GCT OF DISTAL FEMUR WITH RADIOLOGICAL AND PATHOLOGICAL FINDINGS AND RECENT ADVANCES

1. • ORTHO PATHO MEET
PRESENTER-DR.AAYUSH ARORA
CHAIRPERSON-DR.SARANG SHETE

2. • NAME-XYZ
• AGE-26
• SEX-F
• OCCUPATION-HOUSEWIFE

3. • CHIEF COMPLAINTS-
• CAME WITH COMPLAINTS OF PAIN AND SWELLING IN
THE LEFT KNEE SINCE 3 MONTHS

4. • HISTORY OF PRESENT COMPLAINTS-
• ALLEGED H/O FALL 3 MONTHS BACK.PATIENT SUSTAINED
INJURY TO THE LEFT KNEE.COMPLAINS OF PAIN IN THE
LEFT KNEE AND DIFFICULTY IN WALKING.SWELLING IS
ASSOCIATED WITH PAIN,WHICH IS INCIDIOUS IN ONSET
AND HAS GRADUALLY PROGRESSING IN NATURE.

5. • PAST HISTORY-
NO H/O DM,HTN,ASTHMA,TB,EPILEPSY
• FAMILY HISTORY-NOT SIGNIFICANT

6. • GENERAL PHYSICAL EXAMINATION-
• A YOUNG FEMALE PATIENT,MODERATELY BUILT AND NOURISHED,CONCIOUS
AND ORIENTED TO TIME,PLACE AND PERSON
• VITALS-
BP-120/80MMHG
PR-80B/M
TEMPERATURE-AFEBRILE
NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,EDEMA,LYMPHADENOPATHY

7. • INSPECTION-
SINGLE SWELLING PRESENT OVER THE DISTAL 1/3RD OF LEFT
FEMUR
IRREGULAR IN SHAPE
SKIN OVER THE SWELLING APPEARS TO BE STRECHED
NO SINUS/SCAR/REDNESS
NO ANY OBVIOUS DEFORMITY

8. • PALPATION-
ALL THE INSPECTORY FINDINGS CONFIRMED BY PALPATION
TENDERNESS PRESENT
SIZE-4X4 CM
SURFACE-IRREGULAR
NO LOCAL RISE OF TEMPERATURE
NO MOBILE IN RELATION TO THE UNDERLYING STRUCTURES
SKIN OVER THE SWELLING IS PINCHABLE
MOVEMENT OVER THE KNEE JOINT-PAINFULL
NO DISTAL NEUROVASCULAR DEFICIT

9. • INVESTIGATIONS-
HB-9.9GMS%
WBC-12.8
PLATELETS-445
PT/INR-1.02
RBS-89MG/DL
UREA-26
CREATININE-0.64
BLOOD GROUP-B POSITIVE
VIRAL MARKERS NEGATIVE

10. XRAY OF KNEE JOINT

11. MRI OF KNEE JOINT-

14. Giant cell tumour
• Giant Cell tumour Of bone is one of the
most common bone tumour
encountered by an orthopaedic surgeon
and has a well known propensity for
local recurrence after surgical
treatment(1).

15. • ETIOLOGY-
Although the incidence in Caucasians population is low,constituting 5%
of all skeletal tumour and 20% of bening tumours(1).
• AGE-
Gct mainly occurs in skeletal mature Individual with its peak incidence in
third decade of life.Less than 2 % are found in individual with open
epiphysis and only about 10% of cases occur in patient older than
65%.Gct of the small bones of hand and foot seems to occur in younger
age group(1)
. Although these tumors typically are benign,pulmonary metastases occur
in approximately 3% of patients, recurrence rates of 5% to 15%(2).
• M:F-1:1.5

16. • SITE-
It typically involves the epiphysiometaphyseal Junction of long bones(1).
Distal femur and proximal tibia are the most comman sites to be involved(1).
• CLINICAL PRESENTATION-
Giant cell tumour are generally symptomatic in majority of patients.The
presenting complain is pain of variable severity that may be associated with a
mass present from few weeks to several months(1).
Trauma or pathological fracture may direct attention to site of involvement
and lead to discovery of tumour.5-10% may present as pathological
fractures.The knee is the commonest site followed by distal radius.The other less
common sites are distal tibia,sacrum,proximal humerus(1).

17. • RADIOGRAPHIC FINDINGS-
• On Plain radiographs Gct demonstrate a lytic lesion
centered in the epiphysis but involving the metaphysis
and extending to subchondral bone(1).
• The tumour usually bulges beyond the confines of
cortex,which had undergone varying degree of
Resorption(1).
• Apart from a thin subperiosteal new bone outlining the
outer surface of tumour,No periosteal reaction is present
unless there is a pathological fracture present(1).

18. • The margins of the lesion bodering the adjacent
cancellous bone are generally well defined or sometimes
ill defined and seldom a thin shell of reactive bone may be
present(1).
• Multiple septa transverese the interior and produces a
characteristic loculated soap bubble appearance(1).
• On mri, GCT shows low intensity on T1 and high intensity
on T2-weighted images.Therefore intramedullary tumour
is best seen in T1W,and its extraosseous part is best seen
in T2 W images(1).

19. CLASSIFICATION OF GCT-
1)Campanacci attempted to grade the lesion based on radiological appearance
using the designation Grade 1,Grade 2 ,Grade 3
GRADE 1-The tumour had a well-marginated border of a thin rim of mature
bone and the cortex was intact or slightly thinned but not deformed.
GRADE 2-The tumour had relatively well defined margins but no radio-opaque
rim;the combined cortex and the rim of reactive bone was rather thin and
moderately eaxpanded but still present.
GRADE 3-Tumour with fuzzy borders,suggesting a rapid and possibly
permeative growth;the tumour bulged into the soft tissue,but the soft-tissue
mass did not follow the contour of the bone and was not limited by an apparent
shell of reactive bone(1).

21. ENNEKING : STAGING OF GCT :
• STAGE 1 : LATENT (10-15%) ,
• ASYMPTOMATIC ,
• DISCOVERED INCIDENTALLY ,
• MAY CAUSE PATHOLOGICAL # INTRACAPSULAR,
• WELL DEFINED MARGINS ,
• SCLEROTIC RIM ON XRAY/CT
• STAGE 2 : ACTIVE( 70-75%) ,
• SYMPTOMATIC,
• OFTEN ASSOC. PATHOLOGICAL # INTRACAPSULAR,
• HAS EXPANDED/ THINNED OUT CORTEX ,
• ACTIVE ON BONE SCANS
• STAGE 3 : AGGRESSIVE(10-15%) ,
• SYMPTOMATIC,
• RAPIDLY GROWING MASS ,
• EXTRA CAPSULAR, CORTICAL BREAKOUTWITH SOFT TISSUE EXTENSION ,
• ACTIVTY ON BONE SCAN EXTENDS BEYOND LESION ON XRAY

22. • PATHOLOGY-
• GROSS APPEARANCE-The tumor is epiphyseal in location and
eccentrically placed.The bone appears expanded and the tumor
may be surrounded by a thin shell of reactive bone.The tumor is
reddish brown to yellow in color.Soft-tissue extension of the tumor
may be present(1).
• MICROSCOPIC APPEARANCE-
• The tumor is composed of round to polygonal mononuclear cells
and multinucleate osteoclast like giant cells.
• The giant cells are uniformly scattered throughout the tumor(1).

24. •The nuclei of the mononuclear cells
are identical to the nuclei of the giant
cells,a feature that helps to distinguish
giant cell tumors from other tumors
that may contain many giant cells.

25. • DIFFERENTIAL DIAGNOSIS-(1)
1)Brown tumor of hyperparathyroid-other skeletal
manifestations like
• Osteopenia,
• sub-periosteal resorption,
• resorptive changes at distal phalanges
• loss of lamina Dura of teeth
• Elevated ALP & serum calcium levels & decreased
phosphorus levels.

26. 2)Aneurysmal bone cyst-
• 75% located in metaphysis
• double density fluid-fluid level on CT/MRI
3)chondroblastoma-
• adolescent with open physis
• polygonal stromal cells
• Rim of sclerotic bone
• multiple punctuate calcifications
4)osteosarcoma

27. • TREATMENT-
1)In view of benign nature,there is generalised
consensus that function preserving
surgery(Intralesional currettage) Is preferable to
more morbid resections(1).
2)The aim is to maximize functional preservation
while minimizing the chances of recurrence(1).
3)Intralesional currettage with appropriate
reconstruction is treatment of choice(1).

28. 4)It is important to create a cortical window that is at least
as large as the lesion to prevent leaving residual tumor cells
“around the corner” adjacent to the near-side cortex. Also,
use of a power burr to enlarge the cavity 1 to 2 cm in all
directions is now considered standard(2).
5)Care should be taken,however, to avoid perforation
through the subchondral bone into the joint(2).
6)The use of adjuvants, such as liquid nitrogen,phenol, bone
cement, electrocautery, or an argon beam
coagulator,theoretically helps to kill any remaining tumor
cells(2).

29. 7)To fill the defect after curettage, the surgeon has several
options, including autograft bone, allograft bone, an
artificial bone graft substitute, or methyl methacrylate bone
cement(2).
8)If an autograft is to be harvested from another site,
separate gloves and instruments should be used because
crosscontamination could lead to transplantation of tumor
cells to the harvest site(2).

30. • A bone graft (or artificial substitute) has the theoretical advantage of restoring
normal biomechanics to the joint surface to prevent future degenerative joint
disease(2).
• There are two main disadvantages,however, to using bone grafts(2):
(1) The joint must be protected for an extended time to prevent a pathologic
fracture
(2) Tumor recurrence often is difficult or impossible to distinguish from graft
resorption
These disadvantages may be overcome with the use of bone cement as a filling
agent. Bone cement provides immediate stability, which aids in quicker
rehabilitation; allows easier detection of recurrence, which is evident as an
expanding radiolucency adjacent to the cement mantle; and may kill residual
tumor cells through the heat of polymerization(2).

31. • Screws placed in a crossed or divergent pattern are used to
augment the cement mantle(2).
• The use of bisphosphonates in treating giant cell tumor of bone as
these drugs inhibit osteoclastic activity and promote osteoclast
apoptosis(2).
• Oral alendronate was given continuously at a dose of 70 mg/week,
to patients of distal femur GCT for a period of 24 months.
• Another new treatment under examination is the systemic
administration of denosumab. Denosumab is a fully human
monoclonal antibody that inhibits normal and tumor associated
bone lysis by limiting osteoclastic maturation (i.e., prevents
activation of receptor activator of nuclear factor-kB [RANK]).

33. SANDWICH TECHNIQUE-
• When tumor is <1cm from articular surface,the incidence
of degenerative changes in cartilage after the use of
cement alone is 2.5 times greater than when tumor is
>1cm away.
• In such conditions, multilayer reconstruction technique is
recommended
• Interposing bone graft between the cartilage & cement
reduces heat damage and the resultant degenerative
changes.

34. • A layer of gel foam is layered over cement to reduce heat damage
to graft.

35. RECURRENT GCT OF DISTAL FEMUR(3)
• A 37-year-old male presented with an aggressive
recurrent giant cell tumor of the distal femur. He was
diagnosed with a GCT of the left distal femur 2 years ago
for which he was treated with an intralesional curettage
and Poly methylmetacrylate implantation. A resection
arthrodesis using a bilateral non-vascularised
intramedullary fibular graft and a custom made
intramedullary nail was performed. The follow-up
radiographs showed union at graft-host junction and
hypertrophy of the grafted fibula at 2 years post surgery.

36. MRI OF LEFT KNEE REVEALS AN AGGRESSIVE LESION
CHARACTERIZED BY EXTENSIVE LOCAL BONY DESTRUCTION
(THIN ARROW), BREACH OF THE CORTEX AND A SOFT-TISSUE
LESION (THICK ARROW).

37. PRE-OPERATIVE PLANNING. LENGTH OF FIBULAR GRAFT (X)
WAS CALCULATED TAKING INTO ACCOUNT THE POST
RESECTION GAP (A), THE DESIRED INTRAMEDULLARY
LENGTH IN THE FEMUR (B) AND THE TIBIA (C).

38. FOLLOW-UP RADIOGRAPHS AT 2 WEEKS (A). AT 6 MONTHS
(B) AND 1-YEAR POST SURGERY (C), SIGNS OF UNION AT THE
GRAFT-HOST INTERFACE. AT 2 YEARS POST SURGERY (D),
THERE IS GOOD CONSOLIDATION AT THE GRAFT-HOST
JUNCTION. HYPERTROPHY OF THE FIBULAR GRAFT IS ALSO
NOTED (ARROW).

39. • The follow-up radiographs showed union
at graft-host junction and hypertrophy of
the grafted fibula at 2 years post surgery.

40. • PATIENT FOLLOW UP-
1)Patients diagnosed with giant cell tumors
require longterm follow-up(2).
2)At minimum, patients should have
radiographs of the primary tumor site and the
chest at 3- to 4-month intervals for 2 years, at 6-
month intervals for the following year, and
annually thereafter(2).

41. INTRAOPERATIVE PICTURES-

42. C-ARM IMAGES-

43. POST OPERATIVE X RAYS-

44. OPEN BIOPSY-

45. REFERENCE-
1)Jain Ak.Tureks orthopaedics principles and their
applications.7thedition 2016:638-640p
2)Robert k.,Heck jr.Campbell’s operative orthopaedics.13th edition
2017;923-927p
3)Sanesh T,sachin K. Recurrent GCT of Distal Femur Treated with
Resection Arthrodesis with Non-Vascularized Bilateral Fibular Graft
and A Custom-Made Interlock Nail. 2016 Jul-Aug;6(3):16-18. doi:
10.13107/jocr.2250-0685.480