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Giant cell Giant cell tumour of bonetumour of bone
Dr Abdul G SuhailDr Abdul G SuhailMBBS,D.Ortho,MS (Ortho)MBBS,D.Ortho,MS (Ortho)
Assistant Professor in OrthopaedicsAssistant Professor in Orthopaedics
HistoryHistory First described in 1818 by First described in 1818 by
Sir Astley CooperSir Astley Cooper
Described in detail in 1940 Described in detail in 1940 by Jaffe and Litchensteinby Jaffe and Litchenstein
GIANT CELL TUMOURGIANT CELL TUMOUR
DEFINITION:DEFINITION:
DistinctDistinct neoplasm arising from non-bone neoplasm arising from non-bone forming supportive connective tissue of forming supportive connective tissue of marrow with network of stromal cells regularly marrow with network of stromal cells regularly interspersed with giant cells.interspersed with giant cells. ( Jaffe & Liechtenstein( Jaffe & Liechtenstein ) )
AGE OF PRESENTATIONAGE OF PRESENTATION
75-80% OF PATIENTS 20-50 75-80% OF PATIENTS 20-50 YRSYRS
10% 15-20 YRS10% 15-20 YRS
10% >60 yrs10% >60 yrs
<1.7% BELOW 15 YRS<1.7% BELOW 15 YRS
SEXSEX
Male:Female- 1:1.3 (Benign)Male:Female- 1:1.3 (Benign)
-3:1 (Malignant)-3:1 (Malignant)
SITESITE Epiphyseo-metaphysealEpiphyseo-metaphyseal region of long bonesregion of long bones
GCTGCT –Described from all bones –Described from all bones EXCEPTEXCEPT middle ear bonesmiddle ear bones
Axial skeleton- 8%Axial skeleton- 8%
UL:LL-1:3UL:LL-1:3
SiteSite 55% AROUND THE KNEE 55% AROUND THE KNEE
10% in the distal radius10% in the distal radius
6% in the proximal humerus6% in the proximal humerus
SPINE rarely involved (commoner in the SPINE rarely involved (commoner in the sacrum)sacrum)
In the head and neck region the maxilla and In the head and neck region the maxilla and mandible are more commonly involvedmandible are more commonly involved
GIANT CELL TUMOURGIANT CELL TUMOUR
TRANS OSSIOUS EXTENSION- 5%TRANS OSSIOUS EXTENSION- 5%
Common sitesCommon sitesWristWrist
Ankle & footAnkle & foot
ForearmForearm
LegLeg
INTRA ARTICULAR EXTENSION- 10%INTRA ARTICULAR EXTENSION- 10%
Incidence-0.5-5%Incidence-0.5-5% SimultaneousSimultaneous Peculiar featuresPeculiar features
hand hand metaphyseal metaphyseal abundant spindle abundant spindle cellscells
GOLTZ syndromeGOLTZ syndrome `̀
occular defectsoccular defects
skeletal anomaly skeletal anomaly
multifocal GCTmultifocal GCT
MULTICENTRIC INVOLVEMENTMULTICENTRIC INVOLVEMENT
GIANT CELL TUMOURGIANT CELL TUMOUR
SIGNS&SYMPTOMSSIGNS&SYMPTOMS
1.1. PAINPAIN
2.2. SWELLINGSWELLING
3.3. JOINT RESTRICTIONJOINT RESTRICTION
4.4. MUSCLE WASTINGMUSCLE WASTING
5.5. NEUROLOGICAL SIGNSNEUROLOGICAL SIGNS
6.6. PATHOLOGICAL #PATHOLOGICAL #
PathologyPathologyGROSS-GROSS- End of bone is expanded.End of bone is expanded. Eccentric lesion at the epiphyseo-Eccentric lesion at the epiphyseo-
metaphyseal region.metaphyseal region. Thin periosteum.Thin periosteum. Fleshy dark brown, soft, friable mass.Fleshy dark brown, soft, friable mass. Cystic spaces seenCystic spaces seen. .
PATHOLOGYPATHOLOGYGROSSGROSS--
PathologyPathologyMicroscopy-Microscopy- Vascularized network of round,oval or Vascularized network of round,oval or
spindle shaped stromal cells and spindle shaped stromal cells and multinucleated giant cells with numerous multinucleated giant cells with numerous centrally placed nucleicentrally placed nuclei
PATHOLOGYPATHOLOGYMICROSCOPYMICROSCOPY
GradingGradingJaffe,Lichenstein and Jaffe,Lichenstein and
Portis(1940Portis(1940))
GRADE 1-GRADE 1-o Conventional GCTConventional GCTo Stroma is inconspicuous Stroma is inconspicuous o Giant cells dominate the fieldGiant cells dominate the fieldo No atypism of stromal cells and are No atypism of stromal cells and are
loosely arrangedloosely arrangedo Stromal cells are predominantly Stromal cells are predominantly
spindle shapedspindle shaped
GradingGradingGRADE 2-GRADE 2-o Boderline tumoursBoderline tumourso Stromal cells are prominent and tightly Stromal cells are prominent and tightly
packedpackedo Giant cells are less in number compared to Giant cells are less in number compared to
grade 1 and their nuclei may show grade 1 and their nuclei may show atypismatypism
o Stromal cells show atypismStromal cells show atypismo These tumours have a strong chance for These tumours have a strong chance for
recurrence and some may undergorecurrence and some may undergo malignant changemalignant change
GradingGradingGRADE 3-GRADE 3-o Sarcomatous type of stromaSarcomatous type of stromao Frequently metastaseFrequently metastaseo Stromal cells abundant and closely Stromal cells abundant and closely
compacted and present an irregular compacted and present an irregular whorled arrangementwhorled arrangement
o Nuclei are unusually large, irregular and Nuclei are unusually large, irregular and atypicalatypical
o Giant cells are few in number and atypicalGiant cells are few in number and atypical
Modified gradingModified gradingSannerkin et al(1980)Sannerkin et al(1980)
Malignant GCT- Malignant GCT- with frank with frank sarcomatous changes and full sarcomatous changes and full metastatic potentialmetastatic potential
Borderline GCT-Borderline GCT- without sarcomatous without sarcomatous changes but with abnormal mitoses changes but with abnormal mitoses or vascular permeation or bothor vascular permeation or both
Conventional GCT-Conventional GCT- without features without features of any of the above two typesof any of the above two types
No correlation exists No correlation exists between histological between histological grading and clinical grading and clinical behavior of the tumour.behavior of the tumour.
Hence grading not widely Hence grading not widely accepted.accepted.
GIANT CELLS inGIANT CELLS inGiant cell tumorGiant cell tumor Numerous Numerous
nuclei(15-150)nuclei(15-150) Centrally placed Centrally placed
uniform size nucleiuniform size nuclei
TuberculosisTuberculosis Number of nuclei Number of nuclei
are lessare less Peripherally placed Peripherally placed
nucleinuclei
Enneking staging for GCTEnneking staging for GCT
Stage 1-Stage 1-(10-15%)(10-15%)
Patients asymptomaticPatients asymptomatic Discovered incidentallyDiscovered incidentally May cause pathological fractureMay cause pathological fracture Has sclerotic rim on x-ray or CTHas sclerotic rim on x-ray or CT Relatively inactive on bone scansRelatively inactive on bone scans Histologically benignHistologically benign
Enneking staging for GCTEnneking staging for GCT
Stage 2-Stage 2-(70%)(70%)
SymptomaticSymptomatic Often associated with path: fractureOften associated with path: fracture Has expanded cortex but no break throughHas expanded cortex but no break through Is active on bone scansIs active on bone scans Histologically benignHistologically benign
Enneking staging for GCTEnneking staging for GCTStage 3-Stage 3-(10-15%)(10-15%)
SymptomaticSymptomatic Rapidly growing massRapidly growing mass Has cortical perforation with Has cortical perforation with
accompanying soft tissue massaccompanying soft tissue mass Activity on bone scan extends beyond Activity on bone scan extends beyond
the lesion in x raythe lesion in x ray Shows intense hypervascularity on Shows intense hypervascularity on
angiogramangiogram Histologically benignHistologically benign
RADIOLOGYRADIOLOGYType of OsteolysisType of Osteolysis
Geographic destruction (I)Geographic destruction (I)
Moth-eaten (II) Permeative(III)Moth-eaten (II) Permeative(III)
LodwickLodwick
1A1A 1B1B 1C1C
RADIOLOGYRADIOLOGY ExpansileExpansile
RADIOLOGYRADIOLOGY TRABACULATIONTRABACULATION
PURE LYTIC (60%) FINE TRABACULTION(40%)
RADIOLOGYRADIOLOGY
AGGRESSIVENESSAGGRESSIVENESS
LARGE INTRAOSSEOUS CONTENTPURELY LYTIC
CORTICAL BREACHSOFT TISSUE INVASION
SCINTI GRAPHYLess useful
Inconsistent uptake“Doughnut sign”
M.R.I.Soft tissue spread
Joint breachLocate N.V. bundle
C.TIntraossous contentIntra articular spread
Cortical breachSite of window
ANGIO GRAPHYLocate vessels type of feeders
For embolisation
INVESTIGATIONSINVESTIGATIONS
GCT UlnaGCT Ulna
GCT of OlecranonGCT of Olecranon
GCT RadiusGCT Radius
GCT distal femurGCT distal femur
GCT lower end femurGCT lower end femur
GCT FibulaGCT Fibula
GCT CalcaneumGCT Calcaneum
GCT IliumGCT Ilium
GCT C7
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
1.ANEURYSMAL BONE CYST1.ANEURYSMAL BONE CYST
2. GIANT CELL REPARATIVE GRANULOMA2. GIANT CELL REPARATIVE GRANULOMA
3.CHONDROBLASTOMA3.CHONDROBLASTOMA
4.BROWN TUMOR4.BROWN TUMOR
5.INTRA OSSEOUS GANGLION5.INTRA OSSEOUS GANGLION
6.BENIGN FIBROUS HISTEOCYTOMA6.BENIGN FIBROUS HISTEOCYTOMA
Bubbly lesions of boneBubbly lesions of boneTumorsTumors Aneurismal bone cystAneurismal bone cyst Unicameral bone cystUnicameral bone cyst Non ossifying fibromaNon ossifying fibroma OsteoblastomaOsteoblastoma Hyper parathyroidismHyper parathyroidism Chondromyxoid fibromaChondromyxoid fibroma Histiocytosis XHistiocytosis X MyelomaMyeloma Metastasis(kidney,thyroidMetastasis(kidney,thyroid))
InfectionInfection Brodies abscessBrodies abscess CoccidioidomycosisCoccidioidomycosis EcchinococcusEcchinococcus
BIOPSYBIOPSY
CLOSED FINE NEEDLECLOSED FINE NEEDLE
TRUECUTTRUECUT
TREPHINETREPHINE
OPEN INCISIONALOPEN INCISIONAL
EXCISIONEXCISION
TREATMENTTREATMENTSTAGESTAGE TYPETYPE GRADEGRADE SITESITE METASTASISMETASTASIS
STAGE1STAGE1 LATENTLATENTLodwick2Lodwick2
G0G0 T0T0 M0M0
STAGE 2STAGE 2 ACTIVE ACTIVE Lodwick3Lodwick3
G0G0 T0T0 M0M0
STAGE 3STAGE 3 AGGRES.AGGRES. G0G0 T1,2T1,2 M0,1M0,1
SURGICAL TREATMENTSURGICAL TREATMENTStage1& Stage2 --- Intralesional or Marginal Excision
Stage3 --- Wide resection with Reconstruction
Radiation, Embolaisation
Curettage & Bone GraftingCurettage & Bone Grafting
INDICATION STAGE-1&2
ADEQUATE WINDOW
MOTORISED BURR
ExtendedExtended Curettage Curettage
PHENOL
BONE CEMENT
LIQUID NITROGEN
CAUTERY
CO 2 LASER
EN.BLOC EXCISIONEN.BLOC EXCISION
Better result
Dispensable bone ---- Patella, head of Fibula Sub articular lesion
RECONSTRUCTION
Auto graft Allograft Arthrodesis Custom made prosthesis
Reconstruction With Reconstruction With AutograftAutograft
Reconstruction With Reconstruction With AllograftAllograft
Reconstruction With Reconstruction With ArthrodesisArthrodesis
Reconstruction With ProsthesisReconstruction With Prosthesis
MetastasisMetastasis
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.
Pushpavally 32yrs
Pushpavally 32yrs
FEMALE 21YRS.
15-5-92
Lady 28yrs.
Recurrent GCTRecurrent GCT
Recurrent GCTRecurrent GCT
Recurrent GCTRecurrent GCT
Recurrent GCTRecurrent GCT
Recurrent GCTRecurrent GCT
Recurrent GCTRecurrent GCT