Giant Cell Tumor of Bone

1. Giant Cell Tumor of Bone

2. Overview • Definition • Epidemiology • Hx • Presentation/Exam • Radiology • Dx • Tx • Outcomes

3. Definition • 10 bone neoplasm • First described Cooper 1818 • Lebert microscopic description 1845 • Generally benign • Potential for : • Recurrence • Pulmonary metastasis • Frank malignancy

4. Epidemiology • 5-10% 10 bone tumors • 20% benign bone tumors • F : M 1.5 : 1 • 70-80% age 20-40 • Rare skeletally immature • Epiphyseal • Monostotic

5. Incidence • Ends of long bones • >50% about knee • High recurrence rate • 1-2% benign pulm. Mets • 10 malignant GCT <1% • Rare polyostotic form <1%

6. Location

7. Presentation • Pain x wks. – mos. • Swelling • Mass • Pathologic # • Neuro deficit (spine / sacrum) • incidental

8. Radiology • Lytic lesion • Epipyseal • Eccentric or central • Narrow zone transition • Cortical thinning • expansile • No sclerotic margin

9. Imaging • Occ. Cortical breakthrough • +/- soft tissue mass • Extend to subarticular cortex • Typically no host response • Often large @ presentation

10. Other modalities • CT • Integrity cortical rim • MRI • Assess subchondral breakthrough • Bone Scan • Suspect multicentri loci • ie. HAND

11. DDx • Consider: Age & Location • Fibrogenic/Telangiectatic Osteosarcoma • MFH • Brown tumor • Chondroblastoma • ABC • Chondromyxoid fibroma (rare) • Mets / Myeloma

12. Histology • Fibrohistiocytic origin • Multinucleated giant cells • Mononuclear stroma • Round / ovoid / spindle • Indistinct cell membrane • Mitoses • Giant cells 20 fusion stromal cells

13. Gross

14. Enneking Staging

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

16. Curettings

17. Tx • Controversial • Traditionally: • Intralesional curettage / resection & bone graft • Recurrence 35-42% • En Bloc resection • Recurrence ~10% • Multiple complications • Adjuvant

18. Curettage • Wide decortication (windowing) • Curettage / high speed burr • Aggressive • Choice of adjuvant

19. Adjuvant Tx • Radiation - ~10% sarcomatous degeneration • PMMA, Liquid N2, Phenol, CO2 laser, Electrocautery • Local extension of margin • Kill residual foci

20. PMMA • Fill tumor cavity • Heat kill of tumor cells? • Effect size dependent • 8-26% recurrence • Easy recurrence detection • Degenerative changes

21. Recurrence

22. Subchondral bone grafting

23. Cryotherapy • 3 freeze thaw cycles • Irrigate cartilage with cool saline • Circumferential necrosis • “difficult” • Complications • Soft tissue injury • Late fractures

24. Cryotherapy

25. Phenol • Wash cavity • Alcohol rinse • 10-20% recurrence

26. Enbloc Resection • Expendable bones • Prox fibula / Distal ulna • High recurrence with other Tx • Hand / Distal radius • Recurrence • Pathologic # • Joint involvement • Osteochondral allograft reconstruction

27. Reconstruction

28. Spine • < 3% vertebrae above sacrum • All levels affected equally • Affects vertebral body c ext. pedicle • Resection with stabilization • Often incomplete • ?radiation as adjuvant (low dose 3000 Gyc) • Incomplete excision • Local recurrence

29. Sacrum / Pelvis • Intalesional excision • Adjuvant • +/- radiation

30. Pelvis • GCT often vascular • Pre-op angiography • ? embolization

31. Angiography

32. Outcome