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AUGUST 2017

GIANT CELL TUMOR


By :

MUH.YUSUF M C11111 893 NURHIDAYAH C11111 120

YORICHE TALLAMMA C11111 293 ANDI NIRMAWATI. AR C11112 063

ADVISOR:

dr. ALFA JANUAR

dr. MOH. ASRI ABIDIN

SUPERVISOR :

dr. DEWI KURNIATI, M.Kes, Sp.OT

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 August 2017
Chief Complain : Pain in the left leg
Pain is felt since +/- 1 year ago, pain is felt especially
during the night and not affected by activity. The patient is
difficult to move normally
Looks lumps on the left leg since +/- 6 months ago, initially
only as big as marbles and getting bigger since last 3
months.
History of weight loss since 2 months ago
There is no cough history
Fever(-), nausea(-), vomiting (-)
There is no history of trauma
There was no family history
Prior treatment from RSUD Jayapura
GENERAL STATUS
Moderate sick/malnutrition/compos mentis
(E4M6V5)
Vital sign :
- BP : 130/80 mmHg
- HR : 89 bpm
- RR : 18 bpm
- T : 36.5 C
VAS : 4/10
Localized status
( Left Leg Region)
Lumps on the left leg, spherical, not hyperemic, no wound on
LOOK the lump (abscess / ulcer), no venectasi.

FEEL Consistency of solid hard, immobile, flat surface is not lumpy,


borderless, warm, with a size of 6cm x 5cm x 3cm

MOVE The movement of the hip joint and the knee joint within normal
limits, the ROM within normal limits

NVD Sensibility (Peroneus profundus nerve) within normal limits,


arterial pulsation (Tibialis and doraslis pedis artery) within
normal limits, CRT <2 sec
CLINICAL FINDING
RADIOLOGY FINDING
There is an expansive lytic lesion that
gives a soap bubble that destroys the
cortex on the epifise area, the
metaphysical proximal os tibia sinistra
No periosteal reaction
Soft tissue swelling
reduced bone mineralization
Femoro tibia joint gap narrowed
impression media

Impression: Sugestif Giant cell

1. Lower Leg AP/Lateral 2/08/2017 Tumor proximal tibia sinistra


RADIOLOGY FINDING

Reduced bone mineralization


Soft tissue in the distal femur
looks swelling
Impression:
Disused osteoporosis
Soft tissue swelling

2. Knee AP/Lateral 02/08/2017


RADIOLOGY FINDING

CT-SCAN of Genu-Proximal-Cruris sinistra


Jayapura 20 /07/2017
CT-SCAN OF GENU
Sclerotic and lytic lesions appear, the central
(central osteosarcoma) in the metaphysical part
of the proximal left tibia bone
Lusen looked round or oval lesions with ill
defined in the proximal tibia and the genu
Mass-soft tissue looks, no calcification appears
Popcorn matrix calcification distal femur and
patella
Looks minimal periosteal reaction
LABORATORY FINDING
WBC 8700/ul
HGB 14.8 g/dl
HCT 44 %
PLT 283.000/ul
HbsAg Non-reactive
CT 8.00 menit
BT 3.00 menit
SGOT 25
SGPT 15
GDS 90 mg/dl
Ur/Cr 21/ 0.90
Na/K/Cl 143/5.2/104
LED I=21 II=40
ASSESMENT
Benign Primary Bone Tumor of Left Proximal
Tibia susp.Giant Cell Tumor Campanaci Grade
III
MANAGEMENT
Analgesic
Biopsi
PLANNING
Waiting for biopsy results
DISCUSSION
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)
Bone scan
Investigations
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
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
REFERENCES
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Maj Kedokt Indon, Volum: 57, Nomor: 11, Nopember 2007. h. 404-407

3. Silvers A R, Peter M S, Margaret B, dkk. The Role of Imaging in the Diagnosis of


Giant Cell Tumor of the Skull Base. in : Tumor of Skull Base, August 1996. h .
1392-1395.

4. American Academy of Orthopedic Surgeons. Giant Cell Tumor of Bone. June 2010.
Available from URL://orthoinfo.aaos.org

5. Haque A U and Moatasim A. Giant Cell Tumor of Bone: A Neoplasm or a Reactive


Condition. Int J Clin Exp Pathol ;2008 .h. 489-501
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URL : http://emedicine.medscape.com

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http://emedecine.medscape.com

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from URL : http://atlasgeneticsoncology.org

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from URL:http//.www.bonetumor.org
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