1. Giant Cell Tumor of Bone
Dr Milind Merchant

2. Overview
– Definition
– Epidemiology
– location
– Presentation
– Imaging
– DDx
– Tx

3. Definition
• 10 bone neoplasm
• Generally benign
• First described Cooper 1818
• Nelton microscopic description 1923
• Potential for :
– Recurrence
– Pulmonary metastasis
– Frank malignancy

4. Epidemiology
• 5% of all bone tumors
• 30 % of all bone tumours in
India
• 21% benign bone tumors
• F : M 1.5 : 1
• 70-80% age 20-40
• Epiphyseometaphyseal
• Rare skeletally immature
• Monostotic

5. Incidence
• Ends of long bones
• >50% about knee
• Distal femur most common
• 2nd MC is proximal tibia
• 3rd MC is distal end radius
• High local recurrence rate
• Malignant GCT <1%
• Rare polyostotic form <1%

6. Gross
• Involves epiphysiometaphyseal region
of long bones
• Tumour extends upto adjuvant articular
cartilage which remains intact and
rarely when neglected may involve
diaphysis.
• Usually eccentric to long axis of bone
• The overlying cortex undergoes
resorption and the contour of bone is
expanded by the tumour which is
covered by thin shell of subperiosteal
new bone.
• Tumour is grey to reddish brown in
colour with soft vascular friable tissue.
• Firm grey yellow areas of fibrosis and
collagenisation and osteoid formation.

7. Histology
• Fibrohistiocytic origin
• Osteoclast like multinucleated giant cells (40 to 60 nuclei)
• Mononuclear stroma with single large nucleus, Round / ovoid
/ spindle shape with Indistinct cell membrane
• Mitoses and intravascular extension of tumour may not
indicate malignancy.

8. Presentation
• 3rd to 4th decade with 1.5
times female
preponderance
• Pain x wks. – mths
• Mass x wks. – mths
• Pathologic # at presentation
in 5 to 10%
• Neuro deficit (spine /
sacrum)
• Less common sites are
sacrum,distal tibia,prox
humerus,prox femur,prox
fibula
• Small bones of hands
feet,ribs and spine are rare

9. • Lytic lesion Radiology
• Epiphysiometaphyseal location
• Eccentric or central
• Bulges beyond confines of cortex which
has undergone varying degrees of
resorption.
• Occ. Cortical breakthrough
• Thin shell of subperiosteal new bone
• No periosteal rxns unless pathological #
• Margins generally well defined or
sometimes ill defined.
• No sclerotic margin
• Peripheral bony ridges give appearance of
trabaculations
• Soap bubble appearance on x ray

10. Other modalities
CT
– Integrity cortical rim
– Interosseous ext
– Subchondral relation
MRI
• Low intensity on T1 and high on T2
• Intramedulary tumour best seen on T1W
and extraosseous portion best seen on
T2W
• Best to see extraosseous extent and joint
involvment
Bone Scan
– Suspect multicentric loci

11. DDx
– Chondroblastoma
– Brown tumor
– ABC
– Chondromyxoid fibroma (rare)
– Fibrogenic/Telangiectatic Osteosarcoma
– Multiple fibrous histiocytoma

12. Enneking Staging
Stage 1
(Latent)
Stage 2
(Active)
Stage 3(local
aggeressive)
Pt % 10-15% ~70% 10-15%
Symptoms asymp pain pain
Radiograp
h
sclerotic
rim
expanded
cortex
cortical
perforation
Histology benign benign benign

13. Campanacci grading
• Based on radiological appearance.
• Grade I: well marginated border of thin rim of
mature bone, cortex intact thinned but not
deformed.
• Grade II: weel defined margins,no radioopaque
rim,combined cortex and rim of reactive bone is thin
and moderately expanded but still present.
• Grade III: Fuzzy borders sugg/o rapid growth, bulges
into soft tissues

14. Biopsy
• Necessary for Dx
• Histologic grade not
helpful
• R/O 10 malignant GCT
• Occ assoc.
– ABC
– Pagets

15. Tx
• Local control w/o sacrificing joint function
• Traditionally:
– Intralesional curettage / resection & bone graft
– Recurrence 60%
• En Bloc resection
– Recurrence ~10%
– Multiple complications
• Adjuvant

16. Curretage
Adequate curretage?
• Adequate exposure of lesion
• Wide cortical window to access
tumour to avoid having to
curette under overhanging
shelves or ridges of bones
(windowing)
• Head lamp or dental mirror use
to see small pockets
• high speed burr to break bony
ridges
• Pulatile jet lavage to expose raw
cancellous bone and wash out
tumour cells.
Phenol in 5 to 80 pc concentration
to decrease recurrence rates
H2O2 may also be used as an
adjuvant

17. Curettings

18. Adjuvant Tx
• PMMA (polymethylmethacrylate), Liquid N2,
Phenol, CO2 laser, Electrocautery
– Local extension of margin
– Kill residual foci
• Radiation – for in-operable lesions of spine or
pelvis
~10% risk of sarcomatous degeneration

19. Cementation using
methylmethacrylate
• Fill tumor cavity
• Exothermic reaction or
chemical cytotoxic effect
associated with
polymerization
• Heat kill the tumor cells
• Cytotoxic agents like
adriamycin and
methotrexate added in
cement
• 8-26% recurrence
• Easy recurrence detection

20. Advantages of bone graft
• Undergoes remodelling along stress lines
• Once incorpoated,reconstruction is
permanent
Drawbacks of bone graft
• Autograft qty is limited
• Donor site morbidity
• Allograft is expensive, requires bone bank
• Recurrance relatively difficult to spot

21. Advantages of cementing
• PMMA monomer is cytotoxic
• Thermal effect- hyperthermia extend the boundary
of tumour kill
• Xray detection of recurrance is easier
• Immediate structural support and rapid weight
bearing ambulation
Drawbacks of cementing
• Relatively weak in shear forces so when used in head
and neck of femur,high chances of # thro cement
• Chances of long term degen of articular cartilage in
subchondral lesions an wt bearing areas.

22. To decrease the chances of late articular degeneration in
subarticular lesions where residual suchondral bone after
extended curretage is <1cm
• Multilayer reconstruction technique used
• Mixture of morsellised autograft packed adjacent to
subarticular surface.
• Layer of gelfoam layered over this.
• Remaining cavity is packed with cement.
• If recurrance occurs danger of damage to articular cartilage
during cement removal is reduced.

23. Recurrence

24. Cryotherapy
• 3 freeze thaw cycles
• Irrigate cavity with liq
nitrogen
• Circumferential necrosis
• Complications
– Soft tissue injury
– Late fractures
– Delayed wound healing

25. Excision
• For expendable bones like lower end ulna and
upper and fibula

26. Marginal / wide local excision
Reconstruction done using
• Megaprosthetic joint replacement-prone to
loosening,wear or breakage and revisions
• Biologic reconstructions:
1. Autograft arthrodesis with internal fixation
(wrist,knee, shoulder)
2. Live microvascular fibula reconstructions
3. Illizarov method
4. Osteo articular allografts

27. Reconstruction

28. Local recurrence in GCT
• Characterised clinically by pain and radiologically by lysis of
bone graft or adjacent cancellous bone.
• Following curretage and cementation an osteolytic zone
caused by thermal injury of 2mm surrounds the cement. This
is bordered by thin outer sclerotic rim for 6 mths.lysis or failed
development of this sclerotic rim may suggest recurrence.
• Soft itssue recurrence seen on xray coz of peripheral
calcification.
• Total serum acid phosphatase used as a serum marker for
monitoring response to t/t
• Majority of recurrences occur in 1st 2 yrs.
• High recurrence in grade 3 lesions
• t/t like primary lesions

29. Phenol
• Wash cavity
• Alcohol rinse
• 10-20% recurrence
Embolization
Biphosphonates act by targeting osteoclast like
giant cells inducing apoptosis and limiting
tumour progression

30. Thank you
Have a nice day