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Giant cell tumors of bone
- 1. Giant cell tumour of bone Dr Abdul G Suhail MBBS,D.Ortho,MS (Ortho) Assistant Professor in Orthopaedics
- 2. History First described in 1818 by Sir Astley Cooper Described in detail in 1940 by Jaffe and Litchenstein
- 3. GIANT CELL TUMOUR 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 )
- 4. AGE OF PRESENTATION 75-80% OF PATIENTS 20-50 YRS 10% 15-20 YRS 10% >60 yrs <1.7% BELOW 15 YRS
- 5. SEX Male:Female- 1:1.3 (Benign) -3:1 (Malignant)
- 6. SITE Epiphyseo-metaphyseal region of long bones GCT –Described from all bones EXCEPT middle ear bones Axial skeleton- 8% UL:LL-1:3
- 7. 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
- 8. GIANT CELL TUMOUR INTRA ARTICULAR EXTENSION- 10% TRANS OSSIOUS EXTENSION- 5% Common sites Wrist Ankle & foot Forearm Leg
- 9. MULTICENTRIC INVOLVEMENT Incidence-0.5-5% Simultaneous Peculiar features hand metaphyseal abundant spindle cells GOLTZ syndrome ` occular defects skeletal anomaly multifocal GCT
- 10. GIANT CELL TUMOUR SIGNS&SYMPTOMS 1. PAIN 2. SWELLING 3. JOINT RESTRICTION 4. MUSCLE WASTING 5. NEUROLOGICAL SIGNS 6. PATHOLOGICAL #
- 11. Pathology GROSS End of bone is expanded. Eccentric lesion at the epiphyseometaphyseal region. Thin periosteum. Fleshy dark brown, soft, friable mass. Cystic spaces seen.
- 12. PATHOLOGY GROSS-
- 13. Pathology Microscopy Vascularized network of round,oval or spindle shaped stromal cells and multinucleated giant cells with numerous centrally placed nuclei
- 15. Grading Jaffe,Lichenstein and Portis(1940) GRADE 1o Conventional GCT o Stroma is inconspicuous o Giant cells dominate the field o No atypism of stromal cells and are loosely arranged o Stromal cells are predominantly spindle shaped
- 16. Grading GRADE 2o Boderline tumours o Stromal cells are prominent and tightly packed o Giant cells are less in number compared to grade 1 and their nuclei may show atypism o Stromal cells show atypism o These tumours have a strong chance for recurrence and some may undergo malignant change
- 17. Grading GRADE 3o Sarcomatous type of stroma o Frequently metastase o Stromal cells abundant and closely compacted and present an irregular whorled arrangement o Nuclei are unusually large, irregular and atypical o Giant cells are few in number and atypical
- 18. Modified grading Sannerkin et al(1980) Malignant GCT- with frank sarcomatous changes and full metastatic potential Borderline GCT- without sarcomatous changes but with abnormal mitoses or vascular permeation or both Conventional GCT- without features of any of the above two types
- 19. No correlation exists between histological grading and clinical behavior of the tumour. Hence grading not widely accepted.
- 20. GIANT CELLS in Giant cell tumor Numerous nuclei(15-150) Centrally placed uniform size nuclei Tuberculosis Number of nuclei are less Peripherally placed nuclei
- 21. Enneking staging for GCT Stage 1-(10-15%) Patients asymptomatic Discovered incidentally May cause pathological fracture Has sclerotic rim on x-ray or CT Relatively inactive on bone scans Histologically benign
- 22. Enneking staging for GCT Stage 2-(70%) Symptomatic Often associated with path: fracture Has expanded cortex but no break through Is active on bone scans Histologically benign
- 23. Enneking staging for GCT Stage 3-(10-15%) Symptomatic Rapidly growing mass Has cortical perforation with accompanying soft tissue mass Activity on bone scan extends beyond the lesion in x ray Shows intense hypervascularity on angiogram Histologically benign
- 24. RADIOLOGY Type of Osteolysis Geographic destruction (I) Lodwick 1A 1B Moth-eaten (II) 1C Permeative(III)
- 26. RADIOLOGY TRABACULATION PURE LYTIC (60%) FINE TRABACULTION(40%)
- 27. RADIOLOGY AGGRESSIVENESS LARGE INTRAOSSEOUS CONTENT PURELY LYTIC CORTICAL BREACH SOFT TISSUE INVASION
- 28. INVESTIGATIONS SCINTI GRAPHY Less useful Inconsistent uptake “Doughnut sign” ANGIO GRAPHY Locate vessels type of feeders For embolisation C.T Intraossous content Intra articular spread Cortical breach Site of window M.R.I. Soft tissue spread Joint breach Locate N.V. bundle
- 29. GCT Ulna
- 30. GCT of Olecranon
- 31. GCT Radius
- 32. GCT distal femur
- 33. GCT lower end femur
- 34. GCT Fibula
- 35. GCT Calcaneum
- 36. GCT Ilium
- 37. GCT C7
- 38. DIFFERENTIAL DIAGNOSIS 1.ANEURYSMAL BONE CYST 2. GIANT CELL REPARATIVE GRANULOMA 3.CHONDROBLASTOMA 4.BROWN TUMOR 5.INTRA OSSEOUS GANGLION 6.BENIGN FIBROUS HISTEOCYTOMA
- 39. Bubbly lesions of bone Tumors Aneurismal bone cyst Unicameral bone cyst Non ossifying fibroma Osteoblastoma Hyper parathyroidism Chondromyxoid fibroma Histiocytosis X Myeloma Metastasis(kidney,thyroid) Infection Brodies abscess Coccidioidomycosis Ecchinococcus
- 41. TREATMENT STAGE STAGE1 TYPE LATENT Lodwick2 STAGE 2 ACTIVE Lodwick3 STAGE 3 AGGRES. GRADE SITE METASTASIS G0 T0 M0 G0 T0 M0 G0 T1,2 M0,1
- 42. SURGICAL TREATMENT Stage1& Stage2 --- Intralesional or Marginal Excision Stage3 --- Wide resection with Reconstruction Radiation, Embolaisation
- 43. Curettage & Bone Grafting INDICATION STAGE-1&2 ADEQUATE WINDOW MOTORISED BURR
- 44. Extended Curettage PHENOL BONE CEMENT LIQUID NITROGEN CAUTERY CO 2 LASER
- 45. EN.BLOC EXCISION Better result Dispensable bone ---- Patella, head of Fibula Sub articular lesion
- 51. Metastasis Benign pulmonary metastasis seen in 2% of patients unpredictable course Some spontaneously regress Others treated by pulmonary wedge resection 25% mortality Other sites Lymph nodes, mediastinum ,pelvis.
- 55. Lady 28yrs.
- 56. Recurrent GCT
- 57. Recurrent GCT
- 58. Recurrent GCT
- 59. Recurrent GCT
- 60. Recurrent GCT
- 61. Recurrent GCT