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GIANT CELL TUMOUR ANDOSTEOSARCOMA
GIANT CELL TUMOUR AND
OSTEOSARCOMA
GIANT CELL TUMOUR• Common bone tumour
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.
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.
• Common presenting complaints:
– Swelling and vague pain
– Pathological fracture
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).
DIAGNOSIS
• Solitary lytic lesion of bone.
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 femurUpper tibia
Lower radius
Upper humerus
Upper femur
TibiaHumerus
Neck of femurTibia
Location Epiphysis Metaphysis Metaphysis Metaphysis
X-raySoap 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
RADIOLOGICAL FEATURES
• Solitary- loculated or lytic.
• Eccentric location, often subchondral.
• Expansion of the overlying cortex(expansile lesion)
• ‘Soap-bubble appearance’-– Tumour homogenously lytic
with trabeculae of the remnants of bone traversing it – loculated appearance.
• No calcification within the tumour
• None or minimal reactive sclerosis
• Cortex thinned out or perforated at places.
• Usually does not enter the adjacent joint.
TREATMENT• Best treatment- EXCISION• If not possible(spine)-
Radiotherapy• Commonly used treatment
methods:a) Excisionb) Excision with reconstructionc) Curettage with or without
supplementary procedures.d) Amputatione) Radiotherapy
Excision• When tumour affects a bone
whose removal does not hamper with functions.
• Eg: FibulaLower end of ulna…
Excision with reconstruction
• When excision results in significant functional impairment.
• Defect created is made up, usually partially, by some reconstructive procedure.
• 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.
Arthrodesis by bridging the gapBy double fibulae
Arthroplasty:ExcisedAutograft(patella to substitute
articular defect)Allograft(Using a preserved
bone)Artificial joint(prosthesis)
Curettage With Or Without Supplementary Procedures
• Supplementary procedures to reduce recurrence.
• Cryotherapy and thermal burning.
• Thermal effect of bone cement.
Amputation
• Aggressive tumours
• Following recurrence
Radiotherapy
• GCT affecting vertebrae.
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
PROGNOSIS
• Recurrence – a serious problem
OSTEOSARCOMA(OSTEOGENIC SARCOMA)
Highly malignant primary bone tumour.
PATHOLOGY• Malignant tumor of
mesenchymal cells.
• Osteoid or bone formation by tumor cells
CLASSIFICATION• Based on clinical setting:
a) Primary osteosarcoma 15-25 years No known pre-malignant
conditionsb) Secondary osteosarcoma
Older age(>45yrs) Paget’s disease, fibrous
dysplasia…
• Based on dominant histo-morphology:
a) Osteoblastic
b) Chondroid
c) Fibroblastic
d) Telengiectatic or osteolytic type
FEATURES• Age of onset:
– 15-25yrs
• Sites of origin:– Any bone– Lower end of femur– Upper end of tibia– Upper end of humerus
• 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
• Histologically,Basically anaplastic
mesenchymal parenchyma with tumour cells surrounded by osteoid.
CLINICAL FEATURES
• Pain- constant and boring
• Swelling
• Pathological fracture
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
INVESTIGATIONSRADIOLOGICAL 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.
• Sun-ray appearance:– Tumour grows to overlying
soft tissues.– New bone laid down along
the blood vessels within the tumour growing centrifugally.
SERUM ALKALINE PHOSPHATASE
(SAP):
– Generally elevated
– No diagnostic significance.
– Useful for follow-up
– Rise after tumor removal- Indicator of recurrence or metastasis.
BIOPSY
–Open biopsy
TREATMENT• Aims:
– Confirm diagnosis
– Evaluate spread
– Adequate treatment
• 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
• Extent of involvement need to be known to:
– Plan amputation surgery
– Plan limb saving operation
• Treatment of the tumour:
– Local control:
• Surgical ablation.
• Amputation remains the mainstay.
• ROLE OF RADIOTHERAPY:– Surgically inaccessible sites.
–Control of distant macro or micro-metastasis
• ROLE OF CHEMOTHERAPY:– Drug used: high dose
Methotrexate, Endoxan…
• ROLE OF IMMUNOTHERAPY
FOLLOW UP• Patient is checked up every
6-8 weeks.
• Recurrence needs to be diagnosed early and treated.
PROGNOSIS• Without treatment: death
within 2 years.• 5 year survival with surgery
alone(20%).• Primarily lytic
type(telengiectatic) osteosarcoma-worst prognosis.