #106842 year female withGCT distal radius
  281. 281. Post op cementationwith pins
  282. 282. Lateral view
  283. 283. Case #1069 19 year female with GCT distal radius
  284. 284. Lateral view
  285. 285. 3 years later showing recurrent tumor
  286. 286. tumorSurgical resection specimen
  287. 287. Allograft replacement fixed to side plate
  288. 288. Allograft reconstruction completed
  289. 289. allograftEarly post op x-ray
  290. 290. 4 years later showing collapse of allograft
  291. 291. Case #107074 year female withpath fracture thruGCT distal radius
  292. 292. Resection of distal radius and ulna
  293. 293. Distal face of radius engulfed with tumor
  294. 294. Macro section of distal radius
  295. 295. Photomic
  296. 296. carpusSurgical appearance prior to reconstruction
  297. 297. Completion of cemented Volz total wrist arthroplasty
  298. 298. Post op x-ray
  299. 299. Lateral view
  300. 300. Case #1070.1X-ray of 40 yearmale with wrist painfor 4 months
  301. 301. Axial T-1 Axial T-2 hemorrhagic cysts Gad C.
  302. 302. Sagittal T-1Sagittal T-2
  303. 303. Post op x-rayfollowing curettmentand cementation witha single Steinman pin
  304. 304. Case #107122 year female withGCT distal ulna
  305. 305. Post op Darrachresection distal ulna
  306. 306. Case #107229 year female withGCT distal ulna
  307. 307. Case #107331 year male with GCTdistal humerus andproximal ulna
  308. 308. Lateral view
  309. 309. Axial T-2 MRI
  310. 310. Coronal T-2 MRI
  311. 311. Post op x-ray withCompress total elbowarthroplasty
  312. 312. Case #1074 42 year female with large aneurysmal GCT prox radius
  313. 313. AP viewThis huge benign tumor required an AE amputation
  314. 314. Case #107531 year male withprior history of GCTprox ulna treated 5years ago with bonegraft and radiationNow we see x-rayevidence of OGS2nd to the radiation
  315. 315. osteoidPhotomic of benign GCT 5 yrs ago
  316. 316. Photomic of present biopsy showing OGS
  317. 317. Numerous largepulmonary mets seenfollowing AE ampand chemotherapy
  318. 318. Case #1076 62 year male with GCT proximal humerus
  319. 319. Coronal T-1 MRI
  320. 320. Axial T-1 MRI
  321. 321. Coronal T-2 MRI
  322. 322. Photomic
  323. 323. Post op cementationwith pins one year later
  324. 324. Case #107723 year female withABC arising from aGCT of distal humerus
  325. 325. Lateral view showinganeurysmal appearance
  326. 326. Sagittal T-1 MRI
  327. 327. Sagittal T-2 MRI showing large hemorrhagic cysts
  328. 328. Axial T-2 MRI showing fluid-fluid levels
  329. 329. Post op cementationwith single pin
  330. 330. Lateral view
  331. 331. Case #1078 57 year male with GCT body of scapula
  332. 332. Case #1079 33 year female with GCT 3rd metatarsal
  333. 333. Case #108033 year female withGCT 1st metatarsal
  334. 334. Case #108110 year male withpath fracture thru agiant cell reparativegranuloma of the2nd metatarsal
  335. 335. Case #108221 year male withlarge GCT mid foot
  336. 336. Laminogram x-ray
  337. 337. Case#1083 26 year male with GCT great toe
  338. 338. Case #1084 23 year female with GCT os calcis
  339. 339. CT scan
  340. 340. Case #1084.1 AP and lat x-ray of a 43 yr. female with GCT talus
  341. 341. T-1 MRI sagittal coronal axial
  342. 342. Sagittal T-2 MRI
  343. 343. Sagittal & coronal Gad MRI
  344. 344. Post op curettement and cementation
  345. 345. Case #1085 31 year male with GCT 2nd metacarpal
  346. 346. Case #108625 year female withGCT middle finger
  347. 347. Lateral view
  348. 348. Case #1087 28 year male with GCT 5th metacarpal
  349. 349. Case #1088 44 year male with GCT hamate bone
  350. 350. Oblique view
  351. 351. Coronal T-1 MRI
  352. 352. Axial T-2 MRI
  353. 353. Case #1089 35 year female with aggressive GCT finger
  354. 354. photomic
  355. 355. Pulmonary metastasis
  356. 356. Photomic from pulmonary met
  357. 357. Case #1090 26 year male with GCT body od L-2
  358. 358. AP view
  359. 359. Photomic
  360. 360. Post op spine fusion
  361. 361. Lateral view with posteriorHarrington rods andanterior bone graft
  362. 362. Case #109127 year male withGCT lumbar spinetreated with anteriorbone graft and postHarrington rods 6years ago
  363. 363. AP view
  364. 364. Case #1092 52 year male with GCT T-1 vertebra
  365. 365. RBone scan
  366. 366. CT scan
  367. 367. Case #109324 year female with GCTC-spine 3 years post opcurettement and combinedanterior and posteriorspinal fusion

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