Giant cell reparative granuloma of the phalanx of the hand with aggressive radiographic features

Giant cell reparative granuloma of the phalanx in a violinist

Giant cell reparative granuloma (GCRG) is a rare, pseudotumoural intraosseous lesion, considered a reactive injury after repeated trauma. Reactive lesions and benign bone tumours may show aggressive clinical and radiographic findings. Differential diagnosis must be performed in order to offer suitable treatment to the patient. Excisional biopsy and curettage of the lesion are the preferred methods of treatment. We present the first case of a GCRG of the distal phalanx of the left little finger in a professional violinist.

[Giant cell reparative granuloma of the metacarpal bone : Diagnostic difficulties]

Giant cell reparative granuloma (GCRG) is benign, non-tumorous granulation tissue. It mainly arises in the jaw bone and occasionally in the hand and foot. Because of the high rate of recurrence, wide surgical resection and autologous bone grafting are recommended. However, this can be problematic for hand function. We present a case report of a 16-year-old boy with a GCRG of the fifth metacarpal bone and the diagnostic difficulties. To treat the patient, we performed a wide resection with the interposition of a corticocancellous bone graft and plate osteosynthesis. 24 months postoperatively the patient shows no signs of recurrence and has good hand function.

Effect of denosumab on recurrent giant cell reparative granuloma of the lumbar spine

STUDY DESIGN

A case of recurrent giant cell reparative granuloma (GCRG) of the lumbar spine successfully treated with denosumab is reported; a fully human monoclonal antibody against the receptor activator of nuclear factor kappa B (RANK) ligand (RANKL).

OBJECTIVE

To report the first case of recurrent GCRG of the lumbar spine treated with denosumab.

SUMMARY OF BACKGROUND DATA

GCRG is a non-neoplastic osteofibrous lesion usually found in the maxilla and mandible but rarely in the spine. It is clinically distinct from giant cell tumor of bone (GCTB), although common histological characteristics such as the proliferation of spindle-shaped stromal cells and multinucleated giant cells are shared. Denosumab has recently been reported to be effective for unresectable GCTB; however, there is only one report of its effect on GCRG. Moreover, the effect of denosumab on GCRG of the spine is unknown.

METHODS

The clinical course, radiological features, pathology, and treatment outcome of a patient with recurrent GCRG of the lumbar spine treated with denosumab are documented.

RESULTS

Denosumab treatment was used for this patient with unresectable recurrent GCRG of the lumbar spine. Follow-up lumbar radiography showed significant bone formations in the tumor lesion after 3 months of treatment. On follow-up computerized tomography scans of the L2 and L3 vertebral lesions, the replacement of osoteolytic lesions by the formation of cortical-like bone tissue was clearly identified.

CONCLUSION

We report the first case of recurrent GCRG of the spine successfully treated with denosumab. Treatment with denosumab induced significant bone formation in the unresectable lumbar lesion with stable clinical improvement during the 12-month follow-up period without apparent complications. Denosumab shows promise as a new alternative treatment option for osteoclastic giant cell-rich tumors, such as GCRG, especially for unresectable lesions of the spine.

LEVEL OF EVIDENCE

4.

Giant Cell Reparative Granuloma of the Proximal Phalanx: A Case Report and Literature Review

The present article is a case report of a 16-year-old boy who presented with a benign bony tumour, which on histological analysis suggested giant cell reparative granuloma (GCRG), but was not corroborate by blood tests. The implications of this type of tumour and the correct diagnostic requirements were investigated. The correct identification of GCRG from other giant cell-containing tumours is important because the treatment modalities for these tumours significantly differ from one another. In most cases, histological findings are sufficient to identify the tumours. In most GCRG cases, curettage is usually a curative treatment option. However, due to high recurrence rates of GCRGs, close follow-up of these patients is warranted. Also, due to osteoclastic activity of the giant cells in GCRGs, the use of drugs such as calcitonin or bisphosphonates, which inhibit osteoclast differentiation and activation, may have an important influence on future treatments or in reducing the recurrence rate of these tumours.

Tumours of the hand: a review on histology of bone malignancies

Malignant bone tumours of the hands are uncommon. Although almost all lesions that occur in other parts of the skeleton can also affect the hands, their frequency, distribution and clinical characteristics differ. This review focusses on the histology of these tumours and gives an overview of the main differential diagnoses. Close correlation to radiologic and clinical features usually leads to the correct diagnosis.

Central giant cell granuloma of the jaws: clinical and radiological evaluation of 22 cases

OBJECTIVE

The objective was to investigate the clinical and radiological characteristics of central giant cell granulomas (CGCGs) of the jaws.

METHODS

A retrospective analysis of a 20-year database was performed regarding both clinical and radiological features of 22 patients affected with CGCGs of the jaws.

RESULTS

Fourteen women and 8 men were included with the age range of 7-81 years (mean 31.7 years). Among the 22 lesions, 16 were located in the mandible and 6 in the maxilla. Painless swelling was the most common clinical feature in 18 of all cases. Limited mouth opening was noted in 2 patients where the lesions involved the condyle. Radiographically, 13 lesions were homogeneously osteolytic and 9 lesions were trabeculated. Fifteen lesions were unilocular and 14 lesions presented with well-defined but not sclerotic margins. CT images in 5 patients clearly showed the trabeculation within the lesions. The follow-up ranged from 1.5 to 11 years with a mean period of 5 years. Three out of 9 aggressive and 1 out of 13 nonaggressive lesions developed recurrence.

CONCLUSIONS

Diagnosis of CGCGs of the jaws depends on both correct interpretation of clinical, radiographic and pathological data. Differentiation between aggressive and nonaggressive CGCGs should be considered to improve individual treatment planning.

A case of an aneurysmal bone cyst of a metatarsal: review of the differential diagnosis and treatment options

Aneurysmal bone cyst localized to the metatarsus, while not unheard of, is rather uncommon. The differential diagnosis for this lesion can be challenging, particularly in regard to the possibility of the presence of other giant cells containing tumors of bone, such as giant cell tumor, giant cell reparative granuloma, Brown's tumor of hyperparathyroidism, and telangiectatic osteosarcoma. We report a case of an aneurysmal bone cyst localized to the third metatarsal in a 14-year-old girl who presented with limping, progressively worsening local pain, and swelling in her left foot. The differential diagnosis for her condition was extensive. Ultimately, an en bloc resection was undertaken and the defect was replaced with tricortical iliac autograft. Pathological analysis of the resected tissue was consistent with aneurysmal bone cyst. There was complete healing with no sign of recurrence 3 years after the surgery.

LEVEL OF CLINICAL EVIDENCE

4.

Novel karyotypes in giant cell-rich lesions of bone

Giant cell-rich lesions of bone, including giant cell tumor of bone, giant cell reparative granuloma (GCRG), and aneurysmal bone cyst (ABC), may have overlapping clinical, radiologic, and histopathologic features. In fact, GCRG and solid ABC are currently differentiated solely based on skeletal location. Prior cytogenetic studies have reported that telomeric associations are present in the majority of giant cell tumors of bone, whereas translocations involving 16q22 and/or 17p13 are characteristic of ABCs. There is only one previously published karyotype of a GCRG, which revealed a reciprocal translocation, t(X;4)(q22;q31.3). We report 3 cases of giant cell-rich bone lesions with novel karyotypes: one lesion located in the first metacarpal, a typical location for GCRG, was histologically consistent with a giant cell tumor and showed the following karyotype [46,XX,inv(2)(p13q21),t(inv2;11)(q21;q13)]; the second lesion, also a giant cell tumor of bone, in the sacrum showed the following karyotype [46,XX,r(9)(p24q34)[cp7]/46,idem,?r(16)(p13.3q24)[cp10]/46,XX]. The third lesion, a hard palate mass, had the histopathologic features of a GCRG and a karyotype showing a reciprocal translocation, 46,XY,t(2;10)(q23;q24). These findings suggest that at least a subset of GCRGs may be neoplastic and that these lesions differ cytogenetically from classic giant cell tumors of bone or solid ABC, although the latter entity is otherwise indistinguishable from reparative granuloma. Further cytogenetic characterization of giant cell-rich bone lesions may improve the utility of karyotyping as a tool in their differential diagnosis and may shed light on the pathogenetic relationship between these lesions.

From the archives of AFIP. Imaging of giant cell tumor and giant cell reparative granuloma of bone: radiologic-pathologic correlation

The radiologic features of giant cell tumor (GCT) and giant cell reparative granuloma (GCRG) of bone often strongly suggest the diagnosis and reflect their pathologic appearance. At radiography, GCT often demonstrates a metaepiphyseal location with extension to subchondral bone. GCRG has a similar appearance but most commonly affects the mandible, maxilla, hands, or feet. Computed tomography and magnetic resonance (MR) imaging are helpful in staging lesions, particularly in delineating soft-tissue extension. Cystic (secondary aneurysmal bone cyst) components are reported in 14% of GCTs. However, biopsy must be directed at the solid regions, which harbor diagnostic tissue. These solid components demonstrate low to intermediate signal intensity at T2-weighted MR imaging, a feature that can be helpful in diagnosis. Multiple GCTs, although rare, do occur and may be associated with Paget disease. Malignant GCT accounts for 5%-10% of all GCTs and is usually secondary to previous irradiation of benign GCT. Treatment of GCT usually consists of surgical resection. Recurrence is seen in 2%-25% of cases, and imaging is vital for early detection. Recognition of the spectrum of radiologic appearances of GCT and GCRG is important in allowing prospective diagnosis, guiding therapy, and facilitating early detection of recurrence.

Giant cell tumor of the bones of the hand and foot

BACKGROUND

Giant cell tumor of the small bones of the hand and foot is suspected of having some peculiar features compared with giant cell tumor in other sites. Moreover, it could share some features with other giant cell rich lesions involving the hand and foot, and this may affect the differential diagnosis. The aim of this study was to analyze the features of lesions such as these in the files of the Rizzoli Orthopedic Institute.

METHODS

The incidence of giant cell tumors of the bones of the hand and foot seen at the Rizzoli Orthopedic Institute over 50 years (1947-1997) was taken into consideration. There were 8 lesions of the hand and 21 of the foot. Clinical information and follow-up of the patients were studied and updated. Radiographs were studied and radiographic features analyzed. Histopathologic material was thoroughly reviewed and histologic features analyzed.

RESULTS

Although the location of tumor was helpful information, radiographic features were not specific. Giant cell tumors of the small bones of the hand and foot showed a predominance in females, younger patients and more aggressive behavior than giant cell tumors of large bones. The authors did not observe multicentricity or pulmonary metastases.

CONCLUSIONS

Because the radiographic features of giant cell tumor of the hand and foot overlap those of other giant cell rich lesions in these locations, histologic diagnosis is mandatory, although it may be difficult and require the establishment of diagnostic criteria for giant cell tumor. As this tumor tends to be more aggressive than other giant cell rich lesions, treatments of choice are aggressive curettage or resection.