Giant Cell Tumour

1. BONE TUMOUR - GCT

2. INTRODUCTIO
N
• Bony lesions
• Arises from bone itself (primary)
• Arrived from distant sites
(secondary)
• Benign
• Malignant

3. TUMOURS
Basic definitions
Tumour:
It is a growth of diseased cells in a person or animal
which can become a lump and cause illness . They can
be malignant or benign.
Benign:
A benign tumour is a mass of cells that lacks the ability to
invade nearby structures, metastasize and are relatively
harmless. However they can be quite large sometimes.
Examples include moles and uterine fibroids.
Malignant:
A tumour which invades nearby structures , is capable of
producing metastasis, may recur after attempted removal,
and is likely to cause death unless adequately treated.

4. TUMOUR
S
Cancer:
A malignant growth or tumour resulting from an uncontrolled division of cells
Carcinoma:
A cancer of epithelial cell origin. As a general rule they metastasize through lymphatic route.
Sarcoma:
A cancer of connective tissue or mesenchymal origin. Mode of spread is mostly through
haematogenous route.
Teratoma:
A tumour consisting of several different types of tissue such as muscle, bone and skin(
arising from more than one germ layers). They typically occur in testicles and ovaries.

5. GIANT CELL TUMOUR

6. HISTORY
First described in
1818 by Sir Astley
Cooper
Described in detail in
1940 by Jaffe and
Litchenstein

7. GIANT CELLTUMOUR
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 )

8. EPIDEMIOLOGY
USA- account for 20% of all skeletal neoplasms.
India -incidence - 30% of all bone tumors.
- occurs in skeletally mature individuals
- 3rd decade of life

9. AGE OF PRESENTATION
75-80% OF PATIENTS 20-50
YRS
10% 15-20 YRS
10% >60 yrs
<1.7% BELOW 15 YRS
Male:Female-
1:1.3 (Benign)
3:1 (Malignant)

10. SITE
Epiphyseo-metaphyseal region
of long bones
GCT –Described in all bones
EXCEPT middle ear bones
Axial skeleton- 8%
Upper Limb : Lower Limb-1:3

11. 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

12. SIGNS & SYMPTOMS
1. PAIN
2. SWELLING
3. JOINT RESTRICTION
4. MUSCLE WASTING
5. NEUROLOGICAL SIGNS
6. PATHOLOGICAL #

13. PATHOLOGY
GROSS-
End of bone is expanded.
Eccentric lesion at the epiphyseo- metaphyseal region.
Thin periosteum.
Fleshy dark brown, soft, friable mass.
Cystic spaces seen.

14. PATHOLOGY
Microscopy-
• Richly vascular tissue
• Plump spindle cells
• Numerous giant cells
with multiple
nuclei
• Neither bone nor
cartilage forming

15. STAGING: Campanacci
STAGE I:
- Completely intra-osseous;
- no local aggressive activity
STAGE II:
- Demonstrates cortical erosion without bone destruction;
- imaging studies demonstrate alteration of the cortical bone structure;
STAGE III:
- Cortical destruction with a soft tissue component;
- imaging studies demonstrate a lytic lesion surrounding medullary and
cortical bone;
- there may be indication of tumor penetration through the cortex into the
soft tissues

16. RADIOGRAPHIC
FEATURES
1. Located in epiphyses
mostly
2. Rarely at metaphysis
3. Abuts subchondral bone.
(articular surface intact)
4. Purely lytic
5. Eccentric

17. PLAIN FILM ANDCT
• Zone of transition
• No surrounding sclerosis
• Expansile
• Periosteal reaction
• Soft tissue mass
• No matrix calcification/minerali
zation

18. MRI
T1
• Low to
intermediate solid
component
• Low signal periphery
T2
• Intermediate to
high signal
• High signal in
adjacent bone
marrow represent
inflammatory edema
Intramedullary tumor is best seen on T1W, while its
extraosseous portion is best appreciated on T2W
images.

20. BIOPSY
CLOSED FINE NEEDLE
TRUECUT
TREPHINE
OPEN INCISIONAL
EXCISION
Biopsy always provides definite diagnosis. And should be
perfermed after consultation with surgeon so that biopsy tract
can be included in surgical resection.

21. TREATMENT AND PROGNOSIS
• Curettage and Filling . Options include Allograft bone
, auto graft bone . Meth acrylate bone cement.
• Chemotherapy (limited success)
• Radiotherapy ( for symptomatic inoperable cases)
• Monoclonal antibodies ( Denosumab)
• Bisphoshonates ( zolendronic acid)
• Local recurrence is still a risk despite treatment

22. TREATMENT
Rx is - local control without sacrificing joint function.
Traditionally - intralesional curettage with autograft
reconstruction by packing cavity of excised tumor with
morcellized iliac cortico-cancellous bone.
Regardless of how thoroughly performed, intralesional excision
leaves microscopic disease in bone & hence recurrence rate as
high as 60%
In order to counter the above problems, a great deal of effort
has been expended on attempting to “extend the curettage or
intralesional excision” by chemical or physical means

23. Use of a high power burr to break the bony ridges and extend the
curettage is recommended.
Use of phenol & hydrogen peroxide???
Cementation using methylmethacrylate?
It is postulated that the exothermic
reaction of methylmethacrylate generates
local hyperthermia which induces necrosis
of any remaining neoplastic tissue

24. If Pt is Rx by cementation, especially in cases of minimal
residual subchondral bone it is believed that it may lead
to late articular
degeneration.
To prevent this complication some authors recommend
the use of bone graft & cement as a filler
material.
This is indicated in subarticular lesions where the
amount of residual subchondral bone after an
extended curettage is less than 1 cm.
The cavity is reconstructed in layers.
A mixture of morcellized auto and allograft (about 1
cm thick) is packed adjacent to subarticular surface.
A layer of gelfoam is layered over this and the remaining
cavity is packed with cement

25. RECONSTRUCTION AFTER MARGINAL/WIDE EXCISION
If there is significant dysfunction of joint surface the
options include use of
- megaprosthesis for joint replacement
- biologic reconstructions including autograft arthrodesis
with fixation
- Ilizarow method of bone regeneration or the use of osteo-
articular allografts.

27. ROLE OF CHEMOTHERAPY &
RADIOTHERAPY
At present ,there are no recognised effective
chemotherapeutic agents available for GCT.
Literature documents a close association of secondary
sarcomatous transformation in the region of GCT treated
by radiation therapy.
In the rare unresectable primary or secondary lesions with a
clear cut diagnosis, high voltage irradiation therapy has a
place in their management

28. ROLE OF CHEMOTHERAPY &
RADIOTHERAPY
In lesions involving axial skeleton, with the
exception of the sacrum, it is felt that excision
with stabilization of spine as dictated by
resection & biologic reconstruction of anterior
column, followed by reduced levels of irradiation
based on assumption that you are dealing with
microscopic residual tumor only, would offer the
patient the best chance of long term local
control.

29. THE ROLE OF EMBOLISATION
AND BIPHOSPHONATES
Unresectable giant cell tumors (e.g. certain sacral and
pelvic tumors) can be managed with transcatheter
embolisation of their blood supply.
Since flow reconstitution invariably occurs,
embolisation is performed at monthly intervals until
significant pain palliation is achieved.
Subsequent embolisations are performed when there
is symptomatic or radiographic relapse of the tumor.

30. Tumors in these areas amenable to surgical
resection also benefit by preoperative
embolisation in an attempt to reduce the
amount of intraoperative blood loss.
Recently researchers have demonstrated the
efficacy of bisphosphonates as an effective
adjunctive modality in the management of large
unresectable lesions.

31. METASTASIS IN GIANT CELL TUMORS
Incidence - 1% to 6%.
Majority of metastatic lesions are to lung.
Solitary metastasis to regional lymph nodes, mediastinum
& pelvis have been reported, as has involvement of the
scalp, bone & para-aortic nodes.
Metastatic lesions should be resected if possible

32. RECONSTRUCTION WITH
Autograft

33. RECONSTRUCTION WITH
Allograft

34. RECONSTRUCTION WITH
Arthrodesis

35. RECONSTRUCTION WITH
PROSTHESIS

36. FOLLOW
UP
Most recurrences and pulmonary metastasis occur
within 3 years but can occur later.
Patient should have radiographs of tumour site at 3
-4 monthly intervals for 2 years and 6 monthly for
the following year and yearly after that.
Any suspicious lesion should be further investigated
with ct scan.

37. THANK YOU