Giant cell tumor of bone

An expansile lytic lesion involving the right third metacarpal with soft tissue swelling and suspicion of cortical breach.

By dr.alghamdi

History: 35 years old female with right hand pain and swelling.

Findings:

:: X-Ray 1 ::
An expansile lytic lesion involving the right third metacarpal with soft tissue swelling and suspicion of cortical breach.

:: X-Ray 2 ::
An expansile lytic lesion involving the right third metacarpal with soft tissue swelling and suspicion of cortical breach.

Discussion:
Incidence: 4–9.5% of all primary bone tumors; 18–23% of benign skeletal tumors; unusually high prevalence in China + southern India

Age: peaks in 3rd decade; 1–3% < age 14; 80% between 20 and 50 years; 9–13% > age 50; M:F = 1:1.1 to 1:1.5 (in spine 1:2.5)

May be associated with: Paget disease (in 50–60% located in skull + facial bones)

Location:

• long bones (75–85–90%) › lower extremity (50–65% about knee):
distal end of femur (23–30%) > proximal end of tibia (20–25%) > proximal femur (4%) > distal tibia (2–5%) > proximal fibula (3–4%) > foot (1–2%)

RARE in patella (the largest sesamoid bone) + greater trochanter (epiphyseal equivalent)

› upper extremity (away from elbow):
distal end of radius (10–12%) > proximal end of humerus (4–8%) > hand and wrist (1–5%)

•flat bones (15%) › pelvis: sacrum near SIJ (4%), iliac bone (3%)
› spine (3–6%): thoracic > cervical > lumbar spine (tumor frequency 2nd only to chordoma)
› rib (anterior / posterior end)
› skull (sphenoid bone).

Site: eccentric (42–93%) in metaphysis of long bones adjacent to ossified epiphyseal line; extension to within 1 cm of subarticular bone (84–99%) after fusion of epiphyseal plate (MOST TYPICAL) with possible transarticular spread.

well-circumscribed expansile solitary lytic bone lesion with a narrow zone of transition:
• wide zone of transition (10–20%)
• large lesions are more centrally located

"soap bubble" appearance (47–60%) = expansile remodeling with multiloculated appearance:
• NO internal mineralization of tumor matrix
• prominent trabeculation (33–57%): a. reactive with appositional bone growth
b. pseudotrabeculation of osseous ridges in endosteal scalloping .

No sclerosis (80–85%) / periosteal reaction (10–30%) due to aggressive rapid growth in absence of fracture.

Cortical penetration (33–50%):
• cortical thinning
• soft-tissue invasion (25%)
• complete / incomplete pathologic fracture (11–37%) .
Destruction of vertebral body with secondary invasion of posterior elements (DDx: ABC, osteoblastoma).

Frequently vertebral collapse.

Involves adjacent vertebral disks + vertebrae, crosses sacroiliac joint.

May cross joint space in long bones (exceedingly rare).

Complications:in 5–10% malignant transformation within first 5 years (M:F = 3:1); metastases to lung.

Prognosis: locally aggressive; 80–90% recurrence rate within first 3 years after initial treatment.

Rx: currettage + bone grafting (40–60% recurrence); currettage with filling of void with high-speed burr + polymethylmeth-acrylate (2–25% recurrence); wide resection (7% recurrence) and reconstruction with allografts / metal prosthesis; radiation therapy for inoperable GCT (39–63% recurrence).

Differential diagnosis: 1. Aneurysmal bone cyst (contains only cystic regions; in posterior elements of spine)
2. Brown tumor of HPT (lab values)
3. Osteoblastoma
4. Cartilage tumor: chondroblastoma, enchondroma (not epiphyseal), chondromyxoid fibroma, chondrosarcoma
5. Nonossifying fibroma
6. Bone abscess
7. Hemangioma
8. Fibrous dysplasia
9. Giant cell reparative granuloma

Diagnosis confirmation: Surgery / Histo

Category: Musculoskeletal

Region / Organ: Arm-Bones

Etiology: neoplastic

References:
Radiology Review Manual 5th Ed.

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