Upload
vyomphysio2010
View
217
Download
0
Embed Size (px)
Citation preview
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 1/58
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 2/58
GIANT CELL TUMOUR
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 3/58
TUMOUR
CAUSE
STAGES
DIFFERENCES
GIANT CELL GIANT CELL TUMOR
OF BONE
ATHOLOGY
CLINICAL FEATURE
SYMPTOM
STAGE
DIAGNOSIS MANAGEMENT
NON SURGICAL
SURGICAL PHYSIOTHERAPY
MANAGEMENT RESEARCH ARTICLE PURPOSE METHOD
RESULT
CONCLUSION
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 4/58
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 5/58
An abnormal mass of tissue that results from
excessive cell division .
That is uncontrolled and progressive, also called a
neoplasm.
They may be either benign (not cancerous) or
malignant.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 6/58
A neoplasm is an abnormal proliferation of
tissues, usually caused by genetic mutations.
Most neoplasms cause a tumor, with a few
exceptions like leukemia.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 7/58
There are of two types:-
Benign:- A Benign tumor arising from the fibroblastic
cell is called fibroma.A cartilaginous tumor is a chondroma.
A tumor of osteoblasts is an osteoma.
Malignant:- Malignant tumor arising in mesenchymaltissue are usually called sarcomas.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 8/58
Slow growing
Well circumscribed
Non- invading
No or few symptoms
Do not metastasise
Do not cause death of the patient
Rapidly growing
Not well circumscribed
Invading
Associated with pain anddisability
Metastasises
May cause death of the
patient
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 9/58
A giant cell is a mass formed by the union of several distinct cells (usually macrophages).
Giant cell tumors are named for the way they look
under the microscope. Many "giant cells" are seen.
They are formed by fusion of several individual
cells into a single, larger complex.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 10/58
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 11/58
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 12/58
First described- Cooper 1818Lebert - microscopic description 1845
A giant cell tumor is one that is made up of a
large number of benign (non-cancerous) cells
that form an aggressive tumor - usually near
the end of the bone near a joint.
Giant cell tumors most often occur when
skeletal bone growth is complete.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 13/58
Giant cell tumors of bone occur spontaneously.
They are not known to be associated with trauma,environmental factors, or diet.
They are not inherited.
In rare cases, they may be associated with
hyperparathyroidism.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 14/58
The location of a giant cell tumor is often in the
knee, but can also involve the bones of the arms
and the legs, or the flat bones such as thesternum (breastbone) or pelvis.
Giant cell tumor of bone occurs almost
exclusively in the end portion of long bones nextto the joints (epiphysis). In rare cases, this tumor
may spread to the lungs.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 15/58
A mixture of four components can be
distinguished: -
Spindled - shaped and rounded multinucleatedcell.
Osteoclastic - type giant cells and small blood
vessels.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 16/58
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 17/58
CLINICAL FEATURES
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 18/58
Age 20 40 yrs
Sex females>males 1.5 : 1
Occur around the knee joint in the lower end of
the femur or the upper end of the shinbone.
Wrist (lower end of the lower arm bone),The hip (upper end of the thighbone),
The shoulder (upper end of the upper arm bone),
Lower back (connection of the spine and pelvis).
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 19/58
Pain at the adjacent joint
A visible mass (tender)
Swelling (smooth)
Bone fracture (pathological)
Limited movement in theadjacent joint
Fluid accumulation in the joint
adjacent to the affected bone
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 20/58
The first symptom most patients notice is pain inthe area of the tumor.
There may be pain with movement of a nearby
joint. Pain generally increases with activity and decreases
with rest.Pain is usually mild at first, but it progressively
increases.Occasionally the bone weakened by the tumor may
break and cause sudden onset of severe pain.Sometimes patients will notice a mass or swollen
area that may not be painful.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 21/58
STAGES STAGES I STAGES II STAGES III
Patient % 10-15% 70% 10-15%
Symptoms Asymptomatic pain pain
Radiograph Sclerotic rim Expandedcortex
Cortical perforation
Histology Benign Benign Benign
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 22/58
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 23/58
-ray
CT scanMRIBone scanBiopsyBlood examination
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 24/58
-rays demonstrated ageographic, expansile lesionof the head of the fibula.
There was a surrounding eggshell rim of calcificationindicating the periosteum wasintact.
The lesion was expansile anddisplaced the peroneal nerveand popliteal blood vessels.
The entire head of the fibula
was destroyed by theneoplasm.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 25/58
CT scan shows a thin corticalshell around the tumorindicating the periosteum is
intact and the tumor is likelybenign.
There was no ossification or
calcification within thetumor indicating that thetumor was probably not abone or cartilage producing
tumor.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 26/58
The MRI findings were
not specific for aparticular type of
neoplasm or infection.
There were no fluid-
fluid levels thatwould indicate cystic
changes.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 27/58
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 28/58
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 29/58
A procedure in which tissue samples are removed(with a needle or during surgery) from the body forexamination under a microscope; to determine if
cancer or other abnormal cells are present.
The nuclei of the mononuclear cells resembled thenuclei in the giant cells.
There were no granulomas.
Cultures were negative.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 30/58
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 31/58
MANAGEMENT
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 32/58
Patient age, overall health, and medical history
Extent of the disease
Patient tolerance for specific medications,
procedures, or therapies
Expectations for the course of the disease
Patient opinion or preference
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 33/58
To remove the tumor and prevent damage to theaffected bone. Treatment may include:
I. Surgery (to remove the tumor and any damagedbone)II. Bone grafting - a surgical procedure in which
healthy bone is transplanted from another part of
the patient's body into the affected area.III. Bone reconstructionIV. Amputation (may be required in severe cases)V. Physical therapy (to regain strength and mobility
to the affected area)
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 34/58
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 35/58
Radiation therapy is a nonsurgical treatment
option that has proven effective.
However, this can result in the formation of
cancer in as many as 15 percent of patientswho receive it.
Therefore, radiation therapy is used only in the
most difficult cases where surgery cannot be
performed safely or effectively.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 36/58
Some centers have reported successful
treatment of giant cell tumors withembolization.
A process where the blood vessels supplyingthe tumor are occluded by means of a catheter
threaded through the main arteries. Blockingthe blood supply to the tumor can cause it to
shrink and even disappear because the tumor
loses its source of nutrition.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 37/58
Clinical trials of a drug called interferon are
currently underway.
This drug works by interfering with the ability
of the tumor to grow new blood vessels.Because tumors require an ever-increasing
blood supply to grow, interferon may alsocause the tumor to shrink or even disappear.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 38/58
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 39/58
Excision is the best treatmentfor giant cell tumor.
This is the treatment of thechoice when the tumor affects
a bone whose removal doesnot hamper with functionse.g. fibula and lower end of ulna.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 40/58
When the excision of atumor at some site mayresult in significant
functional impairment , thedefect created by excisionis made up, usuallypartially, by some
reconstructive procedure.
Arthodesis by Turn-o-plasty Arthrodesis by bridging
Arthroplasty
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 41/58
Scooping out the tumor(curettage) is generallyperformed.
This techniques cause ahole in the bone that canbe filled with a bonegraft.
The bone may be takenfrom other parts of thepatient's own body(autograft) or from a
cadaver (allograft).
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 42/58
If treatment is limited to curettage and bone
grafting alone, the tumor may come back(recur) up to 45 percent of the time.
The use of bone cement rather than bone
graft results in a lower rate of recurrence
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 43/58
Where the liquid nitrogen
is used to produce a
freezing effect and thuskill the residual cells.
Thermal burning of the
residual cell usingcauterization of the wall
of the tumor.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 44/58
In later stage , the thermal effect of bone
cement has been used .
The cavity is filled with Bone cement which
by the heat it produces while setting kills theresidual cells.
For more aggressive tumors or following
reccurence ,amputation may be necessary
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 45/58
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 46/58
The basic aim of physiotherapy is toprovide optimal functionalefficiency to the operated part to
facilitate functional independence.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 47/58
MEASURE TO CONTROL DEPRESSION
Psychological reassurance
Counseling
Rehabilitation program
Functional use of the limbs is initiated at the
earliest
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 48/58
MEASURE TO CONTROL LIMB OEDEMA
Limb elevation
Intermittent compression
Active movements of the affected joints
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 49/58
MEASURE TO IMPROVE MUSCLE STRENGTH
Passive range of motion exercise
Active assistive exercises
Active exercises
Resistive exercises
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 50/58
RESEARCH ARTICLE STUDY
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 51/58
Giant cell tumour of bone with late
presentation: review of treatment and
outcomeES Ng, A Saw, S SenguptaDepartment of Orthopedic Surgery, University
Malaya Medical Center, University of Malaya, KualaLumpur, Malaysia
AR Nazarina, M Path
Department of Pathology, University MalayaMedical Center, University of Malaya, Kuala Lumpur,Malaysia
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 52/58
Purpose.
To review cases of giant cell tumour of boneor osteoclastoma managed at the University
Malaya Medical Center, University of Malaya,
Kuala Lumpur, from January 1990 toDecember 1999.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 53/58
Methods
Medical records of all patients withmusculoskeletal tumours were reviewed.
Demographic data, clinical presentation,
surgical management, and clinical outcomeswere reviewed retrospectively.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 54/58
Most of the 31 patients who were treated f orgiant cell tumour of bone presented late on the basisof the duration of their symptoms and radiological
features.
Five of the patients had been referred for localrecurrences.
26 patients were treated f or primary tumours: 18 needed wide excision, 7 curettage,and one amputation.
.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 55/58
The joint could not be preserved and
arthrodesis was performed for 11 patients.
Three (12%)of the 26 patients had local
recurrence during a mean follow-up of 60months, including one (6%) who had recurrence
after wide excision and 2 (29%) after curettage.
Pulmonary metastasis was noted in 4 cases,
2 of which were confirmed histologically.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 56/58
Even in an advanced stage of disease,good
clinical outcomes can be achieved with
adequate excision and appropriatereconstruction.
For lesions around the knee, autologous
rotational grafting is a good alternativemethod of reconstruction.
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 57/58
ESSENTIAL ORTHOPAEDIC - J. maheshwari
ESSENTIAL OF ORTHOPAEDIC FOR
PHYSIOTHERAPIST - John ebnezar APPLIED PHYSIOTHERAPY - Jayant joshi
Giant cell tumour of bone with late
presentation: review of treatment andoutcome - S Sengupta
INTERNET MATERIALS
8/9/2019 Giant Cell Tumour-Vyom Gyanpuri
http://slidepdf.com/reader/full/giant-cell-tumour-vyom-gyanpuri 58/58