Giant cell tumor of bone

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  • 1. Giant Cell Tumor of Bone
  • 2. Definition • 10 bone neoplasm • First described Cooper 1818 • Generally benign but locally aggressive • Potential for : – Recurrence – Pulmonary metastasis – Frank malignancy
  • 3. • Osteolytic tumour arising from epiphysis • Common in young adults • Though it is benign it is locally malignant
  • 4. Epidemiology • 5-10% 10 bone tumors • 20% benign bone tumors • F : M 1.5 : 1 • 70-80% age 20-40yrs
  • 5. SITES • Most common location –distal femur followed closely by the proximal tibia • In the distal radius(3rd most common location) these are frequently more aggressive
  • 6. Presentation • Swelling with skin over the swelling stretched • Pain x wks. – mos(usually not a presenting feature • Mass • Pathologic # • Neuro deficit (spine / sacrum) • Incidental
  • 7. • EGG SHELL CRACKING sensation may be present • Limitation of joint movement and pathological fractures –usually a late feature
  • 8. Radiology • Lytic lesion near epiphysis • Eccentric or central • Narrow zone transition B/W tmr and surrounding tissue • Cortical thinning • expansile • No sclerotic margin • No periosteal bone formation
  • 9. • Thin septa of bone traverse the interior producing soap bubble appearance • Joint extension usually not a feature • Cortex disrupted in late stages • Intra articular extension is rare as subchondral bone usually remains intact
  • 10. Other modalities • CT – Integrity cortical rim • MRI _extent of lesion within the bone and soft tissue – Assess subchondral breakthrough – Lesion dark on T1 and bright on T2 wt • Bone Scan – Suspect multicentri loci – Uses very low radioactive material (disphosphonate) to see spread to other bone
  • 11. CAMPANACCI’S GRADING • GRADE 1 :CYSTIC LESION • GRADE 2:CORTEX THIN BUT NOT PERFORATED • GRADE 3:CORTEX PERFORATED WITH EXTENSION INTO SOFT TISSUE
  • 12. ENEKING’S STAGING • STAGE 1: LATENT-NO CHARACTERISTIC GROWTH OR PROGRESSIVE CHANGE,RESOLVE SPONTANEOUSLY • STAGE 2:ACTIVE-LESION DEFORM THE HOST BONE BUT REMAINS INSIDE BONE • STAGE3:AGGRESSIVE-TUMOUR EXTEND BEYOND THE BONE
  • 13. Histology • Fibrohistiocytic origin • Multinucleated giant cells (40-60 nuclei per cell) in a sea of mononuclear stroma – Round / ovoid / spindle • Indistinct cell membrane • Mitoses • Appearance of spindle cells-malignant potential
  • 14. • GCT USUALLY ARE SOLITARY LESIONS;HOWEVER 1%-2% MAY BE SYNCHRONOUSLY OR METACHRONOUSLY MULTICENTRIC
  • 15. PULMONARY METASTASIS • OVERALL MORTALITY:15% • PATIENT WITH RECURRENT LESIONS OR PRIMARY LESIONS THAT APPEAR AGGRESSIVE RADIOGRAPHICALLY ARE AT HIGHER RISK • MALIGNANT GCT <5% CASES
  • 16. TREATMENT • Traditionally: – Intralesional curettage / resection & bone graft – Recurrence 35-42% • En Bloc resection – Recurrence ~10% – Multiple complications • Adjuvant
  • 17. • HISTORICALLY TRT CONSISTED OF SIMPLE CURETTAGE • BUT RECURRENCE RATES > 50% • FOR DEFECTS AFTER RESECTION OR CURETTAGE,EITHER ALLOGRAFT OR BONE CEMENT USED AS FILLING AGENTS EXTENDED CURETTAGE –USE OF A POWER BURR TO ENLARGE THE CAVITY 1-2 CM IN ALL DIRECTIONS IS NOW CONSIDERED STANDARD
  • 18. Curettings
  • 19. Adjuvant Tx • PMMA, Liquid N2, Phenol, CO2 laser, Electrocautery – Local extension of margin – Kill residual foci and remaining tumour cell • ASSOCIATED WITH PATHOLOGIC FRACTURES,WOUND HEALING PROBLEMS
  • 20. BONE GRAFT ADVANTAGE: • RESTORING NORMAL BIOMECHANICS TO JOINT SURFACE • PREVENT FUTURE DEGENERATIVE JOINT DISEASES • RESTORING BONE STOCK
  • 21. • DISADVANTAGES JOINT MUST BE PROTECTED FOR AN EXTENDED PERIOD OF TIME TO PREVENT A PATHOLOGICAL FRACTURES TUMOUR RECURRENCE IS DIFFICULT TO DISTINGUISH FROM GRAFT RESORPTION
  • 22. • THE ABOVE DISADVANTAGES OVERCOME BY USE OF BONE CEMENT • PROVIDES IMMEDIATE STABILITY-HENCE QUICKER REHABILITATION • EASIER DETECTION OF RECURRENCE SEEN AS EXPANDING RADIOLUCENCY ADJ TO CEMENT • KILLS RESIDUAL TMR CELLS THRUPOLYMERISATION
  • 23. Enbloc Resection • Expendable bones – Prox fibula / Distal ulna • Eroded cortex and extended into soft tissue • Recurrence • Pathologic # • Joint involvement
  • 24. • INITIAL PROCEDURE OF CHOICE AND HERE 2CM OF NORMAL BONE IS ALSO EXCISED • DEFECTS ARE FILLED WITH CANCELLOUS BONE GRAFTS,FREEZE DRIED ALLOGRAFT OR PROSTHESIS
  • 25. • AROUND THE KNEE,A HEMICONDYLAR OSTEOARTICULAR ALLOGRAFT RECONSTUCTION OR A ROTATING HINGE ENDOPROSTHESIS MAY BE NECESSARY • FOR AGGRESSIVE LESION OF DISTAL RADIUS,PRIMARY RESECTION AND RECONSTRUCTION WITH A PROXIMAL FIBULAR AUTOGRAFT INDICATED
  • 26. • FOR LESIONS IN EXPENDABLE BONES(DISTAL ULNA OR PROXIMAL FIBULA)PRIMARY RESECTION WITHOUT RECONSTRUCTION INDICATED • FOR INOPERABLE LESIONS IN SPINE OR PELVIS,RADIATION MAY BE USED
  • 27. EXCISION AND RECONSTRUCTION • FOR GCT AFFECTING LOWER END OF FEMUROR UPPER END OF TIBIA • AFTER EN BLOCK EXCISION RECONSTRUCTION CAN BE DONE BY 1.TURN-O-PLASTY TECHNIQUE 2.ARTHRODESIS 3.ARTHROPLASTY
  • 28. RECURRENCE OF LESIONS • MOST LOCAL RECURRENCES AND PULMONARY METASTASES OCCUR WITHIN 3YRS OR EVEN UPTO 20 YRS • PATIENT SHOULD HAVE RADIOGRAPH OF THE PRIMARY TUMOUR SITE AND THE CHEST AT 3MONTHS INTERVAL FOR 1YR 6MONTHS INTERVAL FOR NEXT 2 YRS AND ANNUALLY THEREAFTER
  • 29. • TREATMENT IS SAME AS FOR PRIMARY LESIONS. • AFTER BIOPSY SHOWS THAT TUMOUR IS STILL BENIGN,REPEAT CURETTAGE OR RESECTION IS PERFORMED
  • 30. THANK YOU