Orthopaedics

1. GIANT CELL TUMOUR AND
OSTEOSARCOMA
GIANT CELL TUMOUR
AND
OSTEOSARCOMA

2. GIANT CELL TUMOUR
• Common bone tumour

3. PATHOLOGY
• Cell of origin is uncertain.
• Microscopically,
– Undifferentiated spindle cells
interspersed with multinucleate giant
cells.
• Tumour stroma is highly vascular.
• Giant cells mistaken as osteoclasts-
OSTEOCLASTOMA.

4. CLINICAL FEATURES
• Age Group
– 20-40 years(after epiphyseal fusion).
• Bones affected
– Around knee joint.
– Lower end of radius.
• Tumour at epiphysis, may reach upto
joint surface.

5. • Common presenting complaints:
– Swelling and vague pain
– Pathological fracture

7. EXAMINATION
• Eccentrically located bony swelling
at the end of the bone.
• Smooth surface.
• May be tender on firm palpation.
• ‘Egg-shell crackling’ may be
elicited.
• Limb deformity(pathological
fracture).

8. DIAGNOSIS
• Solitary lytic lesion of bone.

9. Features Giant cell
tumour
Simple bone cyst Aneurysmal
bone cyst
Fiibrous
dysplasia
Age 20-40 yrs <20 yrs 10-40 yrs 20-30 yrs
Common bones
Lower femur
Upper tibia
Lower radius
Upper humerus
Upper femur
Tibia
Humerus
Neck of femur
Tibia
Location Epiphysis Metaphysis Metaphysis Metaphysis
X-ray
Soap bubble
appearance,
Eccentrically
placed
Maximum width
less than width
of the growth
plate
Distending
lesion,
‘ballooning’ the
bone
Multi-loculated
Ground-glass
appearance
Trabeculations++
Treatment Excision Curettage and
bone graft
Curettage and
bone graft
Curettage and
bone graft

10. RADIOLOGICAL
FEATURES
• Solitary- loculated or lytic.
• Eccentric location, often
subchondral.
• Expansion of the overlying
cortex(expansile lesion)

11. • ‘Soap-bubble appearance’-
– Tumour homogenously lytic with
trabeculae of the remnants of bone
traversing it – loculated appearance.
• No calcification within the tumour

12. • None or minimal reactive sclerosis
• Cortex thinned out or perforated at
places.
• Usually does not enter the adjacent
joint.

16. TREATMENT
• Best treatment- EXCISION
• If not possible(spine)- Radiotherapy
• Commonly used treatment methods:
a) Excision
b) Excision with reconstruction
c) Curettage with or without
supplementary procedures.
d) Amputation
e) Radiotherapy

17. Excision
• When tumour affects a bone whose
removal does not hamper with
functions.
• Eg: Fibula
Lower end of ulna…

18. Excision with reconstruction
• When excision results in significant
functional impairment.
• Defect created is made up, usually
partially,
by some reconstructive procedure.

19. • Eg: tumours affecting lower end of
femur, affected part is excised, and
defect created made up by:
Arthrodesis by the Turn-o-Plasty
procedure
• Tibia split into two.
• One half turned upside down
• Fixed with the stump of the femur.

21. Arthrodesis by bridging the gap
By double fibulae
Arthroplasty:
Excised
Autograft(patella to substitute
articular defect)
Allograft(Using a preserved bone)
Artificial joint(prosthesis)

23. Curettage With Or Without
Supplementary Procedures
• Supplementary procedures to
reduce recurrence.
• Cryotherapy and thermal burning.
• Thermal effect of bone cement.

24. Amputation
• Aggressive tumours
• Following recurrence

25. Radiotherapy
• GCT affecting vertebrae.

26. Site Treatment of choice
Lower end of femur Excision with Turn-o-Plasty
Upper end of tibia Excision with Turn-o-Plasty
Lower end of radius Excision with fibular grafting
Lower end of ulna Excision
Upper end of fibula Excision

27. PROGNOSIS
• Recurrence – a serious problem

28. OSTEOSARCOMA
(OSTEOGENIC SARCOMA)
Highly malignant primary
bone tumour.

29. PATHOLOGY
• Malignant tumor of mesenchymal
cells.
• Osteoid or bone formation by
tumor cells

30. CLASSIFICATION
• Based on clinical setting:
a) Primary osteosarcoma
 15-25 years
 No known pre-malignant
conditions
b) Secondary osteosarcoma
 Older age(>45yrs)
 Paget’s disease, fibrous dysplasia…

31. • Based on dominant histo-
morphology:
a) Osteoblastic
b) Chondroid
c) Fibroblastic
d) Telengiectatic or osteolytic type

32. FEATURES
• Age of onset:
– 15-25yrs
• Sites of origin:
– Any bone
– Lower end of femur
– Upper end of tibia
– Upper end of humerus

33. • Gross appearance
Osteoblastic tumour: Greyish white,
hard and gritty feeling when cut.
Chondroid type: Opalescent and
bluish grey.
Fibroblastic: Typical fish flesh
sarcomatous appearance.
Telengiectatic: Tumour necrosis and
blood filled spaces

34. • Histologically,
Basically anaplastic mesenchymal
parenchyma with tumour cells
surrounded by osteoid.

35. CLINICAL FEATURES
• Pain- constant and boring
• Swelling
• Pathological fracture

36. EXAMINATION
• Swelling in the region of
metaphysis.
• Skin over the swelling: Shiny with
prominent veins.
• Swelling warm and tender.
• Margins: Not well defined.
• Mechanical block of the swelling.
• Compression
• Regional lymph node enlargement,
usually reactive

37. INVESTIGATIONS
RADIOLOGICAL EXAMINATION:
• Area of irregular destruction in the
metaphysis. Cortex overlying lesion eroded.
– New bone formation in the matrix.
• Irregular periosteal reaction
• Codman’s triangle:
– Triangular area of subperiosteal new bone
– At tumour-host junction at tumour end.

38. • Sun-ray appearance:
– Tumour grows to overlying soft
tissues.
– New bone laid down along the
blood vessels within the tumour
growing centrifugally.

41. SERUM ALKALINE PHOSPHATASE
(SAP):
– Generally elevated
– No diagnostic significance.
– Useful for follow-up
– Rise after tumor removal- Indicator of
recurrence or metastasis.

42. BIOPSY
–Open biopsy

43. TREATMENT
• Aims:
– Confirm diagnosis
– Evaluate spread
– Adequate treatment

44. • Confirmation of diagnosis:
– Histologically, Tumour new bone
formation- pathognomonic of
osteosarcoma.
– Or Clinical and radiological picture
• Evaluation of spread of tumour:
– Lung-Earliest site.
– Chest X-ray.
– CT scan

45. • Extent of involvement need to be
known to:
– Plan amputation surgery
– Plan limb saving operation

46. • Treatment of the tumour:
– Local control:
• Surgical ablation.
• Amputation remains the mainstay.
• ROLE OF RADIOTHERAPY:
– Surgically inaccessible sites.

47. – Control of distant macro or
micro-metastasis
• ROLE OF CHEMOTHERAPY:
– Drug used: high dose Methotrexate,
Endoxan…
• ROLE OF IMMUNOTHERAPY

49. FOLLOW UP
• Patient is checked up every 6-8
weeks.
• Recurrence needs to be diagnosed
early and treated.

50. PROGNOSIS
• Without treatment: death within 2
years.
• 5 year survival with surgery
alone(20%).
• Primarily lytic type(telengiectatic)
osteosarcoma-worst prognosis.