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AUGUST 2017

GIANT CELL TUMOR


By :

MUH.YUSUF M C11111 NURHIDAYAH C11111

YORICHE TALLAMMA C11111 ANDI NIRMAWATI. AR C11112063

ADVISOR:

dr. ALFA

dr. ASRI ABIDIN

SUPERVISOR :

dr. DEWI

ORTHOPEDIC AND TRAUMATOLOGI DEPARTMEN


MEDICAL FACULTY
HASANUDDIN UNIVERSITY
MAKASSAR
CASE REPORT
PATIENTS IDENTITY
Name : Mr. S
Birth : 21-03-1965
Reg. Number : 810209
Sex : Male
Date of Admission : 9th Augustl 2017
Chief Complain : Lump on the left leg
Lumps appearing since 1 year ago as big as
marbles and bigger
Pain every night and when patient walk since 6
month ago, patient cant do normal activity like
usually.
Feels warm, no redness.
Fever(-), nausea(-), vomiting (-)
There was no family history
Prior treatment from RSUD Jayapura
PRIMARY SURVEY
Patent, clear
AIRWAY
18x/min, thoracoabdominal,
BREATHING spontaneous, symmetric

BP 110/70mmHg, HR 80x/min,
CIRCULATION regular, strong on palpation

GCS 15(E4M6V5), light reflex +/+


DISABILITY , pupil isochors, : 2,5mm/2,5mm,

Temp 36.8C (axilla)


EXPOSURE
SECONDARY SURVEY
( Left Leg Region)
Lump on the left leg, the appearance of pain, tissue enlargement
LOOK and signs of inflammation

FEEL Complaints of tenderness, pain when walking, warm,


mobilobilized, not rubbery,

MOVE Limitations of movement and physical weakness


CLINICAL FINDING
RADIOLOGY FINDING

1. Lower Leg AP 2.Lateral Femur


RADIOLOGY FINDING

Knee AP
RADIOLOGY FINDING

CT-SCAN Genu-Proximal-Cruris sinistra


LABORATORY FINDING
WBC 8,7x103
HGB 14.8
HCT 44
PLT 283
HbsAg Non-reactive
CT 8.00
BT 3.00
SGOT 25
SGPT 15
ASSESMENT
Giant Cell Tumor Proximal Tibia Sinistra
MANAGEMENT
Analgesic
Antibiotic
Biopsi
Megaprostesa
Discussion
In this case a 62 year old man came to the Wahidin
Sudirohusodo Polyclinic Hospital with a lump complaint on his
left leg. The age of the second to the fourth decade is one of the
risk factors for experiencing giant cell tumor. The lump has
appeared since 1 year ago. Initially the lump is small, then
gradually become big slowly. Progressive growth indicates that
this lump is benign, but in giant cell tumors may turn aggressive
or malignant. History of trauma and fever is absent, history of
pain exists especially when driven. The absence of fever suggests
that a lump is not a result of inflammation.
Discussion
On physical examination of the antebrachii dextra
region the mass of the tumor appears to be a
tennis ball with a size of 6 x 5 x 3 cm, consistency of
hardness, tenderness. Active and passive motion in
the left leg joint is limited due to pain. Good
sensibility, pulsation of radial artery palpable with
capillary refill <2 sec. In this case it is in accordance
with the theory that giant tumor cells often occur
at or near the epiphytic long bones after the
epifiseal plate is closed. The most frequent
predilections are distal femur, proximal tibia,
proximal humerus, and distal radius
Discussion
In the photo of the AP / Lateral cruris,
impression of Giant Cell Tumor proximal
tibia sinistra. Based on the photograph,
there is a picture of an expansive lytic
lesion giving an overview of soap bubble
that destroys the cortex in the epiphyseal
region, metaphysical proximal dysfunction
of os tibia sinistra, so that the giant cell
tumor can be classified as stage II staging
giant cell tumour according to Campanacci.
GIANT CELL TUMOR
DEFINITION
Locally aggressive benign neoplasm of bone
with tendency for local recurrence
Characterized by varying numbers of
multinucleated giant cells in a stroma of
round, ovoid or spindle shaped cells that fuse
to form the giant cells of the lesio
Epidemiology
4-5% primary bone tumours in USA (20% in China)
20% of all benign bone tumours
Peak incidence in the 3rd-4th decade
M<F 1:1.5
Most common in epiphyseal ends of long bones (may migrate to metaphysis)
Extending to & sometimes through the subchondral bone
50% about the knee
Other common sites are
Distal radius
Proximal humerus
Spine rare
Consider pre-existing Pagets
Vertebral bodies involved (cf. osteoblastoma & ABC in posterior elements)
Rarely multicentric (< 1%)
In rare cases where it occurs in the child with open physis (< 2%) the lesion is metaphyseal
GCT of the small bones of hand & foot have younger age group & higher multicentricity
5% pulmonary metastases
Consider GCT benign if pulmonary metastasis histologically benign
Regular CXR in patients with GCT
Clinical Features
20-50 years old
Pain
Local swelling
Joint effusion
Muscle atrophy
Pathological fracture
Can be pulsatile
Classification
Campanacci
Radiological grading systemBetter for
prognosticating aggressiveness then histology

Grade Description
1 Intramedullary lession confined to bobe
2 Thinned, expanded cortex
3 Cortical breakout
Classification
Enneking
Radiological &
histological
classification
Corresponding to
clinical presentations
Pathology
Gross
Homogenous lesion with tan colour & moderately firm
consistency
Foci of haemorrhage and/ or necrosis seen in many
tumours
Eccentrically located & extends up to articular margin
Overlying cortex expanded & tumour surrounded by
subperiosteal new bone
The cystic/ haemorrhagic tumour may resemble ABC
Histology
Background of proliferating homogenous mononuclear stromal cells
Round to ovoid shape & relatively large nuclei with inconspicuous nucleoli
Within fibrous stroma
Multinucleated Giant cells dispersed throughout with similar appearance
to osteoclasts
Osteoclastoma
50-100 nuclei sometimes
Small stromal cells may be the tumour & the giant cells only reactive
Other areas may show lipid-filled histiocytes
Foci of reactive bone at periphery of tumour
Mitosis may be prominent & intravascular invasion do not indicate
malignancy in GCT
Histologic appearance not related to biological behaviour
One of few benign tumors with areas of spontaneous necrosis
Investigations
X-ray
Well-defined lytic defect
Epiphysis & metaphysis
Eccentrically located
Extends to subchondral bone of articular surface
Can invade articular cartilage
Tends to be spectrum of disease
Benign-looking with well-defined sclerotic margin
More aggressive lesion with permeative appearance
No intralesional densities
May have cortical expansion with thin layer of subperiosteal new bone
Cortical breach & soft tissue extension
Differential for subarticular tumours
GCT
ABC
Chondromyxoid fibroma (in foot)
Investigations
Bone scan
Increased uptake
May be diffuse (40%) or peripheral with little central activity (60%)
Non specific
Angiogram
Hypervascularity of lesion
CT Scan
Help evaluate cortical integrity & extraosseous extent & relationship to adjacent structures
Fluid levels may represent ABC component
MRI
Homogenous
Help to delineate the soft tissue margins
Laboratory Investigations
Serum Calcium & Serum Phosphate to rule out hyperparathyroidism
Browns tumour has similar radiological appearance
(GCT can occur in hyperparthyroidism also)
Differential Diagnosis
Aneurysmal Bone Cyst (ABC)
Brown tumour
Non-ossifying fibroma
Giant Cell Rich Osteosarcoma
Treatment
Biopsy usually performed

Principles
Excise the lesion
Sterilize the cavity
Reconstruct the defect

Traditional
Intralesional curettage & bone grafting
Local recurrence rates 40-60%
Difficult to do intralesional excision without leaving tumour cells behind
Because of proximity to articular cartilage
Prognosis
~ 23% recurrence 3 years
Most recurrences occur within 2 years
Thank you

THANK YOU