1. Giant Cell Tumor of Bone

2. Definition
• 10 bone neoplasm
• First described Cooper 1818
• Generally benign but locally aggressive
• Potential for :
– Recurrence
– Pulmonary metastasis
– Frank malignancy

3. • Osteolytic tumour arising from
epiphysis
• Common in young adults
• Though it is benign it is locally
malignant

4. Epidemiology
• 5-10% 10 bone tumors
• 20% benign bone tumors
• F : M 1.5 : 1
• 70-80% age 20-40yrs

5. SITES
• Most common location –distal femur followed
closely by the proximal tibia
• In the distal radius(3rd most common location)
these are frequently more aggressive

6. Presentation
• Swelling with skin over the
swelling stretched
• Pain x wks. – mos(usually not a presenting
feature
• Mass
• Pathologic #
• Neuro deficit (spine / sacrum)
• Incidental

7. • EGG SHELL CRACKING sensation may be
present
• Limitation of joint movement and pathological
fractures –usually a late feature

8. Radiology
• Lytic lesion near epiphysis
• Eccentric or central
• Narrow zone transition B/W
tmr and surrounding tissue
• Cortical thinning
• expansile
• No sclerotic margin
• No periosteal bone formation

9. • Thin septa of bone traverse the interior
producing soap bubble appearance
• Joint extension usually not a feature
• Cortex disrupted in late stages
• Intra articular extension is rare as subchondral
bone usually remains intact

13. Other modalities
• CT
– Integrity cortical rim
• MRI
_extent of lesion within the bone and soft tissue
– Assess subchondral breakthrough
– Lesion dark on T1 and bright on T2 wt
• Bone Scan
– Suspect multicentri loci
– Uses very low radioactive material
(disphosphonate) to see spread to other bone

15. CAMPANACCI’S GRADING
• GRADE 1 :CYSTIC LESION
• GRADE 2:CORTEX THIN BUT NOT PERFORATED
• GRADE 3:CORTEX PERFORATED WITH
EXTENSION INTO SOFT TISSUE

16. ENEKING’S STAGING
• STAGE 1: LATENT-NO CHARACTERISTIC
GROWTH OR PROGRESSIVE CHANGE,RESOLVE
SPONTANEOUSLY
• STAGE 2:ACTIVE-LESION DEFORM THE HOST
BONE BUT REMAINS INSIDE BONE
• STAGE3:AGGRESSIVE-TUMOUR EXTEND
BEYOND THE BONE

17. Histology
• Fibrohistiocytic origin
• Multinucleated giant cells
(40-60 nuclei per cell) in a sea
of mononuclear stroma
– Round / ovoid / spindle
• Indistinct cell membrane
• Mitoses
• Appearance of spindle cells-malignant
potential

18. • GCT USUALLY ARE SOLITARY
LESIONS;HOWEVER 1%-2% MAY BE
SYNCHRONOUSLY OR METACHRONOUSLY
MULTICENTRIC

20. PULMONARY METASTASIS
• OVERALL MORTALITY:15%
• PATIENT WITH RECURRENT LESIONS OR
PRIMARY LESIONS THAT APPEAR AGGRESSIVE
RADIOGRAPHICALLY ARE AT HIGHER RISK
• MALIGNANT GCT <5% CASES

21. TREATMENT
• Traditionally:
– Intralesional curettage / resection & bone graft
– Recurrence 35-42%
• En Bloc resection
– Recurrence ~10%
– Multiple complications
• Adjuvant

22. • HISTORICALLY TRT CONSISTED OF SIMPLE CURETTAGE
• BUT RECURRENCE RATES > 50%
• FOR DEFECTS AFTER RESECTION OR
CURETTAGE,EITHER ALLOGRAFT OR BONE CEMENT
USED AS FILLING AGENTS
EXTENDED CURETTAGE –USE OF A POWER BURR TO
ENLARGE THE CAVITY 1-2 CM IN ALL DIRECTIONS IS
NOW CONSIDERED STANDARD

23. Curettings

24. Adjuvant Tx
• PMMA, Liquid N2, Phenol, CO2 laser,
Electrocautery
– Local extension of margin
– Kill residual foci and remaining tumour cell
• ASSOCIATED WITH PATHOLOGIC
FRACTURES,WOUND HEALING PROBLEMS

25. BONE GRAFT
ADVANTAGE:
• RESTORING NORMAL BIOMECHANICS TO
JOINT SURFACE
• PREVENT FUTURE DEGENERATIVE JOINT
DISEASES
• RESTORING BONE STOCK

26. • DISADVANTAGES
JOINT MUST BE PROTECTED FOR AN
EXTENDED PERIOD OF TIME TO PREVENT A
PATHOLOGICAL FRACTURES
TUMOUR RECURRENCE IS DIFFICULT TO
DISTINGUISH FROM GRAFT RESORPTION

27. • THE ABOVE DISADVANTAGES OVERCOME BY
USE OF BONE CEMENT
• PROVIDES IMMEDIATE STABILITY-HENCE
QUICKER REHABILITATION
• EASIER DETECTION OF RECURRENCE SEEN AS
EXPANDING RADIOLUCENCY ADJ TO CEMENT
• KILLS RESIDUAL TMR CELLS
THRUPOLYMERISATION

28. Enbloc Resection
• Expendable bones
– Prox fibula / Distal ulna
• Eroded cortex and extended into
soft tissue
• Recurrence
• Pathologic #
• Joint involvement

29. • INITIAL PROCEDURE OF CHOICE AND HERE
2CM OF NORMAL BONE IS ALSO EXCISED
• DEFECTS ARE FILLED WITH CANCELLOUS BONE
GRAFTS,FREEZE DRIED ALLOGRAFT OR
PROSTHESIS

30. • AROUND THE KNEE,A HEMICONDYLAR
OSTEOARTICULAR ALLOGRAFT
RECONSTUCTION OR A ROTATING HINGE
ENDOPROSTHESIS MAY BE NECESSARY
• FOR AGGRESSIVE LESION OF DISTAL
RADIUS,PRIMARY RESECTION AND
RECONSTRUCTION WITH A PROXIMAL
FIBULAR AUTOGRAFT INDICATED

31. • FOR LESIONS IN EXPENDABLE BONES(DISTAL
ULNA OR PROXIMAL FIBULA)PRIMARY
RESECTION WITHOUT RECONSTRUCTION
INDICATED
• FOR INOPERABLE LESIONS IN SPINE OR
PELVIS,RADIATION MAY BE USED

33. EXCISION AND RECONSTRUCTION
• FOR GCT AFFECTING LOWER END OF
FEMUROR UPPER END OF TIBIA
• AFTER EN BLOCK EXCISION RECONSTRUCTION
CAN BE DONE BY
1.TURN-O-PLASTY TECHNIQUE
2.ARTHRODESIS
3.ARTHROPLASTY

34. RECURRENCE OF LESIONS
• MOST LOCAL RECURRENCES AND
PULMONARY METASTASES OCCUR WITHIN
3YRS OR EVEN UPTO 20 YRS
• PATIENT SHOULD HAVE RADIOGRAPH OF THE
PRIMARY TUMOUR SITE AND THE CHEST AT
3MONTHS INTERVAL FOR 1YR
6MONTHS INTERVAL FOR NEXT 2 YRS
AND ANNUALLY THEREAFTER

35. • TREATMENT IS SAME AS FOR PRIMARY
LESIONS.
• AFTER BIOPSY SHOWS THAT TUMOUR IS STILL
BENIGN,REPEAT CURETTAGE OR RESECTION IS
PERFORMED

36. THANK YOU