Synchronous multicentric giant cell tumour: a case report with review of literature

Synchronous multicentric giant cell tumour of immature skeleton with epiphysiometaphyseal origin

Giant cell tumour of bone accounts for 5% of all primary bone tumours. Multicentric giant cell tumour is an infrequent variety be it either synchronous or metachronous accounting for less than 1% of all giant cell tumours. Synchronous multicentric giant cell tumour of foot and ankle with epiphysiometaphyseal origin is unheard of. We delineate a case of soap-bubble appearance lytic lesions at left distal tibia and talus in an early adolescent woman with biopsy proven giant cell tumour for its rarity and its successful management by extended curettage and allogenic impaction bone grafting.

A systematic review of multicentric giant cell tumour with the presentation of three cases at long-term follow-up

Aims

We performed a systematic literature review to define features of patients, treatment, and biological behaviour of multicentric giant cell tumour (GCT) of bone.

Methods

The search terms used in combination were “multicentric”, “giant cell tumour”, and “bone”. Exclusion criteria were: reports lacking data, with only an abstract; papers not reporting data on multicentric GCT; and papers on multicentric GCT associated with other diseases. Additionally, we report three patients treated under our care.

Results

A total of 52 papers reporting on 104 patients were included in the analysis, with our addition of three patients. Multicentric GCT affected predominantly young people at a mean age of 22 years (10 to 62), manifesting commonly as metachronous tumours. The mean interval between the first and subsequent lesions was seven years (six months to 27 years). Synchronous lesions were observed in one-third of the patients. Surgery was curettage in 63% of cases (163 lesions); resections or amputation were less frequent. Systemic treatments were used in 10% (n = 14) of patients. Local recurrence and distant metastases were common.

Conclusion

Multicentric GCT is rare, biologically aggressive, and its course is unpredictable. Patients with GCT should be followed indefinitely, and referred promptly if new symptoms, particularly pain, emerge. Denosumab can have an important role in the treatment. Cite this article: Bone Joint J 2022;104-B(12):1352–1361.

Multicentric giant cell tumor of bone: synchronous and metachronous presentation

A 27-year-old man treated 2.5 years ago for synchronous multicentric giant cell tumor of bone located at the right proximal humerus and the right 5th finger presented now with complaints of pain in his right hip and wrist of two-month duration. Radiology and magnetic resonance revealed multicentric giant cell tumor lesions of the right proximal femur, the left ileum, the right distal radius, and the left distal tibia. The patient has an eighteen-year history of a healed osteosarcoma of the right tibia that was treated with chemotherapy, resection, and allograft reconstruction. A literature review establishes this as the first reported case of a patient with synchronous and metachronous multicentric giant cell tumor who also has a history of osteosarcoma.

Recombinant human bone morphogenetic protein type 2 jaw reconstruction in patients affected by giant cell tumor

Giant cell tumor (GCT) is a relatively common skeletal tumor. Mandibular localization of this tumor is usually treated with resection of the tumor area. Several autogenous bone-grafting techniques are available for the restoration of large continuity defects of the mandible. However, these procedures are associated with limitations involving postoperative morbidity, difficulty in ambulation (hip graft), and pain. The development of a technique of surgical reconstruction not involving autogenous bone would offer new opportunities for facial bone reconstruction, particularly of the mandible. This study aims to underline the effect of recombinant human bone morphogenetic protein type 2 (rhBMP-2) in a collagen carrier with concomitant bone grafting material in the restoration of continuity critical-size defects after GCT resection in the mandible. The rhBMP-2 was used with absorbable collagen sponge. A total dose of 4 to 8 mg of rhBMP-2 was delivered to the surgical site in concentrations of 1.5 mg/mL. The patient was followed up over a period from 6 to 18 months. Occlusal function was initially restored with conventional prosthesis. Bone formation in the surgical area could be palpated at the end of 3 to 4 months and identified radiographically at the end of 5 to 6 months. The results clearly indicated that the use of rhBMP-2 without concomitant bone grafting materials in large critical-size mandibular defects secondary to GCT produced excellent regeneration of the area, establishing the basis for the return of prosthodontic function.

Giant cell tumor of the mandible

A 53-year-old woman presented with left mandibular area pain, trismus, and facial numbness that had persisted for 4 years. Physical examination revealed a 3×5 cm, hard, non-tender, and round mass on the left mandibular area. Computed tomography and magnetic resonance imaging revealed an expansile tumor involving the left mandibular ramus and temporomandibular joint area with bone destruction, extending to the base of middle cranial fossa and left zygomatic bone. The mass at the segment of left mandible and zygomatic bone, and base of middle cranial fossa was removed. Pathological examination of the mass revealed a giant cell tumor. The defect was reconstructed with iliac bone for the mandible and temporal bone and fascia for the cranial bone and dura. The case is described along with a review of the literature.

[Multicentric giant-cell tumor]

Nearly all (99) giant-cell tumors are solitary. The multicentric presentation is exceptional and not well elucidated. We report the case of a patient presenting five foci identified over an eleven-year period (right tibia, left 4th metacarpal, sacrum, right femur, left femur). The proliferation index was identified for each focus. A review of the literature shows that the development of a new center after treatment for giant-cell tumor is a well-known event, with a wide variability in localizations, number and time to development. The most recent data suggest that each center would be independent progressing according to an individual course. Since histological transformation is not observed and multicenter forms are very exceptional, we suggest that it would not be necessary to propose specific screening for patients with a giant-cell tumor but that it would be good to inform the patient of the possibility of multicentric presentations.

Giant cell tumor of the skull in pediatric patients

Giant cell tumors of the bone are rare, locally aggressive lesions that primarily affect the epiphyses of long bones. These tumors can occur in the skull, principally in the sphenoid and temporal bones. Symptoms of these tumors depend on their site of origin but typically include headache, pain, visual field defects, and conductive hearing loss. Histologically, these tumors consist of three cell types: osteoclast-like multinucleated giant cells; round mononuclear cells resembling monocytes; and spindle-shaped, fibroblast-like stromal cells. Radiographically, the tumors appear osteolytic and radiolucent without a sclerotic border. These tumors typically present in the third to fourth decades of life and rarely occur in patients under 20 years of age. The small number of studies of giant cell tumors of the skull has focused on the adolescent and adult populations. The authors report two cases of giant cell tumors of the skull in pediatric patients. In the first case, a 2-year-old girl presented with swelling behind the right ear. In the second case, a 7-week-old girl presented with a mass within the external auditory canal. Both patients underwent metastatic workup and biopsy procedures before resection of the tumor. Both case reports contribute to the literature of giant cell tumors of the skull by describing this condition in pediatric patients. To the authors' knowledge, these cases represent the youngest two patients with giant cell tumors of the skull yet described.

Giant cell tumour (osteoclastoma) of the zygoma: an extremely unusual neoplasm

We report an extremely rare case of a giant cell tumour of the zygomatic bone in a 36-year-old female. The tumour was excised with healthy margins. The patient is asymptomatic without any evidence of recurrence 14 months postoperatively. To our knowledge, this is only the third reported case of this tumour occurring in the zygomatic bone in the medical literature.

Synchronous multicentric giant cell tumor in a 16-year-old boy

Synchronous multicentric giant cell tumor of the bone is a rare variant of a lesion appearing during childhood. The authors report clinical, radiological, and pathological features of a 16-year-old boy who was diagnosed with synchronous multicentric giant cell tumor, which originated in the right distal femur and the left fibula.

Metachronous multicentric giant-cell tumor of the bone in the lower limb. Case report and Ki-67 immunohistochemistry study

Multicentric giant-cell tumors of the bone (GCTs) are rare. Little is known about the mechanisms by which these tumors spread and how 1% of GCT turn out to be multicentric. We report the case of a 19-year-old woman with metachronous multiple and recurrent GCTs that were unusual in their pattern of progression along the right lower limb over a 23-year period. Histology showed no evidence of malignant transformation. The treatment was repeated curettage and packing with cement. This did not permit a wide surgical margin, but avoided amputation and preserved full limb function. We tested the proliferation index marker Ki-67 in the tumor specimens. Ki-67 expression was limited to the mononuclear cell component of the tumors. The proliferation index was similar in each new tumor and higher in recurrences for each location. In this case, proliferation was initially low in the new tumor location, despite the time difference and independent from the initial clone evolution. Proliferation index increased in recurrent GCTs after marginal margin resection.

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.