Malignant Giant Cell Tumor of the Skull Base Originating From Clivus and Sphenoid Bone

Giant Cell Tumor of the Temporal Bone with Direct Invasion into the Middle Ear and Skull Base: A Case Report

Giant cell tumor (GCT) of bone is a rare, benign, osteolytic neoplasm that most commonly occurs in early adulthood and often involves the long bones of the body. Although GCT largely affects the epiphyses of long bones, several reports of GCT involvement of the cranial and facial bones exist in the literature. In addition to reviewing other reported cases of GCT of the lateral skull base in the literature, the authors report here on the clinical presentation, radiographic findings, and management of a patient found to have a GCT of the squamous part of temporal bone invading the middle ear and infratemporal fossae, which was treated by en bloc resection of the lateral skull base.

Treatment of Clival Giant Cell Tumor: A Case Report and Literature Review

Giant cell tumors (GCTs) are locally aggressive primary bone tumors of osteoclast-like cells. Most GCTs occur within the long bones, and primary GCTs involving the clivus are extremely rare. We present the case of an 18-year-old boy with binocular horizontal diplopia with an insidious onset who was found to have a hypointense enhancing mass involving the clivus and left side dorsum sellae on magnetic resonance images. The tumor was completely resected via an endoscopic endonasal transclival approach, and histopathologic examination via immunohistochemistry indicated a GCT. The patient's left abducens nerve palsy improved slightly after surgery. Because of the rarity of GCTs, there is no consensus about the definitive treatment protocol. However, we suggest that gross total resection is the treatment of choice, and denosumab plays a critical role in patients with subtotal resection.

Non-chordomatous clival bony tumors: A rare experience and systematic literature review

BACKGROUND

Non-chordomatous bony tumors of the clivus are extremely rare. Site, extent, and aggressiveness of tumor limits the extent of resection. It poses challenge to the neurosurgeons due to the complexity of anatomy. There is paucity of literature exclusively on non-chordomatous bone tumors of the clivus in young adults.

OBJECTIVES

To analyze the clinical presentation, imaging findings, surgical approach, complications, and outcome of primary clival bony tumors in young adults.

METHODS

We retrospectively reviewed children and young adults with primary clival bony tumors excluding chordoma who underwent surgical resection between years 2010 and 2023 in our center. We analyzed the demographic details, imaging findings, operative variables, perioperative complications, length of stay, complications, and outcome at latest follow-up.

RESULTS

The mean age was 17.5 ± 1.73 years (range 16 to 19 years). Headache was the presenting complaint in all four patients (100%). The mean duration of symptom was 7.25 ± 3.2 months (range 5 to 12 months). The tumor was localized in clivus in all four patients (100%). The mean length of stay in hospital was 30.5 ± 13.48 days (range 11 to 40 days). All patients underwent surgical treatment. Surgical approaches used were anterior approach in four patients (100%). Gross total excision was performed in one patient (25%), sub-total excision was performed in two patients (50%), and tumor decompression was performed in one patient (25%). Of these, three were designated as having benign tumors and one had a malignant tumor. There was no perioperative mortality. There was one mortality (25%) on 2 months follow-up due to tumor progression. Three patients (75%) had improved symptomatically at latest follow-up. Two patients (50%) received adjuvant chemoradiotherapy. The mean follow-up was 38 ± 39.29 months (range 2 to 72 months).

CONCLUSION

Non-chordomatous bony tumors of the clivus are rare and often underestimated. Surgery is the treatment of choice. Tumor consistency and adhesion to critical neurovascular structures precludes gross total resection. Various approaches are in the armamentarium. Approach to be decided based on the expertise of the neurosurgeon to achieve safe maximal resection. Multidisciplinary approach is mandatory for streamlined management. Adjuvant therapy is decided based on the residual tumor following surgery.

Unresectable Clival Giant Cell Tumor, Tumor Control With Denosumab After Relapse: A Case Report and Systematic Review of the Literature

Giant cell tumors (GCTs) of the skull base are rare entities. Although considered histologically benign, GCTs are locally aggressive with a high rate of local recurrence. The present case describes a 14-year-old girl with a clival GCT who underwent long-term therapy with denosumab after local relapse. To our knowledge, it is the second case described with a follow-up term >2 years from the start of denosumab and who did not receive any other adjuvant treatment besides denosumab. The patient achieved a local control of the disease. According to the few available data, radical excision with adjuvant therapy helps in long-term control in uncommon sites, such as the skull. However, the definitive treatment is still controversial because of their rarity and few follow-up data. The present case highlights the benefit of denosumab and its safety as long-term therapy and contributes to the existing literature with analysis and evaluation of the management strategies and prognosis.

Histopathology of Parasellar Neoplasms

The anatomical and histological complexity of the parasellar region as well as the presence of embryonic remnants determine the huge diversity of parasellar neoplasms. Some of them are only located in the parasellar region, whereas others can occur elsewhere, within or outside the central nervous system. Their spectrum ranges from histologically benign and low-grade malignant to high-grade malignant tumours. Although rare, metastases can pose differential diagnostic dilemmas. The severity of the clinical picture, the challenges of surgery and the risk of adverse sequelae related to surgery or radiotherapy make parasellar tumours interesting entities for the clinicians irrespective of their histological malignancy grade. Due to the different cell origins of parasellar tumours, the World Health Organization classification system does not categorise them as a distinct group. Detailed criteria for classification and malignancy grading are presented in the classification systems covering central nervous system tumours, haematological malignancies and tumours of the soft tissue and bone. In the last few years, molecular genetic features have been integrated into the diagnosis of several types of the parasellar tumours enhancing diagnostic accuracy and providing information of the value for targeting therapies. In this review, we will present histopathological and molecular genetic features, updated classification criteria and recent advances in the diagnostics and rationale for novel pharmacological therapies of selected types of parasellar neoplasms.

Preoperative Cytoreduction of Clival Giant Cell Tumor: An Effective Replication of the Systemic Modality in the Skull Base

BACKGROUND

Giant cell tumors (GCTs) are benign tumors with a predilection for the epimetaphyseal region of the long bones. GCTs involving the skull base are rare, and only a few available cases have been reported. Surgical gross total resection is the recommended method of treatment for GCTs. In the case of skull base tumors, it is very difficult to achieve such a result by direct surgical resection alone without any morbidities. Denosumab is a fully humanized monoclonal anti-receptor activator of nuclear factor-κB ligand antibody that has been recently approved by the Food and Drug Administration for the treatment of GCTs that are surgically unresectable, metastatic, and have a high risk of progression and recurrence. Denosumab has been used in many cases involving the long bones. However, in cases of skull base GCTs, only a limited number of cases have been reported. In addition, in such cases, it was used as postoperative chemotherapy owing to subtotal resection.

CASE DESCRIPTION

For the present patient, we adopted a unique approach in which denosumab was administered as neoadjuvant chemotherapy to reduce the size of the tumor to a resectable level. Subsequently, surgical resection was performed with good functional and histopathological outcomes.

CONCLUSIONS

Our findings emphasize the use of denosumab as a neoadjuvant treatment routinely for all cases of skull base GCTs to achieve safe and complete excision of the tumor.

Giant Cell Tumor of the Lateral Skull Base: Diagnostic and Management Options

Giant cell tumor of bone (GCTB) is a rare, benign, osteolytic neoplasm that most commonly occurs in early adulthood and often involves the long bones of the body. Although GCTB largely affects the epiphyses of long bones, several reports of GCTB involvement of the cranial and facial bones exist in the literature. In addition to reviewing other reported cases of GCTBs of the lateral skull base in the literature, the authors report here on the clinical presentation, radiographic findings, and neurosurgical management of a patient found to have a GCTB of the middle and infratemporal fossae, which was treated by aggressive en bloc resection of the lateral skull base.

The identification of H3F3A mutation in giant cell tumour of the clivus and the histological diagnostic algorithm of other clival lesions permit the differential diagnosis in this location

BACKGROUND

Giant Cell Tumour of Bone (GCT) is a locally aggressive primary bone tumour that usually occurs at the epiphyses of the long bones of the appendicular skeleton with a tendency to recurrence. Recurrent somatic H3F3A mutations have been described in 92% of GCT cases. GCTs involving the Clivus are extremely rare lesions and less than 15 cases are described in the literature. They represent a surgery challenge and are easily misdiagnosed. Our aim was to reveal if the genetic bases underlying Clival GCTs were the same of GCTs of long bones to improve the diagnosis and treatment.

METHODS

The targeted somatic sequencing of GCT-related genes (H3F3A, H3F3B, IDH1, IDH2 and ZNF687) was performed on Clival GCT biopsies of two different cases. Histological analyses on the same tissues were used to detect the neoplastic population and its expression profile.

RESULTS

Sanger sequencing revealed that both patients were positive for the p.Gly34Trp mutation in the H3F3A gene. Immunofluorescence assay using monoclonal antibody, specifically detecting the mutant H3.3, highlighted that the mutation only involved the mononuclear cell population and not the multinucleated giant cells. Moreover, immunohistochemistry assay showed that RANKL was highly expressed by the stromal cells within Clival GCT, mimicking what happens in GCT of the long bones. In addition, systematic literature review allowed us to generate a histology-based diagnostic algorithm of the most common clival lesions.

CONCLUSIONS

We conclude that the Clival GCT is genetically defined by somatic mutation in the H3F3A gene, linking it to the GCT of long bones. The similarity with GCTs of long bones let us to hypothesize the utility of Denosumab therapy (already effective for GCTs) in these surgically challenging cases. Moreover, H3F3A genetic screening can be combined to the histological analysis to differentiate GCTs from morphologically similar giant cell-rich sarcomas, while the histological diagnostic algorithm could help the differential diagnosis of other clival lesions.

Central giant cell lesion of the mandible in a 2-year old girl

Central giant cell lesions are rare, benign, osteolytic, pseudocystic, solitary, localized lesions that are common in the skeletal structure, but less so in the maxillofacial region. Furthermore, to perform panoramic radiography and cone-beam computed tomography, it is necessary to prepare patients properly and to position their heads carefully. However, this can be difficult in pediatric patients, who may be anxious. In this report, we describe the case of a central giant cell lesion of the mandible in a 2-year-old girl that was evaluated with multidetector computed tomography.

Denosumab treatment for progressive skull base giant cell tumor of bone in a 14 year old female - a case report and literature review

Background

Giant cell tumor of bone (GCT) is a rare primary bone tumor, which can metastasize and undergo malignant transformation. The standard treatment of GCT is surgery. In patients with unresectable or metastatic disease, additional therapeutic options are available. These include blocking of the receptor activator of NF-kappa B ligand (RANKL) signaling pathway, which plays a role in the pathogenesis of GCT of bone, via the anti-RANKL monoclonal antibody denosumab.

Case Presentation

Herein we report on a female teenager who presented in a very poor clinical condition (cachexia, diplopia, strabismus, dysphonia with palsy of cranial nerves V, VI, VIII, IX, X, XI and XII) due to progressive disease, after incomplete resection and adjuvant radiotherapy, of a GCT which affected the cervical spine (C1 and C2) as well as the skull base; and who had an impressive clinical response to denosumab therapy. To the best of our knowledge, this is the youngest patient ever reported with a skull base tumor treated with denosumab.

Conclusion

In situations when surgery can be postponed and local aggressiveness of the tumor does not urge for acute surgical intervention, upfront use of denosumab in order to reduce the tumor size might be considered. Principally, the goal of denosumab therapy is to reduce tumor size as much as possible, with the ultimate goal to make local surgery (or as in our case re-surgery) amenable. However, improvement in quality of life, as demonstrated in our patient, is also an important aspect of such targeted therapies.

Electronic supplementary material

The online version of this article (doi:10.1186/s13052-017-0353-0) contains supplementary material, which is available to authorized users.

Treatment of a skull-base giant cell tumor with endoscopic endonasal resection and denosumab: case report

A 34-year-old man with a 1-week history of diplopia was referred to the authors' hospital. Neurological examination revealed left abducens nerve palsy. Computed tomography showed a lesion in the left sphenoid sinus involving the medial wall of the left internal carotid artery (ICA) and osteolytic change at the clivus bordering the lesion. Magnetic resonance imaging demonstrated an extensive soft-tissue mass occupying the left sphenoid sinus. Surgical intervention by the endoscopic transnasal method allowed most of the lesion to be removed. Only the portion attached to the medial wall of the ICA was not removed. Postoperatively, the lesion was diagnosed as a giant cell tumor (GCT) and the patient received 120 mg of subcutaneous denosumab every 4 weeks, with additional doses on Days 8 and 15 during the first month of therapy. MRI a week after starting denosumab revealed shrinkage of the initially fast-growing residual tumor. The patient was discharged upon completion of the third denosumab administration. GCT is an aggressive stromal tumor developing mainly in young adults. Complete resection is recommended for GCT in the literature. However, size and location of the CGT often limit this approach. Various adjuvant treatments for skull base GCTs have been reported, including radiation and chemotherapy. However, the roles of adjuvant therapies have yet to be clearly defined. Denosumab, a monoclonal antibody, was recently approved for GCT in several countries. Denosumab may permit less invasive treatments for patients with GCTs while avoiding deleterious outcomes, and may also limit disease progression and recurrence.

Clival giant cell tumor - A rare case report and review of literature with respect to current line of management

Giant-cell tumor (GCT) involving the skull base is rare. Sphenoid bone is the most commonly involved bone followed by petrous temporal bone. Histopathology and radiological features of these lesions are similar to GCT involving bone elsewhere. Unlike other sites, skull base is not an ideal site for the radical surgery. Hence adjuvant treatment has pivotal role. Radiation therapy with intensity-modulated radiation therapy, stereotactic radiosurgery or chemotherapy with adriamycin are promising as described in some case reports. Bisphosphonates showed good control in local recurrence. In vitro studies with Zolendronate loaded bone cement and phase 2 trials of Denosumab showed hopeful results, may be useful in future.

Recurrent Giant Cell Tumor of Skull Combined with Multiple Aneurysms

Giant cell tumors are benign but locally invasive and frequently recur. Giant cell tumors of the skull are extremely rare. A patient underwent a surgery to remove a tumor, but the tumor recurred. Additionally, the patient developed multiple aneurysms. The patient underwent total tumor resection and trapping for the aneurysms, followed by radiotherapy. We report this rare case and suggest some possibilities for treating tumor growth combined with aneurysm development.

Role of Denosumab in Endoscopic Endonasal Treatment for Juvenile Clival Giant Cell Tumor: A Case Report and Review of the Literature

BACKGROUND

Giant cell tumors (GCTs) are histologically benign bone neoplasms with a locally aggressive nature that primarily occur in the epiphyses of the long bones. A small proportion of these tumors, however, occur in the pelvis, spine, or skull bones. Among these, GCTs of the skull base cannot be completely resected and require adjuvant therapy. We report a juvenile case of clival GCT that was successfully treated by endoscopic endonasal transsphenoidal surgery and subsequent adjuvant therapy with denosumab, a monoclonal antibody to receptor activator of nuclear factor-κB ligand.

CASE DESCRIPTION

A 16-year-old boy was admitted to our hospital with progressively intolerable headache and right oculomotor nerve palsy. Computed tomography and magnetic resonance imaging showed a large tumor mass in the sphenoid sinus with extensive erosion of the clivus and compression of the right cavernous sinus. The tumor was resected by endonasal transsphenoidal surgery and histologically diagnosed as GCT. The giant cells showed positive immunostaining for CD68 and Mib-1 labeling index was less than 1.0%. Postoperative course was uneventful and the oculomotor disturbance was markedly improved. However, magnetic resonance imaging 2 weeks after surgery revealed marked enlargement of the tumor. Adjuvant therapy with denosumab was therefore initiated, resulting in marked reductions in tumor size.

CONCLUSIONS

This is the first report to describe beneficial effects of denosumab in the treatment of GCT of the skull base.

Giant cell tumors of the clivus: Case report and literature review

BACKGROUND

Clival giant cell tumors (GCTs) are extremely rare with only eight cases reported to date, and malignant transformation is quite rare. Herein, we report a case of an uncontrolled clival GCT, which was transformed malignant, and review the literature.

CASE DESCRIPTION

A 25-year-old man experienced double vision for 1 month. Computed tomography and magnetic resonance imaging revealed a clival tumor. The endonasal endoscopic transsphenoidal approach (EEA) was used, and partial resection was performed because of massive bleeding. Histological examination showed a GCT. After radiation therapy, the tumor recurred; the EEA and the anterior transpetrosal approaches were used to perform second and third operations, respectively. The MIB-1 index increased from 4.2% to 26.3%.

CONCLUSIONS

GCTs are difficult to treat because of their location, vascularity, and the potential for malignant transformation.

Endoscopic endonasal treatment of a large clival giant cell tumor invading the cavernous sinus and temporal lobe

Giant cell tumors (GCTs) are extremely rare lesions, representing less than 5% of all bone tumors. They primarily occur in the long bones. However, a small percentage of these tumors occur in the pelvis, spine, or skull bones. These lesions are usually benign as well as locally aggressive and require complete removal. Nowadays, GCT and other skull base lesions can be treated using the extended endoscopic endonasal approach. We present a case report of a GCT located in the skull base, originating from the clivus and sphenoid bone, invading through the cavernous sinus, and treated using the fully endoscopic endonasal approach.

Rare Presentation of Giant Cell Tumor in the Internal Auditory Canal: Case Report and Review of the Literature

Giant cell tumor (GCT) is a benign but locally aggressive bone tumor that usually involves the end of long bones. It is a relatively common neoplasm in patients, constituting 5 to 10% of all benign bone tumors. Approximately 2% of GCTs occur in the craniofacial skeleton with a predilection for the ethmoid, sphenoid, and temporal bones. The skull base location is unique and not commonly described. Hearing loss, headache, tinnitus, and subcutaneous masses are the most commonly reported symptoms in GCTs of the skull base. In this case report we present the first description of a GCT within the internal auditory canal causing cranial neuropathy and review the recent pertinent literature.

A rare case of giant cell tumor involving the clivus resected through Le Fort I Osteotomy and median maxillotomy

Background:

Giant cell tumors (GCTs) are bone tumors that seldom involve the skull. Skull GCTs preferentially occur in the sphenoid and temporal bones with few reported cases involving the clivus. Due to the rarity and complex location, surgical management is not well established for clival GCTs.

Case Description:

A 49-year-old male presented with headaches and blurred vision in the right eye for 2 weeks. Computed tomography (CT) with contrast revealed a sellar mass eroding through the sphenoid sinuses with compression of optic chiasm. Biopsy was consistent with GCT. Patient underwent tumor resection by Le Fort I Osteotomy and median maxillotomy for an extended transsphenoidal approach. Upon discharge, patient showed no neurological deficits and intact cranial nerves.

Conclusion:

This case contributes to the limited amount of skull-based GCT cases worldwide. Additionally, the extended transoral approach can be performed safely in the context of a GCT within the clivus with acceptable morbidity and cosmesis.

Giant cell tumor of the clivus: A case report and review of the literature

Giant cell tumors (GCTs) mainly occur in metaphyses of long bones and are generally considered histologically benign; however, GCTs may be locally aggressive with a high rate of local recurrence and exhibit the potential for distant metastasis. Primary GCT of the clivus is extremely rare and is easily misdiagnosed and, thus, treatment remains controversial. The present report describes the case of a 22-year-old male with GCT located in the skull base originating from the clivus, with the involvement of multiple cranial nerves, which was successfully treated with transnasal transsphenoidal surgery following adjuvant radiotherapy and intravenous bisphosphonate administration. The patient remains symptom free at two years of follow-up. This report contributes to the limited literature regarding GCTs of the skull.

Giant cell tumor of the clivus with presence of epithelioid histiocytes

Giant cell tumor (GCT) is a benign neoplasm but locally aggressive tumor that uncommonly involves the skull bone. We report a case of a 62-year-old male presented with increasing headache and diplopia. Investigations were suggestive of an expanding mass lesion of the clivus. Histopathology was suggestive of diagnosed with GCT with abundant histiocytes.

Endoscopic endonasal approach for the treatment of a large clival giant cell tumor complicated by an intraoperative internal carotid artery rupture

Giant cell tumors (GCTs) are primary bone neoplasms that rarely involve the skull base. These lesions are usually locally aggressive and require complete removal, including the surrounding apparently healthy bone, to provide the best chance of cure. GCTs, as well as other lesions located in the clivus, can nowadays be treated by a minimally invasive fully endoscopic extended endonasal approach. This approach ensures a more direct route to the craniovertebral junction than other possible approaches (transfacial, extended lateral, and posterolateral approaches). The case reported is a clival GCT operated on by an extended endonasal approach that provides another contribution on how to address one of the most feared complications attributed to this approach: a massive bleed due to an internal carotid artery injury.

Giant cell tumor of the frontal bone in a girl: case report

A 2-year-old female presented with a rare case of recurrent giant cell tumor affecting the frontal bone. She had already undergone partial removal twice at the ages of 14 and 18 months. The tumor was located in the frontal bone, expanding to the ethmoid and orbital bones, and invading the frontal base dura mater. The tumor was totally removed including the surrounding bone and frontal base dura mater. No local recurrence and metastasis were observed at 18 months after the last operation. Most giant cell tumors occur in the epiphyses of long bones and are rare in the cranio-facial bone. These tumors usually affect young adults and few pediatric cases are reported.

Prostate cancer metastasis to clivus causing cranial nerve VI palsy

BACKGROUND

An abduction deficit can have many potential etiologies. Clinical testing can help distinguish a neurogenic from a restrictive process. For any patient with a current or past history of cancer, even in the setting of vasculopathic risk factors, a further workup is necessary to rule out a metastatic process.

CASE REPORT

A 66-year-old man reported sudden blurry vision but did not describe a definite diplopia. Clinical evaluation found left cranial nerve (CN) VI palsy. Although he did have vasculopathic risk factors, neuroimaging found prostate cancer metastasis to the mid to left clivus, extending to the left cavernous sinus region as well as a smaller metastasis to the left temporal lobe. The patient underwent radiation treatment with improvement in his clinical presentation and symptoms. His prostate cancer was subsequently treated more aggressively, and 2 years later, despite spinal metastases, he was doing relatively well.

CONCLUSION

Prostate cancer commonly metastasizes, with a high propensity to invade bone. CN VI runs along the midline-structured bony clivus, between the pons and the cavernous sinuses. Therefore, a metastatic lesion to the clivus can be responsible for unilateral or bilateral CN VI palsy. In men, a common primary site of cancer metastasis to the clivus is the prostate. Eye doctors must look closely for evidence of even subtle abduction deficits in all patients with a history of prostate cancer. Early detection can lead to improved medical treatment and extended life expectancy.