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Giant cell tumor of bone
 

Giant cell tumor of bone

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    Giant cell tumor of bone Giant cell tumor of bone Presentation Transcript

    • Giant Cell Tumor of Bone
    • Definition • 10 bone neoplasm • First described Cooper 1818 • Generally benign but locally aggressive • Potential for : – Recurrence – Pulmonary metastasis – Frank malignancy
    • • Osteolytic tumour arising from epiphysis • Common in young adults • Though it is benign it is locally malignant
    • Epidemiology • 5-10% 10 bone tumors • 20% benign bone tumors • F : M 1.5 : 1 • 70-80% age 20-40yrs
    • 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
    • Presentation • Swelling with skin over the swelling stretched • Pain x wks. – mos(usually not a presenting feature • Mass • Pathologic # • Neuro deficit (spine / sacrum) • Incidental
    • • EGG SHELL CRACKING sensation may be present • Limitation of joint movement and pathological fractures –usually a late feature
    • 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
    • • 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
    • 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
    • CAMPANACCI’S GRADING • GRADE 1 :CYSTIC LESION • GRADE 2:CORTEX THIN BUT NOT PERFORATED • GRADE 3:CORTEX PERFORATED WITH EXTENSION INTO SOFT TISSUE
    • 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
    • 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
    • • GCT USUALLY ARE SOLITARY LESIONS;HOWEVER 1%-2% MAY BE SYNCHRONOUSLY OR METACHRONOUSLY MULTICENTRIC
    • PULMONARY METASTASIS • OVERALL MORTALITY:15% • PATIENT WITH RECURRENT LESIONS OR PRIMARY LESIONS THAT APPEAR AGGRESSIVE RADIOGRAPHICALLY ARE AT HIGHER RISK • MALIGNANT GCT <5% CASES
    • TREATMENT • Traditionally: – Intralesional curettage / resection & bone graft – Recurrence 35-42% • En Bloc resection – Recurrence ~10% – Multiple complications • Adjuvant
    • • 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
    • Curettings
    • 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
    • BONE GRAFT ADVANTAGE: • RESTORING NORMAL BIOMECHANICS TO JOINT SURFACE • PREVENT FUTURE DEGENERATIVE JOINT DISEASES • RESTORING BONE STOCK
    • • 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
    • • 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
    • Enbloc Resection • Expendable bones – Prox fibula / Distal ulna • Eroded cortex and extended into soft tissue • Recurrence • Pathologic # • Joint involvement
    • • 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
    • • 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
    • • 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
    • 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
    • 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
    • • TREATMENT IS SAME AS FOR PRIMARY LESIONS. • AFTER BIOPSY SHOWS THAT TUMOUR IS STILL BENIGN,REPEAT CURETTAGE OR RESECTION IS PERFORMED
    • THANK YOU