GIANT CELL TUMOR

VIVEK PANDEY

Introduction
Giant cell tumor: Benign but locally aggressive neoplasm, tendency for local recurrences. Histologically composed of proliferating mononuclear cells and osteoclast like multinuclear giant cells.

Giant cell tumor

1st described by Sir Astley Cooper in 1818. Commonest benign bone tumor.

Epidemiology
Incidence: 30% of all bone tumors Occurs in skeletally mature individual with peak incidence in 3rd decade. < 2% in open epiphyses. > 10% in pts > 65 yrs.

 Metaphysial area in skeletally immature bones (may extend to epiphysis through growth plate) Common sites: Sacrum, Distal Tibia, and Distal Radius. Uncommon sites: Sacrum, Distal Tibia, Proximal Femur, and Proximal Fibula. Rare Sites; Bone of Hand, Vertebra, and Ribs.

Clinical presentation
Pain Swelling Pathological fracture

Pathology
Gross Pathology:
Eccentric or central tumor Expanded cortex which is undergone resorption Tumor covered by thin sheet of new subperiosteal bone Gray to reddish brown in color, soft vascular friable tissue Areas of necrosis and hemorrhange resulting in cystification mimics aneurismal bone cyst.

Histology:
Vasularised network with two types of cells. Stormal cells: Round, oval or spindle shaped cells. Single large nucleus surrounded by indistinct cytoplasm Multinucleated Giant Cells: Nuclei similar to stromal cells, variable in numbers. Mitosis and intravascular invasion does not necessarily represent malignant nature. Osteoid production and Ossification are in small foci particularly at periphery. Correlation between histologic apperance and biologic behavior proved unreliable.

Radiography:
Lytic lesion in epiphysial region involving metaphysis. Expansile growth with thin shell of subpeiosteal new bone No gross periosteal reaction unless pathological fracture Tumor matrix shows no mineralisation Multiple septea may give rise to soap bubble apperance Radionuclide Scintigraphy: Increased uptake of Technitium-99m False uptake in adjacent areas may occur

Hence nonspecific and unreliable in defining the extend of tumor May be useful in rare multiple lesions Angiography: Seldom used as diagnostic modality Useful in determining the relationship with major vessel preoperatively Computed Tomography: Useful in determining cortical integrity, extra ossseous extension its Relation to adjacent structures and tumor recurrence. Distinction between tumor and muscle tissue is difficult. Magnetic Resonance imaging: Best imaging modality due to superior contrast resolution. Intramedullary tumor best seen in T1 weighted images. Extraossous portion best seen in T2 weighted images. Useful in determining joint involvement. Cortical integrity and recurrence are best seen on CT. than M.R.I Biopsy: Needle biopsy (Tru Cut) under Fluoroscopic isualization is preferred than surgical Biopsy. Accuracy is almost up to 90%

 Treatment: The most accepted form of treatment is surgical excision by various ways. Intralesional Excision: Curettage is usually supplemented by bonegrafts (Autografts or Allografts) Even careful and through curettage can leave behind microscopic disease especially in walls. Recurrence rate has been asw high as 40% to 60%. Complete deroofing the tumor, total exteriorization of contents and extensive irrigation are important steps. Sequential use of sharp instruments or high-speed burr is desirable.

 Intralesionaql excision with adjuvant therapy: Addition of adjuvants can extend the margin of excision. Commonly used adjuvants are phenol, Liquid nitrogen or Methylmethacrylate(cement). Phenol: Chemical agent applied to wall after curettage Liquid nitrogen: physical mean(cryosurgery). Marcove reported high incidence of local heat wound and bone complications. Methylmethacrylate: more accepted mode. Exothemic reaction generating local heat induces necrosis of remaining neoplastic tissue. Polymerization of methylmethacrylate may produce local cytotoxic effect. Prevents diffusion of nutrients and lowers local oxygen tension. Local relapse as low as 10%.

Wide local or marginal excision: Most desired form of treatment especially in aggressive lesions. It is advisable to go beyond the tumor margin and reactive zone. Extra-articular excision and even local synovectomy should be done if any doubt.

Reconstruction: Defect after resection of large mass at the end of long needs reconstruction can be achieved in following ways: Reconstruction with prosthesis: Using custom made prosthesis or Megaprosthesis. Young age in which this disease is common restrict these indication. Biologic reconstruction: Arthrodesis using autograft (turn-up or turndown)

 Chemotherapy: There are no effective chemotherapeutic agents available. Radiotherapy: Close association with secondary sarcomatous changes. With new super voltage therapy with different particle or secondary tumor. Should also be considered in sites like spine or sacrum. Tumor dose of 550 Gy divided doses in 5 to 5.5 weeks is considered adequate.

 Tumor Embolization: Preoperative: Done in large vascular growths to reduce the tumor mass and vascularity. Selective injection of Gelfoam or polyvinyl alcohol into arteries supplying the Tumor. Done one day to five days prior. Therapeutic: Done in unresctable tumors of sacrum or spine. Done at month interval till pain occurs (three or four times) Risk: Ischaemic injury to nerves and spinal cord.

 Reconstruction: Defect after resection of large mass at the end of long bone needs reconstruction Can be achieved in following ways: Reconstruction with prosthesis: Using custom made prosthesis or Megaprosthesis. Young age in which this disease is common restrict these indication. Biologic reconstruction: Arthrodesis using autograft (turn-up or turndown). Using Fibula as substitute for Radius. Using massive Allografts. Bone transport using lllizarov technique. Amputation: As a last resort if growth is extensive or intramedullary spread or a recurrence or the malignant changes.

Chemotherapy: There are no effective chemotherapeutic agents available. Radiotherapy: Close association with secondary sarcomatous changes. With new super voltage therapy with different particle or secondary tumor. Should also be considered in sites like spine or sacrum. Tumor dose of 550 Gy divided doses in 5 to 5.5 weeks is considered adequate. Tumor Embolization: Preoperative: Done in large vascular growths to reduce the tumor mass and vascularity. Selective injection of Gelfoam or polyvinyl alcohol into arteries supplying the Tumor. Done one day to five days prior. Therapeutic: Done in unresctable tumors of sacrum or spine.