Pictorial Essay

Mimics on Radiography of Giant Cell Tumor of Bone

Gregory S. Stacy 1, Terrance D. Peabody 2, Larry B. Dixon 1
iant cell tumor of bone often presents with specic imaging features. Many patients are referred to the orthopedic oncology clinic of our institution with a preliminary diagnosis of giant cell tumor based on a radiologists interpreta-

tion of imaging studies showing features typical of this lesion. Although most of these lesions were subsequently conrmed to be giant cell tumors, we have encountered several similar-appearing lesions that were ultimately diagnosed as another entity.

The Typical Giant Cell Tumor of Bone

Giant cell tumor of bone tends to affect patients more than 20 years old, with the peak incidence occurring during the third decade of life [1]. Patients usually present with pain. Radiographically, the lesion is purely

Fig. 1.Giant cell tumors. A, Radiograph of 47-year-old woman shows geographic radiolucent lesion having sharp but nonsclerotic margin (arrow) in proximal bula. B, Radiograph of 37-year-old woman shows geographic radiolucent lesion with poorly dened margin (arrow) in distal femur. C, Radiograph of 19-year-old woman shows geographic radiolucent lesion with sclerotic margin (arrow) in proximal tibial metaphysis and epiphysis. (Fig. 1 continues on next page)

Received December 30, 2002; accepted after revision April 29, 2003.
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Department of Radiology, University of Chicago Hospitals, 5841 S Maryland Ave., MC 2026, Chicago, IL 60637. Address correspondence to G. S. Stacy. Department of Orthopedic Surgery, University of Chicago Hospitals, MC 3079, Chicago, IL 60637.

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Stacy et al. Fig. 1. (continued)Giant cell tumor. D, Radiograph of 38-year-old man shows expansile radiolucent lesion of rst metatarsal extending into soft tissues medially (arrow).

Fig. 2.Chondroblastoma. A, Radiograph of 16-year-old girl shows typical chondroblastoma (arrowheads) of proximal humeral epiphysis. B, Radiograph of 16-year-old boy shows geographic radiolucent lesion with nonsclerotic margins in proximal tibial metaphysis and epiphysis (arrowheads). No calcications were seen, even on CT (not shown). Although radiographic appearance suggests giant cell tumor, youth of patient makes diagnosis atypical.

Fig. 3.Chondromyxoid broma. A, Radiograph of 16-year-old boy shows typical chondromyxoid broma (arrowheads) of metadiaphysis of fth metatarsal. Lesion is well dened with characteristic bubbly lobulated appearance and sclerotic margin. B, Radiograph of 42-year-old man shows geographic radiolucent lesion with nonsclerotic margin in metaphysis and epiphysis of proximal tibia (arrowheads). No calcications are visible. Although radiographic appearance suggests giant cell tumor, ndings of pathology revealed diagnosis of chondromyxoid broma.

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Fig. 4.Enchondroma. Radiograph of 52year-old man shows slightly expansile radiolucent lesion (arrowheads) in proximal phalanx of middle nger approaching articular surface of proximal interphalangeal joint.

Fig. 5.Chondrosarcoma. Radiograph of 32year-old man shows geographic radiolucent lesion (arrowheads) in proximal humeral metaphysis and epiphysis. Small foci of calcication (arrows) effectively exclude giant cell tumor as potential diagnosis. Results of pathology revealed chondrosarcoma.

Fig. 6.Radiograph of 38-year-old woman with osteoblastoma. This case is unusual, in which well-dened radiolucent lesion with nonsclerotic margin (arrowheads) in proximal humerus mimics giant cell tumor. Only rarely do osteoblastomas have this appearance.

lytic, exhibiting geographic bone destruction. Most have well-dened but nonsclerotic margins (Fig. 1A). A minority (1020%) have less well-dened margins (Fig. 1B), and sclerotic margins are rare (Fig. 1C). When present in long bones, the lesions arise in the metaphysis, with characteristic extension across a fused physis into the epiphysis (or apophysis). Radiographs may show internal pseudotrabeculae representing osseous ridges formed by endosteal scalloping. Although periosteal reaction is atypical, expansile remodeling, cortical penetration, and soft-tissue extension are frequent [1] (Fig. 1D).

Chondromyxoid bromas are rare tumors that occur predominantly in the second and third decades of life. They usually arise within the metaphysis of long bones with occasional diaphyseal extension. They characteristically have sclerotic margins and appear lobulated and bubbly (Fig. 3A). Calcica-

tion is uncommon [2]. Rarely, chondromyxoid bromas lack sclerotic margins and extend into the epiphysis of long bones, resembling giant cell tumor (Fig. 3B). The average age of patients with chondromyxoid broma ( 25 years) is only slightly younger than that of patients with giant cell tumor,

Cartilage-Forming Tumors Mimicking Giant Cell Tumor of Bone

Chondroblastomas are radiolucent lesions that typically occupy the epiphysis (or apophysis) of long bones (Fig. 2A). They tend to be small (< 4 cm) with most ( 75%) exhibiting a sclerotic border [2, 3]. A calcied matrix is seen on radiographs in one third of patients [4]. Chondroblastomas may mimic giant cell tumor when they extend into the metaphysis and lack sclerotic margins and calcication (Fig. 2B). Unlike giant cell tumor, chondroblastomas present in a younger age group, usually before skeletal maturity. Extension of tumor into soft tissues is rare with chondroblastoma.

Fig. 7.Radiograph of 18-year-old woman with osteosarcoma. This case is unusual, in which radiolucent lesion (arrowheads) in distal ulna extends to articular surface, with radiographic appearance indistinguishable from giant cell tumor. Only rarely do osteosarcomas have this appearance.

Fig. 8.Radiograph of 78-year-old woman with metastasis of renal cell carcinoma. Radiolucent lesion in distal tibia (arrowheads) extends to articular surface. Although radiographic appearance is compatible with giant cell tumor, advanced age of patient argues otherwise. Results of pathologic examination conrmed metastasis from primary kidney tumor.

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Fig. 9.13-year-old girl with aneurysmal bone cyst. A, Radiograph shows slightly expansile geographic radiolucent lesion (arrowheads) in distal humerus approaching articular surface. B, T2-weighted coronal STIR image reveals multicystic lesion with numerous uid levels (arrowheads), typical of aneurysmal bone cyst.

Fig. 10.25-year-old woman with giant cell tumor with secondary aneurysmal bone cyst formation. A, Radiograph shows radiolucent lesion in proximal tibia (arrow) approaching articular surface. B, T1-weighted axial image with fat saturation reveals uiduid levels (arrowheads) in addition to enhancing solid component (arrow) of lesion.

Fig. 11.Radiograph of 26-year-old woman with giant cell reparative granuloma shows expansile lytic lesion (arrow) of second metacarpal with internal trabeculation extending to metacarpophalangeal joint.

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Fig. 12.Intraosseous ganglionic cysts. A, Radiograph of 23-year-old man shows radiolucent lesion (arrowheads) of proximal tibia. Small size of lesion and sclerotic margin argue against giant cell tumor. B, Radiograph of 32-year-old woman shows radiolucent lesion with sclerotic margin (arrow) in medial malleolus. C, T2-weighted coronal image with fat saturation shows medial malleolus lesion (B) to be of loculate uid signal intensity (arrow). Medial malleolus is common location for intraosseous ganglionic cysts.

with sufcient overlap. Soft-tissue extension is uncommon [5]. Enchondromas are seldom confused with giant cell tumors on radiographs of long bones, but differentiating the two entities in the small bones of the hands (Fig. 4) and feet may be difcult. Both tumors can appear purely lytic and involve most of the volume of a small bone, including the subarticular portion. The margins of enchondromas are commonly sclerotic, however, and enchondromas are asymptomatic unless fractured [2].

Medullary chondrosarcomas, when present in long bones, have a predilection for metadiaphysis or diaphysis; extension to the articular surface may occasionally occur, suggesting the diagnosis of giant cell tumor (Fig. 5). Most medullary chondrosarcomas are low-grade lesions that may have a deceptively benign radiographic appearance. Identifying calcication supports the diagnosis of a cartilageproducing tumor; however, calcication may not be visible on radiographs. Chondrosarcomas tend to occur more often in an older age group than do giant cell tumors [2].

Lesions with sclerotic margins may appear to have matrix mineralization when, in fact, the suspected internal calcication is actually due to the density of peripheral septations of the margin itself. CT allows condent assessment of matrix mineralization.
Bone-Forming Tumors Mimicking Giant Cell Tumor

Bone-forming neoplasms are rarely mistaken for giant cell tumor. Unusual examples of osteoblastoma (Fig. 6) and osteosarcoma (Fig. 7) mimicking giant cell tumor are included [6, 7].

Fig. 13.51-year-old man with rheumatoid arthritis. A, Radiograph shows large, geographic radiolucent lesion (arrow) in proximal humerus extending to articular surface, mimicking giant cell tumor. Glenohumeral joint space is narrowed. Radiograph of contralateral shoulder (not shown) revealed similar ndings. Only rarely do synovial cysts achieve this size and mimic neoplasm. B, Radiograph of hand shows typical ndings of rheumatoid arthritis, including narrowing and erosions involving multiple joints. Note soft-tissue swelling around third and fourth proximal interphalangeal joints and ankylosis of second metacarpophalangeal joint.

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Fig. 14.66-year-old man with pigmented villonodular synovitis. A, Radiograph shows large, geographic radiolucent lesion (arrowheads) in proximal tibia extending to articular surface, mimicking giant cell tumor. This lesion represents atypically large synovial protrusion of pigmented villonodular synovitis. B, Lateral knee radiograph shows unusually dense joint effusion (asterisk) in suprapatellar pouch. C, T2-weighted sagittal image shows tibial lesion (A) (black arrow) as well as multiple intraarticular masses of low signal intensity (white arrows) representing hemosiderin-laden pigmented villonodular synovitis.

Other Tumors and Tumorlike Lesions

The diagnosis of metastases or multiple myeloma is straightforward if numerous lesions are noted throughout the skeleton. A solitary lesion may mimic giant cell tumor if located in the subchondral region of a long bone (Fig. 8). Metastasis or myeloma is likely if the lesion occurs in an elderly individual, beyond the typical age range of patients with giant cell tumor.

Aneurysmal bone cysts are lytic, often expansile lesions most commonly occurring in the metaphysis of long bones. They arise in a younger group (usually between 5 and 20 years old) than do giant cell tumors. If the cyst occurs or persists after physeal closure, then it may extend into the epiphysis and be indistinguishable from giant cell tumor (Fig. 9A). CT or MRI may reveal uid levels, representing layering blood products (Fig. 9B). Lack of en-

hancing solid components would also support the diagnosis of aneurysmal bone cyst over giant cell tumor. An aneurysmal bone cyst may form within a giant cell tumor [1]. This should be suspected if the age of the patient and the radiographic appearance of the lesion are suggestive of giant cell tumor (Fig. 10A) and if ndings of CT, MRI, or both reveal uid levels in addition to an enhancing solid component (Fig. 10B).

Fig. 15.Brown tumors of hyperparathyroidism. A, Radiograph of 71-year-old man shows pathologic fracture through radiolucent lesion (arrow) of proximal phalanx of middle nger. Brown tumor was suspected on basis of subtle subperiosteal resorption along radial aspect of middle phalanges (arrowheads), indicating hyperparathyroidism. B, Radiograph of 55-year-old woman shows pathologic fracture through large lytic lesion (arrow) of proximal tibia. Scalloping of medial border of proximal tibia (arrowheads) suggests subperiosteal resorption of hyperparathyroidism. Results of pathology revealed diagnosis of brown tumor.

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Fig. 16.30-year-old man with pseudotumor of hemophilia. A, Radiograph shows eccentric radiolucent lesion (arrowheads) of proximal tibia with sclerotic margins extending to articular surface. Moderate degenerative changes are noted in knee joint for patient of this age. B, Lateral radiograph of same knee as show in A depicts proximal tibial lesion (arrow) as well as small but unusually dense joint effusion (or synovium) suggestive of hemosiderin deposition.

A Giant cell reparative granuloma is a reactive process that occurs in the small bones of the hands and feet (more frequently in the mandible and maxilla) and mimics giant cell tumor radiographically (Fig. 11). The lesions are lytic and expansile, but extension to the epiphysis is unusual. They tend to occur in a slightly younger age group (second and third decades of life) than do giant cell tumors and do not usually appear as aggressive on radiographs [1].
Mimics of Giant Cell Tumor Caused by Articular Processes

B compatible with repeated intraarticular hemorrhage may be seen (Fig. 16B).

References
1. Murphey MD, Nomikos GC, Flemming DJ, Gannon FH, Temple HT, Kransdorf MJ. Imaging of giant cell tumor and giant cell reparative granuloma of bone: radiologicpathologic correlation. RadioGraphics 2001;21:12831309 2. Moser RP. Cartilaginous tumors of the skeleton. Philadelphia: Hanley & Belfus, 1990:1633, 79 110, 129153, 164202 3. Kaim AH, Hugli R, Bonel HM, Jundt G. Chondroblastoma and clear cell chondrosarcoma: radiological and MRI characteristics with histopathological correlation. Skeletal Radiol 2002;31:8895 4. Bloem JL, Mulder JD. Chondroblastoma: a clinical and radiological study of 104 cases. Skeletal Radiol 1985;14:19 5. Wu CT, Inwards CY, OLaughlin S, Rock MG, Beabout JW, Unni KK. Chondromyxoid broma of bone: a clinicopathologic review of 278 cases. Hum Pathol 1998;29:438446 6. Norman A. Benign osteoblastic tumors. In: Taveras JM, Ferrucci JT, eds. Radiology. Philadelphia: Lippincott Williams & Wilkins, 2000:19 7. Rosenberg ZS, Lev S, Schmahmann S, Steiner GC, Beltran J, Present D. Osteosarcoma: subtle, rare, and misleading plain lm features. AJR 1995;165:12091214 8. Llauger J, Palmer J, Roson N, Cremades R, Bague S. Pigmented villonodular synovitis and giant cell tumors of the tendon sheath: radiologic and pathologic features. AJR 1999;172:10871091

MRI, intraosseous ganglia are of homogeneous uid signal intensity but may be loculate (Fig. 12C). Although the gelatinous cyst contents should not enhance after IV gadolinium administration, a peripheral rim of enhancement, due to surrounding connective tissue, is common. MRI may also reveal adjacent soft-tissue cysts. Arthritides such as rheumatoid arthritis (Fig. 13) and pigmented villonodular synovitis (Fig. 14) uncommonly produce giant synovial cysts or pseudocysts that mimic giant cell tumor [8].
Mimics of Giant Cell Tumor Caused by Systemic Processes

Intraosseous ganglionic cysts are benign lesions located in the subchondral bone adjacent to the joint and are usually found incidentally in young adults. Although the exact pathogenesis of these lesions is unknown, trauma, aseptic necrosis, and idiopathic connective tissue transformation are possible causes. Unlike the typical giant cell tumor, intraosseous ganglia are usually asymptomatic, are surrounded by a sclerotic border on radiographs (Fig. 12A), and are smaller than the average giant cell tumor. Favored sites include the proximal tibia (near the attachments of the cruciate ligaments) and the medial malleolus (Fig. 12B). On

Brown tumors of hyperparathyroidism are expansile and well marginated and can mimic giant cell tumors when they occur in the small bones of the hands (Fig. 15A) and feet, in at bones, or at the ends of long bones. Patients with brown tumors inevitably have additional radiographic features of hyperparathyroidism (Fig. 15B). Adult hemophilic pseudotumor may mimic giant cell tumor radiographically as an expansile lesion with endosteal scalloping (Fig. 16A). Unlike giant cell tumors, pseudotumors typically have sclerotic margins. Additional ndings

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