Giant cell tumor of distal radius: En bloc resection with allograft reconstruction: A case report

Key Clinical Message

Giant cell tumor of bone (GCT) is a rare neoplasm which often presents as a lytic lesion in the epiphyseal region of long bones and which are usually accompanied by pain, swelling, and restricted movement.

Abstract

Giant cell tumor of bone (GCT) is a rare neoplasm that affects individuals in their third and fourth decades of life. Clinically, it often presents as a lytic lesion in the epiphyseal region of bones, notably the distal femur and proximal tibia. Radiologically, GCT appears as a distinct lytic lesion in the epiphyseal region. Histopathologically, GCTs are composed of mononuclear cells, macrophages, and multinuclear giant cells, indicative of osteoclastogenic stromal tumors. A 37-year-old man presented with left wrist pain, swelling, and restricted movement persisting for a year, worsening over the last 7 months. Radiographic assessments revealed a distal radius bone mass involving the radiocarpal joint. Biopsy confirmed a GCT with extension into peripheral muscle. PET/CT scan showed localized pathology without metastasis. Histopathologically, GCT exhibited multinucleated giant cells, spindle cells, and aneurysmal bone cyst-like regions with coagulation necrosis. Surgical resection involved en-bloc removal and reconstruction with a non-vascularized radius bone graft. Postoperatively, the patient showed no complications at the one-year follow-up, suggesting successful intervention.

Evaluating Extended Curettage and Adjuvant Therapy Against Wide Resection and Reconstruction in the Management of Distal Radius Giant Cell Tumors: A Systematic Review and Meta-analysis

BACKGROUND

The management of distal radius giant cell tumors (GCTs) remains challenging, and the optimal approach is still a matter of debate. This systematic review and meta-analysis aimed to compare the outcomes of extended curettage and wide resection, the mainstays of treatment.

METHODS

Medline (via PubMed), Cochrane Library, Web of Science, Google Scholar, ClinicalTrials.gov, and Embase databases were searched for comparative studies that assessed extended curettage with adjuvant therapy and wide resection with reconstruction in patients with GCTs of the distal radius up to April 2023. Data were collected and analyzed on rates of local recurrence, metastasis, overall complications, and functional outcomes. The Newcastle-Ottawa scale was used to appraise the risk of bias within each study.

RESULTS

Fifteen studies (n = 373 patients) were included and analyzed. Patients who underwent curettage were more likely to develop recurrence (risk ratio [RR] = 3.02 [95% confidence interval; CI, 1.87-4.89], P < .01), showed fewer complications (RR = 0.32 [95% CI, 0.21-0.49], P < .01), and showed greater improvement in Visual Analog Scale and lower Disabilities of the Arm, Shoulder, and Hand scores (P < .00001) than those who underwent wide resection. No significant difference was found regarding metastasis (RR = 1.03 [95% CI, 0.38-2.78], P = .95).

CONCLUSIONS

Regarding the surgical approach to GCT of the distal radius, curettage with adjuvant therapy was associated with a higher likelihood of recurrence compared with wide resection with reconstruction. Nevertheless, the curettage approach resulted in significantly lower rates of operative complications, decreased pain scores, and better functional outcomes in comparison to the resection group.

Metacarpophalangeal joint reconstruction using a costal osteochondral graft: A case report

RATIONALE

The conventional treatment of giant cell tumors is intralesional curettage with local adjuvant therapy. Because hand tumors have a high local recurrence, the primary goal for treating tumors of the hand is to eradicate the lesion.

PATIENT CONCERNS

To preserve the metacarpophalangeal (MCP) joint function as well as avoid further recurrence after surgery.

DIAGNOSES

The giant cell tumor invades the patient's MCP joint in an index proximal phalanx.

INTERVENTIONS

Using computer-aided design and three-dimensional printing techniques, we reformed the original shapes of the MCP joint and its peripheral bone to replica models. The surgeon then performed an en bloc resection and proximal phalanx with MCP joint reconstruction by fabricating the patient's costal osteochondral graft during the operation.

OUTCOMES

After 6 months of rehabilitation, the patient's finger functions could pinch and grasp objects naturally. At the 1-year follow-up, the range of motion of the MCP, proximal interphalangeal, and distal interphalangeal joints improved from flexion of 35° to 60°, 75° to 85°, and 60° to 80°, respectively. The hand function achieved the mean performance of non-preferred hands for young females at the postoperative 3-year follow-up.

LESSONS

The customized prototyping technique has the potential to replica the original patient's bony graft to reach the goal of minimizing the defects at the donor site and maximizing the function of the reconstructed MCP joint.

Management of RANKL-mediated Disorders With Denosumab in Children and Adolescents: A Global Expert Guidance Document

CONTEXT

Denosumab is an effective treatment for many receptor activator of nuclear factor kappa-B ligand (RANKL)-mediated disorders but there are potential safety considerations and limited data to guide its use in children and adolescents.

OBJECTIVE

This document seeks to summarize the evidence and provide expert opinion on safe and appropriate use of denosumab in pediatric RANKL-mediated disorders.

PARTICIPANTS

Ten experts in pediatric bone and mineral medicine from 6 countries with experience in the use of denosumab participated in the creation of this document.

EVIDENCE

Data were sourced from the published literature, primarily consisting of case reports/series and review articles because of the lack of higher level evidence. Expert opinion of the authors was used substantially when no published data were available.

CONCLUSION

Denosumab is an effective treatment for RANKL-mediated disorders in children and adolescents but is often not curative and, in some cases, is best used in conjunction with surgical or other medical treatments. Careful multidisciplinary planning is required to define the goals of treatment and expert oversight needed to manage the risk of mineral abnormalities. Substantive, collaborative research efforts are needed to determine optimal treatment regimens and minimize risks.

The Evaluation and Management of Lung Metastases in Patients with Giant Cell Tumors of Bone in the Denosumab Era

Giant cell tumor of bone (GCTB) is characterized by uncertain biological behavior due to its local aggressiveness and metastasizing potential. In this study, we conducted a meta-analysis of the contemporary literature to evaluate all management strategies for GCTB metastases. A combination of the terms "lung metastases", "giant cell tumor", "bone", "treatment", and "oncologic outcomes" returned 133 patients meeting our inclusion criteria: 64 males and 69 females, with a median age of 28 years (7-63), at the onset of primary GCTB. Lung metastases typically occur at a mean interval of 26 months (range: 0-143 months) after treatment of the primary site, commonly presenting as multiple and bilateral lesions. Various treatment approaches, including surgery, chemotherapy, radiotherapy, and drug administration, were employed, while 35 patients underwent routine monitoring only. Upon a mean follow-up of about 7 years (range: 1-32 years), 90% of patients were found to be alive, while 10% had died. Death occurred in 25% of patients who had chemotherapy, whereas 96% of those not treated or treated with Denosumab alone were alive at a mean follow-up of 6 years (range: 1-19 years). Given the typically favorable prognosis of lung metastases in patients with GCTB, additional interventions beyond a histological diagnosis confirmation may not be needed. Denosumab, by reducing the progression of the disease, can play a pivotal role in averting or delaying lung failure.

Zoledronic Acid Supplementation With Excision of a Giant Cell Tumor of the Distal End Radius to Prevent Recurrence: A Case Report

Giant cell tumors are benign yet locally aggressive neoplasms commonly observed in the distal radius, exhibiting higher recurrence rates compared to other tumor types. This study presents a case involving a 50-year-old farmer who presented with swelling at the distal end of his wrist. The patient underwent treatment involving intralesional curettage and supplementation with zoledronic acid, resulting in a significant reduction in the tumor's potential for recurrence. This approach aims to achieve an optimal balance between functional outcomes and disease management in the majority of cases. While this strategy proves effective in most instances, there may be scenarios where resection becomes imperative due to the severity of the disease, ensuring adequate disease clearance. In such circumstances, judicious decision-making coupled with an appropriate treatment plan is crucial to guarantee a satisfactory outcome, even in the face of challenges.

Distal Radius Reconstruction Using Proximal Non-vascularized Fibula Graft in a Patient During the Syrian Conflict: A Case Study of Treatment Outcomes

In conflict zones like Syria, accessing specialized medical care presents significant challenges. Here, we present the case of a 22-year-old female with a giant cell tumor in her distal forearm, exacerbated by limited access to healthcare due to the Syrian conflict. Despite these obstacles, we successfully performed en bloc resection and reconstructed the defect with a proximal non-vascularized fibular graft, restoring arm function. This case underscores the critical importance of adapting to adverse circumstances to deliver essential medical interventions in conflict-affected regions.

Primary Hyperparathyroidism With Brown Tumor of the Mandible Misdiagnosed as a Giant Cell Tumor: A Case Report

In this case study, we present an incidentally discovered giant cell granuloma, which, upon detailed investigation, led to an unexpected diagnosis. A 36-year-old woman exhibited a bone lesion in the right retromolar trigone area, initially suspected of being malignant. However, histopathological examination revealed a giant cell tumor of bone. Further biochemical profiling, including serum calcium, phosphorus, and parathyroid hormone (PTH) levels, showed elevated PTH and hypercalcemia, prompting consideration of primary hyperparathyroidism and the diagnosis of a brown tumor due to this condition. This case underscores the importance of considering brown tumors associated with primary hyperparathyroidism as a potential differential diagnosis in patients with lytic bone lesions.

Unusual Presentation of a Giant Cell Tumor of the Bone: A Case Report

Bone giant cell tumors (GCTs) are rare, non-cancerous tumors that mostly affect the meta-epiphyseal region of long bones in the legs and arms. We are reporting a case of GCT of bone of a 14-year-old male; it usually occurs in the age group of 20-40 years. The presence of multinucleated giant cells and stromal cells in the proximal diaphysis of the left tibia serves as a distinguishing characteristic. The majority of GCTs are benign; they have the potential to induce bone loss and can be locally aggressive. Treatment options often include surgery, and in some cases, medications like denosumab may be used to help shrink the tumor or manage recurrent cases.

Giant Cell Tumor of Patella with Secondary Aneurysmal Bone Cyst-A Rare Case Report of Anterior Knee Pain in Young Adults

Introduction

Primary bone tumors of the patella are rare, with an incidence as low as 0.12%. The majority are benign, with giant cell tumors (GCT) being the predominant tumor affecting this sesamoid bone. An associated secondary aneurysmal bone cyst (ABC) component with a primary patellar GCT is rarely seen.

Case Report

We report a case of a 20-year-old male with long-standing anterior knee pain for 9 months. Having visited multiple clinics and found no relief, the patient presented to us at our out-patient department. Clinical examination suggested patellar tenderness, and knee radiographs showed a lytic lesion with cortical erosions. Computed tomography and magnetic resonance imaging were suggestive of GCT. A patellectomy with a good extensor repair was performed. A patellar biopsy revealed a mixed picture of a primary GCT with a secondary ABC. The patient was closely followed up, and at 12 months, he recovered completely and recorded an excellent functional outcome.

Conclusion

With the incidence of bone tumors on the rise, one should be aware of this relatively rare cause of anterior knee pain. A simple radiograph will help in early diagnosis and will go a long way toward better salvage procedures than more radical procedures like patellectomy.

Multimodality imaging of an unusual giant cell tumor of thoracic spine with mediastinal invasion: a case report

Giant cell tumor (GCT) is a benign yet locally aggressive bone neoplasm typically situated in the juxta-articular metaphysis of long bones. Although spinal involvement is rare, it is predominantly reported in the axial skeleton, with the sacrum being the primary location. Conversely, GCTs are notably uncommon in the thoracic spine. In this report, we present computed tomography (CT), magnetic resonance imaging (MRI), and 2-Deoxy-2-[fluorine-18]-fluoro-D-glucose (18F-FDG) positron emission tomography combined with computed tomography (PET/CT) multimodality imaging findings of a 36-year-old woman diagnosed with a GCT of the thoracic spine. CT scans provide a precise evaluation of cortical thinning and penetration. While MRI lacks specific diagnostic indicators for GCT, it remains invaluable for delineating the extent of soft tissue expansion and the tumor's relationship with intraspinal neural elements - critical information for surgical planning. 18F-FDG PET/CT effectively illustrates the lesion's hypermetabolic and locally aggressive characteristics. It is noteworthy that GCT occasionally exhibits metastatic malignant potential, underscoring the value of FDG PET as a pivotal modality for staging, restaging, or assessing therapy response, and for monitoring the efficacy of radiotherapy. Familiarity with the imaging features of GCT is essential for physicians to avoid misinterpretation. This tumor should be considered in the differential diagnosis of spinal tumors, distinguishing it from bone metastases or neurogenic tumors.

A new joint reconstruction technique in the treatment of giant cell tumors around the knee: Structural allograft and unicompartmental arthroplasty

OBJECTIVE

The long-term prognosis of patients who underwent unicompartmental knee arthroplasty (UKA) with a structural allograft or hemiarticular allograft transplantation to treat giant cell tumors (GCTs) around the knee and the prosthesis survival rate were analyzed.

METHODS

We retrospectively reviewed 73 patients who were diagnosed with GCTs around the knee and underwent surgery to restore joint function from 2000 to 2015. Patients were divided into two groups according to the surgical procedure used for functional knee reconstruction: hemiarticular allograft transplantation or structural allograft and UKA. The Knee Society Score (KSS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) were used to analyze postoperative knee function between the two groups. The Kellgren-Lawrence (K-L) classification system was used to evaluate the progression of osteoarthritis. The incidence of complications and the prosthesis survival rate were also investigated.

RESULTS

Patients who underwent UKA to treat GCT demonstrated significantly improved knee function. The rate of an excellent or good KSS was significantly different between the two groups (p = 0.041 at the 1-year follow-up, p = 0.033 at the last follow-up). The proportion of severe cases according to WOMAC in the two groups was also different (p = 0.030 at the 1-year follow-up, p = 0.021 at the last follow-up). According to the K-L grade of unaffected compartments, UKA better prevented the progression of osteoarthritis (p = 0.034).

CONCLUSIONS

Patients with GCTs around the knee could benefit from UKA. In addition to providing better knee function and range of motion, UKA could also slow the progression of osteoarthritis in the knee joint. This new surgical method could meet the needs of patients wishing to preserve joint integrity and favorable joint function.

Total en bloc spondylectomy of thoracic giant cell tumor with secondary aneurysmal bone cyst: case reports and review of literature

Spinal giant cell tumor (GCT) combined with secondary aneurysmal bone cyst (ABC) is a locally aggressive primary bone tumor. Total en bloc spondylectomy has never been reported to treat thoracic GCT combined with secondary ABC. We retrospectively reviewed two cases of spinal GCT combined with secondary ABC. A 41-year-old male patient was presented with back pain due to irregular expansive bone destruction involving the T6 vertebral body and intraspinal space-occupying lesion. Total en bloc spondylectomy of T6 vertebra was performed with good neurological status after the surgery. A 29-year-old female patient was presented with right scapular region pain due to irregular expansive bone destruction involving the T5 vertebral body and intraspinal space-occupying lesion. Total en bloc spondylectomy of T5 vertebra was performed with good neurological status after the surgery. Adjuvant radiation therapy was applied after the surgery without local recurrence at the 12-month or 24-month follow-up. Spinal GCT combined with secondary ABC appears to have a high local recurrence rate. Therefore, total en bloc spondylectomy should be applied to treat thoracic GCT combined with secondary ABC.

Non‑surgical outcomes and risk factors for pulmonary metastasis from giant cell tumor of bone

The present study detailed four factors associated with an increased risk of pulmonary metastasis, age, pathological fracture, local recurrence and mode of treatment. Local recurrence and pathological fracture were independent risk factors for developing metastasis. From January 2016 to December 2021, data from 50 patients diagnosed with giant cell tumor of bone (GCTB) treated in Khon Kaen Hospital, Thailand, were retrospectively analyzed. The risk factors, including age at diagnosis, location of GCTB, clinical presentation, Campanacci stage and no. of local recurrences, for GCTB-induced pulmonary metastasis were evaluated using univariate and multivariable logistic regression analyses. Of the 50 patients analyzed, 9 patients (18%), with a mean age of 46.3 years (range, 18-68 years), developed pulmonary metastasis. No patients died from pulmonary metastasis in the present study. Statistically significant associations were observed between the development of metastasis and both clinical fracture [odds ratio (OR), 6.107; 95% confidence interval (CI), 1.08-34.70] and local recurrence (OR, 6.48; 95% CI, 1.03-40.87). Patients presenting with both a clinical fracture and local tumor recurrence require more rigorous clinical observation due to the significantly elevated risk of disease progression.

Giant Cell Tumor: A Case Series of Seven Patients with GCT at Atypical Sites

Introduction

Giant cell tumor (GCT) represents 5% of all primary bone tumors and 20% of biopsy analyzed benign tumors. More than half of these lesions occur in the 3rd and 4th decades of life. There is no absolute treatment method selection. Techniques ranging from intralesional curettage to wide resection can be used. Goal is to eradicate the tumor, preserve limb function, and prevent local recurrence and distant metastasis.

Case Report

We are presenting seven cases of GCT at five different and rare sites involving tibia, calcaneum, metatarsal, proximal humerus, and clavicle with tumor being limited to bone in all seven cases not involving the soft tissue. There were three male patients and four female patients. Six patients underwent intralesional curettage using high-speed burr and curette, along with adjuvant irrigation with hydrogen peroxide and normal saline followed by polymethyl methacrylate reconstruction. One patient with GCT clavicle underwent wide resection.

Results

In all seven cases, we were able to able to remove the tumor completely. Six patients had a gradual and complete recovery with return to near normal activity within 6 month-1 year after surgery. One patient with proximal humerus GCT had a recurrence which got resolved with injection denosumab. All patients have been followed up for a minimum duration of 2 years.

Conclusion

Intervention in the early stages can avoid radical procedures such as wide local excision or amputation. We recommend aggressive surgical approach with close follow-up to detect recurrence if any, at an early stage.

Keratin-positive giant cell-rich tumors of soft tissue with HMGA2::NCOR2 fusions

BACKGROUND

Giant cell tumor of soft tissue (GCT-ST) is a rare soft tissue neoplasm that is morphologically similar to but genetically distinct from giant cell tumor of bone. A novel keratin-positive GCT-ST (KPGCT-ST) harboring HMGA2::NCOR2 fusions was recently discovered. Fewer than 30 cases have been described; herein is reported an additional seven.

METHODS

Cases diagnosed as GCT-ST were retrieved from institutional archives and consultation files. The histopathologic characteristics were assessed, and the electronic medical record was reviewed.

RESULTS

Seven tumors were identified in six women and one man with a median age of 23 years. All patients underwent excision; no recurrences or metastases were noted during a median follow-up period of 7 months. Histopathologically, the tumors were characterized by a multinodular proliferation of keratin-positive mononuclear cells with evenly admixed osteoclast-like giant cells and absent neoplastic bone. A fibrous capsule with lymphoid cuffing was frequently seen. Foamy macrophages, inflammation, hemorrhage, and hemosiderin were variably present. The HMGA2::NCOR2 fusion was detected in all cases.

CONCLUSIONS

Our findings support previously reported hypotheses that KPGCT-ST is a spectrum of the same entity as the recently described xanthogranulomatous epithelial tumor. Although follow-up data are limited, to date, KPGCT-ST appears to follow an indolent course.

The Role of Denosumab in the Treatment of Primary Tumors of Bone

Many hand surgeons treat benign bone tumors without referral to orthopedic oncologists. However, there have been considerable advances in medical therapy for some of these tumors, with which hand surgeons may not be as familiar. This review focuses on the mechanism and uses of denosumab in the treatment of benign tumors of bone. Although the hand surgeon may not be directly prescribing this therapy, they are often the only physician treating the patient for these conditions. As such, awareness regarding the use of this therapy in reducing pain, decreasing tumor volume, and treatment of potential lung metastases is critical to those taking on these cases without the support of an orthopedic oncologist. This article aims to familiarize hand surgeons with denosumab to help promote knowledge of this therapeutic option and the potential role of this medication in the treatment of primary bone tumors in the hand.

Histomorphometric Analysis of 38 Giant Cell Tumors of Bone after Recurrence as Compared to Changes Following Denosumab Treatment

Giant cell tumor of bone (GCTB) is an osteolytic tumor driven by an H3F3A-mutated mononuclear cell with the accumulation of osteoclastic giant cells. We analyzed tissue from 13 patients with recurrence and 25 patients with denosumab therapy, including two cases of malignant transformation. We found a decrease in the total number of cells (p = 0.03), but not in the individual cell populations when comparing primary and recurrence. The patients treated with denosumab showed induction of osteoid formation increasing during therapy. The total number of cells was reduced (p < 0.0001) and the number of H3F3A-mutated tumor cells decreased (p = 0.0001), while the H3F3A wild-type population remained stable. The KI-67 proliferation rate dropped from 10% to 1% and Runx2- and SATB2-positive cells were reduced. The two cases of malignant transformation revealed a loss of the H3F3A-mutated cells, while the KI-67 rate increased. Changes in RUNX2 and SATB2 expression were higher in one sarcoma, while in the other RUNX2 was decreased and SATB2-positive cells were completely lost. We conclude that denosumab has a strong impact on the morphology of GCTB. KI-67, RUNX2 and SATB2 expression differed depending on the benign or malignant course of the tumor under denosumab therapy.

Reconstruction After En Bloc Resection of a Distal Radius Tumor. An Updated and Concise Review

The distal radius is rarely affected by either primary or metastatic bone cancers. The most frequent tumors of the distal radius are giant cell tumors, which are benign tumors with the propensity to invade. En bloc excision of giant cell tumors of the distal radius achieves a low recurrence rate but compromises the wrist joint, necessitates a significant reconstruction, and has functional consequences. Reconstruction after en bloc resection of a distal radius bone tumor is challenging. Furthermore, orthopedic oncologists disagree on treating such long bone anomalies most effectively. The present article summarizes the various biological and non-biological reconstruction techniques performed after en bloc resection of a distal radius tumor, discusses the advantages and disadvantages of each reconstruction strategy, and summarizes several case studies and case reports.

Tuberculosis of the Tibial Plateau Mimicking a Giant Cell Tumor: A Case Report

Tuberculous osteomyelitis is infrequent and occurs most often in the femur, the tibia, and the small bonne of hands and feet. Herein, we report a 39-year-old female who presented with chronic pain and motion range reduction of the left knee joint for two years. A knee radiograph revealed a geographic lytic lesion of the epiphyseal and diaphyseal region of the tibia mimicking giant cell tumor (GCT). A minimally invasive biopsy of the lytic lesion was performed, and pathological assessment revealed granulomatous inflammation made of numerous caseating necrotizing epithelioid and giant cells granulomas, diagnostic of tibial plateau tuberculosis. This case underscores the importance of taking tuberculosis into consideration in lesions mimicking GCTs in the tibial plateau, especially in endemic regions.

Giant Cell Reparative Granuloma in the Thumb Distal Phalanx: A Case Report

Giant cell reparative granulomas (GCRG) often affect the bones of the hands and the feet. Treatment of this lesion depends on the exact location and amount of localized bony destruction. Ours is the first case report to discuss the nuances of treating this lesion in the thumb distal phalanx. A 19-year-old male presented with lytic, destructive expansion of his left thumb distal phalanx; imaging was suggestive of an aneurysmal bone cyst. Open biopsy was interpreted as giant cell reparative granuloma. Curettage and bone grafting resulted in complete healing of the distal phalanx with an excellent range of motion and interphalangeal joint stability. GCRG is a rare, benign entity typically presenting as a lytic bone lesion. Despite the initial massive bony destruction, this lesion nevertheless healed with curettage and bone grafting with maintained flexor pollicis longus and extensor pollicis longus function, permitting excellent active motion postoperatively.

Giant Cell Tumour of the Small Bones of Hand and Foot

Introduction Giant cell tumor (GCT) or bony tumor mainly involving long bones of arms and legs is very rarely associated with the small bones of hands and feet. Due to its nonspecific signs and symptoms, it is not easy to diagnose based on clinical findings; therefore, histopathological evidence is required to confirm it. Method A total of 16 patients with positive histopathological bone lesions enriched with giant cells were included in our study. After a complete evaluation of their case records, the required radiological assessment was carried out. Campanacci's method of staging was used to evaluate the advancement of lesions. The Musculoskeletal Tumour Society (MSTS) score was recorded postoperatively. All the patients were followed up for a mean duration of 2.8 years until they were lost to follow-up. Result The result of the current study shows that 62.5% of our patients presented in their twenties and 81.25% of patients came at a reasonably advanced stage. Hand and foot were involved in 1:1 cases. Patients were treated by one of the following options: extended curettage with bone graft or cement, wide excision, or en bloc resection. Phenol, a neoadjuvant, was used in all patients. Two of our patients (6.25%) who underwent curettage with bone graft showed up with recurrence during follow-up - one was then treated with wide excision and the other with amputation. Conclusion Giant cell tumors should undoubtedly be aggressively approached with the goal of preserving limb function while reducing recurrence risk to as minimal as possible. GCT of hand is more aggressive comparatively and should be treated accordingly.

Treatment of Recurrent Giant Cell Tumor of Bones: A Systematic Review

The giant cell tumor of bones (GCTB) is a benign bone tumor with high postoperative recurrence potential. No specific treatment protocol has been developed to date in case of tumor recurrence, and the kind of re-operative surgery depends upon the surgeon's preferences. The aim of this systematic review is to determine the second recurrence rate and the respective functional results of the available treatment options applied to recurrent GCTB. Medline/PubMed and Scopus were searched to identify articles published until March 2023. Twelve studies fulfilled the inclusion criteria, comprising 458 patients suffering from recurrent GCTB. The overall incidence of second recurrence was 20.5%, at a mean interval of 28.8 months after the first surgery, and it was more evident after intralesional curettage (IC) surgery than en-bloc resection (EBR) (p = 0.012). In the IC group of patients, the second recurrence rate was lower and the functional outcome was greater when polymethylmethacrylate cement (PMMAc) was used as an adjuvant instead of bone grafting (p < 0.001 for both parameters). Reconstruction of the created bone defect after EBR with a structural allograft provided a better outcome than prosthesis (p = 0.028). According to this systematic review, EBR (first choice) and IC with PMMAc (second choice) are the best treatment options for recurrent GCTB.

A Unique Way of Treatment of Giant Cell Tumor of the Distal Femur in a 19-Year-Old Female, a Case Report

Giant Cell tumors (GCT) are benign tumors with aggressive characteristics and the potential to metastasize. These are seldom lethal benign bone tumors but are associated with massive local bony architecture distraction making their treatment difficult, especially if found in peri-articular locations. Several long bone giant cell tumor (GCT) cases have been reported. We report a unique treatment of distal femur GCT in a 19-year-old in a resource-limited setup whose initial presentation was following a pathologic fracture. We used a staged surgical protocol. In the first stage, distal femur resection and implantation of poly methyl methacrylate (PMMA) cement spacer for induced membrane formation was done, followed by SIGN nail and non-vascularized fibula strut graft. There was adequate healing and no recurrence was noted during the two-year follow-up.

Coexisting Benign Tumors in a Finger Are Rare but Not Impossible

Giant cell tumors of the tendon sheath (GCTTS) and enchondroma are identified as the most prevalent benign soft tissue and bone tumors of the hand. While their individual presence is a common finding, their concurrent appearance in the same anatomic region is exceptionally rare, making simultaneous diagnosis more burdensome. We present a noteworthy case of GCTTS and enchondroma in the index finger of a young patient, along with the therapeutic strategy for correct diagnosis and effective treatment of such an occurrence.

Giant cell tumor of tendon sheath: A report of 216 cases

BACKGROUND

In this article on giant cell tumor of tendon sheath (GCTTS), we intend to summarize and analyze the clinical and pathological features of GCTTS hoping to improve clinical management and patient treatment.

METHODS

The study retrospectively reviewed 216 patients of GCTTS, registered at the Affiliated Hospital of Southwest Medical University from January 2010 to December 2020. These cases were diagnosed by surgical excision. The clinicopathological features and the prognosis were reviewed in the light of the current literature.

RESULTS

Of these 216 GCTTS patients, 72 were males (33.3%) and 144 females (66.7%), with a ratio male-to-female of 1:2. The patients' age ranged from 5 to 82, the average being 41.5 years at diagnosis. A total of 96 cases (44.4%) occurred in the hand region, followed by 35 cases (16.2%) in the knee, 32 cases (14.8%) in the foot, 25 cases (11.6%) in the ankle, 12 cases (5.6%) in the wrist, 12 cases (5.6%) in the leg, 2 cases (0.9%) in the head, 1 case (0.5%) in the forearm, and 1 case (0.5%) inside and outside the spinal channel. Histopathology mainly revealed large synovial-like monocytes, small monocytes, and osteoclast-like giant cells.

CONCLUSION

Our results confirm that GCTTS predominantly occurs in the hands of young women. Complete surgical resection with long-term follow-up is the preferred management.

Histopathological response to denosumab in giant cell tumours of bone - A review of 11 cases

Background

Giant cell tumor (GCT) of the bone is a locally aggressive primary bone tumor, that can rarely metastasize. Arising mostly in epiphysis of the long bones in young adults, the tumor is composed of mononuclear cells that are admixed with osteoclastic giant cells(OLGCs), which express RANK ligand and RANK respectively. Denosumab a monoclonal antibody against RANK ligand has been shown to reduce the tumor by causing bone lysis by inhibiting RANKL. Histological changes in 11 patients of GCT who were treated with denosumab are presented here.

Materials and Methods

Clinical records and slides of 11 patients of GCT who had been administered neoadjuvant denosumab were included in the study. Evaluation of pre and post therapy GCT specimens was performed by two pathologists (RK and VM). There were 4 males and 7 females. Their mean age was 30 years. All the patients received 120 mg denosumab subcutaneously every week with additional 120 mg on days 8 and 15 of therapy. The histological slides were reviewed and following points noted: 1) degree of ossification,2) fibrosis,3) loss of osteoclastic giant cells,4) proliferation of mononuclear cells,5) atypia,6) Permeation of osteoid by malignant cells.

Results

Out of 11 cases, 2 cases did not show any significant histological improvement. 7 cases showed reduction in giant cells, increased fibrosis, enhanced mononuclear cell proliferation and ossification consistent with a pathological response. Atypia and osteoid permeation were noted in 2 cases which showed transformation to osteosarcoma.

Conclusion

Denosumab treated giant cell tumor show dramatic histological changes. The post therapy lesions may bear no resemblance to pretherapy lesion. There may be complete resolution or may be confused with benign or malignant lesions Rarely they may show sarcomatous transformation. It is imperative that the pathologist is aware of these changes to prevent diagnostic pitfalls as it poses therapeutic and prognostic implications.

Carbon fiber lumbopelvic reconstruction following sacral giant cell tumor resection: illustrative case

BACKGROUND

The use of carbon fiber or polyetheretherketone spine constructs has proven to be a safe and effective alternative to standard metal alloy. The mechanical properties of carbon fiber while unique provide a construct that is comparable in strength to previous titanium-based constructs and have additionally shown greater fatigue resistance. These constructs have been especially useful for the mechanical stabilization of the spine following tumor resection. The subsequent interference seen when imaging a patient with a traditional metallic construct is reduced and allows for improved tumor surveillance after the procedure, and a more accurate delivery of radiotherapy when indicated.

OBSERVATIONS

This case report details the treatment of a 25-year-old female diagnosed with a sacral giant cell tumor. The authors discuss the use of a carbon fiber-reinforced polyetheretherketone for lumbopelvic reconstruction.

LESSONS

Carbon fiber-reinforced polyetheretherketone with its radiolucency and rigidity is a reliable option for complex spinal reconstruction after tumor resection.

Giant cell tumor of bone with H3F3B mutation: A case report

RATIONALE

Giant cell tumor of bone is a locally aggressive and rarely metastasizing neoplasm that typically affects the ends of long bones or the axial skeleton of young to middle-aged adults. As many as 69% to 100% of giant cell tumors harbor H3F3A gene mutations, while H3F3B gene mutations have rarely been reported.

PATIENT CONCERNS

A 53-year-old male patient who underwent right distal femoral tumor resection.

DIAGNOSES

Preoperative CT plain scan indicated giant cell tumor of bone with pathological fracture. Laboratory findings were as follows: serum calcium was 2.23 mmol/L (reference range: 2.1-2.55 mmol/L) and serum phosphorus was 1.35 mmol/L (reference range: 0.81-1.45 mmol/L).

INTERVENTIONS

The histological morphology showed the typical features of a conventional GCT. The immunoprecipitation analysis results were as follows: H3.3G34W(-), H3.3G34R(-), H3.3G34V(-), and H3K36M(-). Sanger sequencing showed that the H3F3A and H3F3B gene mutations were wild type. The high-throughput gene sequencing results revealed the H3F3B gene mutations H3.3p.Gly35Trp and H3.3p.Val36Leu.

OUTCOMES

The patient was stable with no recurrence in 12 months follow-up.

LESSONS

Giant cell tumor of bone with H3F3B gene mutations is extremely rare. In the pathological diagnosis of bone tumors, we need to analyze clinical presentation, imaging features, histology, immunophenotype, and cytogenetic/molecular alterations, in order to get a correct diagnosis.

Images of giant cell tumor and chondroblastoma around the knee: retrospective analysis of 99 cases

Background

It is difficult to differentiate giant cell tumors of the bone (GCTB) from chondroblastoma around the knee based on imaging findings. This study analyzed the imaging features of these 2 diseases for better differentiation.

Methods

This retrospective cross-sectional cohort study reviewed data of patients with pathologically confirmed GCTB (n=81; age 15-75 years; median age 33 years) and chondroblastoma (n=18; age 12-34 years; median age 14 years). In all, 18 imaging signs were analyzed.

Results

Patients with chondroblastoma were relatively younger than those with GCTB. On imaging, lesion length was significantly (P<0.00001) smaller in chondroblastoma [range, 15.80-78.30 mm; mean ± standard deviation (SD) 34.15±18.24 mm; 95% confidence interval (CI): 24.05-44.25 mm] than in GCTB [range, 30.10-117.50 mm; mean ± SD 59.73±15.28 mm; 95% CI: 56.24-63.22 mm]. Significantly more (P<0.05) chondroblastoma lesions had calcification (76.5% vs. 1.3%), lobulation (77.8% vs. 32.1%), and swelling range >15 mm (84.6% vs. 41.1%) than did GCTB lesions, whereas significantly more (P<0.05) GCTB lesions were greater than half the host bone diameter (74.1% vs. 16.7%) and had a lesion long axis that was consistent with that of the host bone (98.8% vs. 27.8%). There were no significant differences (P>0.05) between the 2 tumors in the remaining 11 imaging signs.

Conclusions

A narrow zone of transition, intratumor calcification, lobulation, tumor transverse diameter greater than the bone diameter, maximum lesion length, consistency between the tumor and bone long axes, and edema range around the lesion >15 mm are parameters that can be used to differentiate GCTB from chondroblastoma around the knee.

En Bloc Resection With Reconstruction Using a Customized Megaprosthesis in a Case of Proximal Humerus Giant Cell Tumor: A Case Report

A giant cell tumor is a common, benign but locally aggressive bone tumor faced by orthopedic surgeons. The proximal humerus is a rare site of occurrence for this tumor, and the challenges posed while approaching such a case are discussed in this report of a 29-year-old male who presented with pain, swelling, and restricted motion at the left shoulder. Plain radiographs and MRI were suggestive of an aggressive giant cell tumor of the proximal humerus, which was confirmed on histopathological examination. Due to the lesion's extensive soft-tissue involvement, en-bloc resection with reconstruction was planned, but due to the COVID-19 pandemic, surgery was delayed. During the same period, the patient had trivial trauma to the same shoulder, following which the size of the lesion began increasing. The patient was operated on with en-bloc resection and reconstruction with a custom megaprosthesis; following the surgery, there was a complete resolution of pain and improvement in the range of motion. En bloc resection and replacement with a customized megaprosthesis, though technically demanding, offer a safe and cost-effective modality for limb salvage surgery for large giant cell tumors, with good functional outcomes and decreased chances of recurrence.

Giant Cell Tumor and Giant Cell Reparative Granuloma of Bone of the Head: CT and MR Imaging Findings

BACKGROUND

This study aimed to determine the features and differentiation of Giant Cell Reparative Granuloma (GCRG) and Giant Cell Tumor (GCT) of the head on CT and MRI.

METHODS

This retrospective study included six patients with histopathology-confirmed head GCRG and 5 patients with histopathology-confirmed head GCT. All images were independently reviewed by two radiologists. The growth pattern, bone changes, MRI signal intensity, enhancement patterns and other image features were recorded. All patients received CT scans and MR images.

RESULTS

All the lesions were located centrally in the bone. Osteolytic bone destruction and expansive growth patterns were observed on CT images. Four of six cases broke the cortical bone with residual cortical bone, and the last two showed a thin cortex in GCRG. Five cases broke the cortical bone with residual cortical bone in GCT. There were enhancing septations in GCT lesions on contrast- enhanced T1-Weighted Images (T1WI) while enhancing septations were not present in GCRG cases. The size of GCT lesions was larger than that of GRCG. GCRG and GCT showed iso-low signals on T1WI and iso-high signals on T2-Weighted Images (T2WI). There was a case with cystic or necrotic lesions in each of the two types of lesions. Osteolytic bone destruction and expansive growth patterns were observed in GCTs and GCRGs.

CONCLUSION

The size of the GRCG lesion was smaller than that of the GCT. The presence of enhancing septations and the size of the lesion may distinguish GCTs from GCRG.

Giant Cell Tumor of Lumbar Vertebrae on MR and 18F- FDG PET/CT: A Case Report and Literature Review

Teaching Point: Giant cell tumor of bone may show a moderate to high FDG uptake, and attention should be paid to differentiate from malignant tumors.

Undifferentiated Pancreatic Carcinomas, Clinical Features and Therapeutic Options: What We Know

Undifferentiated pancreatic carcinomas are rare malignant tumors of the pancreas that are very aggressive and challenging to diagnose. The WHO categorizes them into undifferentiated osteoclast-like giant cell, sarcomatoid, and rhabdoid pancreatic carcinomas. Patients present with nonspecific symptoms such as jaundice, vague abdominal or back pain and itchy skin. Their histological characteristics include positive pan-cytokeratin mononuclear pleomorphic cells, osteoclast-like giant cells and CD68. Patients may have KRAS, TP53 and SMAD4 alterations, homozygous deletions of CDKN2A and CDKN2B, as well as INI1 deficiency. Surgical resection is the only curative treatment. Patients may benefit from postoperative adjuvant therapy. There are no widely accepted guidelines specific to this type of tumor; however, some chemotherapy regimens may be promising. The patient prognosis is mostly poor, especially in patients with unresectable tumors. However, several studies have shown patients achieving long-term survival with adjuvant therapy. In conclusion, although undifferentiated pancreatic carcinoma is rare and very aggressive, there is still potential for improved patient survival with proper diagnosis and treatment.

A Case Report of a Sacral Giant Cell Tumor Treated With Block Resection and Lumbo-Pelvic Fixation

Giant cell tumors (GCT) are benign but locally aggressive neoplasms composed of osteoclast-like giant cells and fusiform to ovoid mononuclear stromal cells. GCT generally comprise 5-10% of all benign bone tumors; they appear most frequently between the second and third decades of life. These tumors are also distributed throughout the vertebral column. Approximately half of all spinal GTCs develop in the sacrum. Many cases remain clinically silent and are discovered incidentally during the study of minor trauma. Symptomatic tumors often mimic other common spinal pathologies. Imaging studies ideal for diagnosis are CT and MRI. The techniques used in the treatment of giant cell tumors are curettage or intralesional surgery, block resection, radiotherapy, and chemotherapy. Herein, we report on a 23-year-old female patient diagnosed with a tumoral mass in the anterior part of the sacrum, suggestive of GCT. The lesion was completely excised in two consecutive surgeries, and lumbopelvic fixation was performed with favorable immediate postoperative results. Careful surgical planning with a multi-disciplinary approach leading to block resection still remains the most viable option for the treatment of vertebral GCT.

A Case Report on One-Stage Revision for Failed Bipolar for Proximal Femur Giant Cell Tumor

Introduction

Osteotomy around proximal femur provides excellent exposure and helps in revision of both cemented and uncemented femoral stem. Hereby, describing our case report on wedge episiotomy, a new surgical technique for removal of distal fitting cemented or uncemented femoral stem in conditions were extended trochanteric osteotomy (ETO) becomes inappropriate and episiotomy becomes inadequate.

Case Report

A 35-year-old lady presented with painful right hip and difficulty in walking. Her X-rays showed a dissociated bipolar head and long cemented femoral stem prosthesis. She gave history of proximal femur giant cell tumor operated with cemented bipolar which failed in 4 months (Figs. 1, 2, 3). There were no signs of active infection such as discharging sinus and elevated blood infection markers. Hence, she was planned for one-stage revision of the femoral stem and conversion into total hip arthroplasty.

Surgical Technique

A small trochanter fragment, along with the abductor and vastus lateralis continuity, was preserved and mobilized away augmenting hip exposure. The long femoral stem was found well fixed with a cement mantle all around in an unacceptable retroversion. There was metallosis with no macroscopic signs of infection. Taking in consideration of her young age and the long femoral prosthesis with cement mantle, the idea of ETO was considered inappropriate and more iatrogenic.Initially, an episiotomy was done along the lateral border of femur with an oscillating saw to interrupt the radio compressive force of the bone along the cement mantle and stem. However, the lateral episiotomy was not sufficient to loosen up the tight fit between bone and cement interface. Hence, a small wedge episiotomy was done along the full length lateral border of the femur (Figs. 5 and 6). A lateral wedge of 5 mm bone was removed increasing the exposure of bone cement interface with intact 3/4th cortical rim. This exposure allowed 2 mm K-wire, drill bit, flexible osteotome, and micro saw to go in between the bone and cement mantle to dissociate it. A 240 x 14 mm long uncemented femoral stem was fixed using bone cement extending along the entire femur length, With utmost care, all the cement mantle and implant were removed. The wound was soaked with three minutes of hydrogen peroxide and betadine solution and washed with high jet pulse lavage. A long 305 × 18 mm Wagner-SL revision uncemented stem was placed with adequate axial and rotational stability (Fig. 7). The long straight stem of 4 mm wider than the extracted was passed along the anterior femoral bowing augmenting the axial fit and the wagner fins helped in getting the much need rotational stability (Fig. 8). The acetabular socket was prepared with uncemented cup size of 46 mm with a posterior lip liner poly and 32 mm metal head was used. The wedge of bone was kept back along the lateral border and help with 5-ethibond sutures. Intraoperative histopathology sampling did not show any evidence of giant cell tumor recurrence, ALVAL score of 5 and microbiology culture grew negative. The physiotherapy protocol included non-weight-bearing walking for 3 months, later then partial loading was started and complete loading was done by end of fourth month. The patient had no complication such as tumor recurrence, periprosthetic joint infection (PJI) and implant failure at end of 2 years(Fig. 9).

Giant Cell Tumor of Talus: A Case Report

Introduction

Giant cell tumor of bone most commonly involves ends of the long bones in a skeletally mature patient. Giant cell tumor of the bones of the hand and feet is very rare, so is the giant cell tumor of talus.

Case Report

We are reporting a case of giant cell tumor of talus in a 17-year-old female who presented with a history of pain and swelling around left ankle since 10 months. Radiographs of the ankle showed lytic expansile lesion involving whole of talus. Talectomy followed by calcaneo-tibial fusion was done as intralesional curettage was not feasible in this patient. Histopathology confirmed the diagnosis of giant cell tumor. There was no evidence of recurrence even at 9 years follow-up and the patient was able to carry out her daily activities without much discomfort.

Conclusion

Giant cell tumor is most commonly encountered around the knee or distal radius. Involvement of foot bones especially talus is extremely uncommon. In early presentation, extended intralesional curettage with bone grafting and, in late, talectomy with tibiocalcaneal fusion are the treatment options.

Imaging Features of Aggressive Giant Cell Tumors of the Mobile Spine: Retrospective Analysis of 101 Patients From Single Center

STUDY DESIGN

Retrospective study.

OBJECTIVES

Giant cell tumors (GCTs) of the mobile spine can be locally aggressive. This study described and classified the typical and atypical appearance of aggressive spinal GCTs according to imaging findings to help the imaging diagnosis, especially for patients with rapid neurological deficit that may require emergent surgery without biopsy.

METHODS

Computed tomography (CT) and magnetic resonance imaging (MRI) scans of patients diagnosed with aggressive spinal GCTs at single center were reviewed.

RESULTS

Overall, 101 patients with 100 CT images and 94 MR images were examined. All lesions were osteolytic with cortical destruction; 95 lesions showed epidural extension; 90 were centered in the vertebral body; 82 showed pathological fracture and/or collapse of the vertebral body; 78 had pseudotrabeculation on CT; 80 showed low-to-iso signal intensity or heterogeneous high-signal intensity with cystic areas on the T2-weighted images; 9 showed fluid-fluid level on T2-weighted images; and 61 patients showed marked enhancement on contrast-enhanced CT and/or MRI. Forty-one lesions (40.6%) had at least 1 atypical radiographic feature: 19 involved ≥2 segments; 11 were centered in the posterior neural arch; 10 had a paravertebral mass over 2 segments; 16 showed partial margin sclerosis with partial cortical destruction on CT scans; and 3 showed mineralization within the tumor on CT. Eighty-eight patients underwent CT-guided biopsy with a diagnostic accuracy rate of 94.3%.

CONCLUSIONS

Spinal GCTs might appear more radiologically atypical, and about 40% of the lesions may have at least 1 atypical feature. CT-guided biopsies are recommended for definitive diagnosis.

Multimodal Management of Combined Posterior and Anterior Surgical Approach and Postoperative Pharmacological Therapy for Giant Cell Tumor of the Cervical Spine Encasing the Vertebral Artery: A Technical Case Report

Giant cell tumor (GCT) of bone is essentially benign but locally aggressive, and the rate of local recurrence is high when the resection is not enough. En bloc resection is recommended as an ideal solution for GCT to decrease the risk of local recurrence, but it remains challenging for cervical GCT. In this technical case report, we present a case of extensively infiltrating GCT of the cervical spine completely encasing the vertebral artery (VA) on one side. The tumor was distributed to layers A-D, sectors 3-8 based on the Weinstein-Boriani-Biagini staging. Combined posterior and anterior surgical approach for the cervical spine was successfully performed and followed by postoperative adjuvant pharmacological therapy. This kind of multimodal management may be one of the solutions for advanced cervical GCT.

Anti-histone H3.3K36M Antibody is a Highly Sensitive and Specific Immunohistochemistry Marker for the Diagnosis of Chondroblastoma. A Validation Based on Study 136 Cases Comprising Chondroblastoma and its Mimics from Single a Centre in India

Introduction: Chondroblastoma has a wide range of differential diagnosis encompassing various benign and malignant entities. The closest differential diagnosis is giant cell tumor of the bone due to overlapping radiological and histomorphological features. Extensive aneurysmal bone cyst like changes and lack of adequately sampled chondroid matrix often masquerades the primary bone lesion and amplifies the diagnostic difficulty in small biopsies with limited tissue. Immunohistochemistry is helpful in such instances to resolve the diagnostic dilemma. Objectives: To analyze the immunohistochemical expression of anti-histone H3F3K36M antibody inchondroblastoma and validate its utility in differentiating chondroblastomafrom its histological mimics. Material and methods: Immunohistochemistry was performed using anti-histone antibody H3.3K36M in 44 histologically diagnosed chondroblastoma and 92 other histological mimickers. All chondroblastoma and giant cell tumor of the bone included in the study were also tested for anti-histone H3.3 G34W antibody. Of the 33 giant cell tumors of bone with classic morphology and imaging findings, 24 H3.3 G34W positive and 9 negative tumors were included intentionally to rule out the possibility of chondroblastoma. The sensitivity, specificity, positive and negative predictive value of marker with regard to chondroblastoma was calculated. Results: Immunohistochemistry revealed unequivocal nuclear positivity for H3.3K36M in the mononuclear cells in all the 44 Chondroblastoma tested, denoting a sensitivity of 100% cases. Allthesetumors tested simultaneously for anti-histone H3.3G34W were negative. None of the histological mimickers were positive H3.3K36M indicating a specificity of 100%. The positive and negative predictive value was 100%. Conclusion: H3.3K36M mutant antibody is highly sensitive and specific IHC marker and can be used as a valuable adjunct to distinguish chondroblastomafrom its histological mimics especially on small biopsies.

[Low-cost reconstructive treatment after resection of distal radius giant cell tumor]

INTRODUCTION

giant cell tumor (GCT) is a benign intramedullary bone tumor that frequently arises at the ends of long bones. After the distal femur and proximal tibia, the distal radius is the third most affected site with particularly aggressive tumors. Our objective is the presentation of the clinical case of a patient diagnosed with distal radius GCT classified in grade III of Campanacci who received a treatment adjusted to her economic possibilities.

CASE REPORT

a 47-year-old female, without economic solvency and with some medical service. Treatment included block resection, reconstruction with distal fibula autograft, and radiocarpal fusion with blocked compression plate. Eighteen months later, the patient had good grip strength (80% on the healthy side) and had fine motor function in the hand. The wrist presented stability with pronation of 85o, supination of 80o, flexion-extension of 0o and a score of 6.7 in the DASH functional outcomes assessment questionnaire. His radiological evaluation five years after his surgery continued with no evidence of local recurrence and pulmonary involvement.

CONCLUSION

the result in this patient, together with the published data, indicate that the block tumor resection technique, plus distal fibula autograft and arthrodesis with blocked compression plate provide an optimal result of functionality for the grade III distal radial tumor at low cost.

Benign Hand Tumors (Part II): Soft Tissue Tumors

Background: Benign soft-tissue tumors of the hand are more common than both their benign bone and malignant soft-tissue counterparts. This study evaluates the characteristics and treatment of benign soft tissue tumors in light of 1 institution's experience. Methods: Histologically confirmed benign soft-tissue tumors of the hand were retrospectively identified using International Classification of Disease codes from 1992 to 2015. A medical chart review was conducted to collect patient demographics, tumor epidemiology, and treatment. Results: A total of 199 soft-tissue tumors were identified. The median patient age at time of treatment was 47.4 ± 14.7 years in age. The majority of tumors were located in the digits (n = 168, 84%) and treated by excision (n = 191, 96%). Localized type tenosynovial giant cell tumors (n = 71, 36%) were the most common and had the highest rates of recurrence (8.5%) in this series. Other frequent histologies included hemangioma, schwannoma, and glomus tumors. Conclusion: Awareness and understanding of tumor characteristics may help physicians with diagnosis and treatment. There is an extensive variety of tumors, but the principles of clinical and imaging diagnosis are common to all of them. Marginal excision for the treatment pain, improvement of function, and cosmetic correction applies to all these tumors independent of the histology.

Multimodal Virtual 3D Representation of a Giant Cell Tumor of the Thyroid Cartilage

Virtual three-dimensional (3D) scanning of pathologic specimens may allow for improved communication between the surgeon and pathologist, as well as enhanced patient counseling and engagement. We report the rare case of a giant cell tumor of the thyroid cartilage and present a multimodal 3D representation. Preoperative 3D printing of the anatomic structures from cross-sectional imaging, as well as novel ex vivo 3D scanning of the fresh pathologic specimen for virtual 3D specimen mapping, was performed.

Management of Giant Cell Tumor of Talus With Extended Intralesional Curettage and Reconstruction Using Polymethylmethacrylate Cement

An 18-year-old man presented with complaints of pain and swelling around the left ankle region. Local examination revealed diffuse, hard, mildly tender swelling with ill-defined margins over the medial aspect of the left ankle joint just below the medial malleolus. Radiographic and computed tomographic assessment revealed osteolytic lesion with moderately defined margins. Provisional diagnosis of Campanacci grade 2 giant cell tumor was made, which was later confirmed on histopathology. Extended intralesional curettage and reconstruction with polymethylmethacrylate cement was done under spinal anesthesia. Full weight bearing was allowed at 4 weeks when the below knee back slab was removed. Radiographic assessment was done every 3 months during the first year of follow-up and then every 6 months. No evidence of recurrence of tumor, collapse of talus, or avascular necrosis was found during follow-up. Managing such rare form of bone tumors with extended intralesional curettage and bone cement is an appropriate treatment and gives good functional results.Level of Evidence: Level V.

Benign Hand Tumors (Part I): Cartilaginous and Bone Tumors

Background: Benign tumors of the hand present in a wide array of histological subtypes and compose most of the bony tissue tumors in the hand. This study evaluates the characteristics and treatment of benign bone tumors in light of one institution's experience. Methods: Histologically confirmed benign tumors of the hand were retrospectively identified using International Classification of Diseases codes from 1992 to 2015. A medical chart review was conducted to collect patient characteristics and tumor epidemiology and treatment. Results: A total of 155 benign bone tumors were identified. The median age of patients at the time of surgery was 39.9 ± 12.8 years. All bone tumors were located in the digits, and most were treated by intralesional curettage (n = 118, 76%). Pathologic fractures occurred in 79 bone tumors (51%). Conclusion: Enchondromas (n = 118, 76%) were the most common bone tumor in this series, whereas giant cell tumors were the most destructive and also had the highest recurrence rate (40%). Awareness of tumor features may help physicians with diagnosis, and awareness of recurrence rates is important when counseling patients.

Evaluating the Optimal Management of Inoperable Giant Cell Tumors of the Spine: A Systematic Review and Meta-Analysis

Simple Summary

Spine giant cell tumors (SGCTs) are intermediate malignant bone tumors, sometimes aggressive and responsible for debilitating axial pain and sensorimotor impairments. Non-surgical therapies, including denosumab, radiotherapy, and selective arterial embolization (SAE), have shown promising results in the treatment of patients with inoperable SGCTs. In this systematic review, we aimed to comprehensively analyze the current literature on denosumab, radiotherapy, and SAE for inoperable SGCTs, comparing treatment outcomes and complications using a random-effect model meta-analysis. We found that all three treatments were equally effective in providing symptom improvement and radiological tumor response, also showing low and comparable rates of treatment-related complications. Patients treated with denosumab showed lower rates of local recurrences and distant metastases.

Abstract

Background: Surgical resection remains the preferred treatment in spine giant cell tumors (SGCTs), but it is not always feasible. Conservative strategies have been studied for inoperable cases. We systematically reviewed the literature on inoperable SGCTs treated with denosumab, radiotherapy or selective arterial embolization (SAE). Methods: PubMed, Scopus, Web-of-Science, Ovid-EMBASE, and Cochrane were searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to include studies of inoperable SGCTs treated with denosumab, radiotherapy or SAE. Treatment outcomes were analyzed and compared with a random-effect model meta-analysis. Results: Among the 17 studies included, 128 patients received denosumab, 59 radiotherapy, and 43 SAE. No significant differences in baseline patient characteristics were found between the three groups. All strategies were equally effective in providing symptom improvement (p = 0.187, I² = 0%) and reduction in tumor volume (p = 0.738, I² = 56.8%). Rates of treatment-related complications were low (denosumab: 12.5%; radiotherapy: 8.5%; SAE: 18.6%) and comparable (p = 0.311, I² = 0%). Patients receiving denosumab had significantly lower rates of local tumor recurrence (10.9%) and distant metastases (0%) compared to patients receiving radiotherapy (30.5%; 8.5%) or SAE (35.6%; 7%) (p = 0.003, I² = 32%; p = 0.002, I² = 47%). Denosumab was also correlated with significantly higher overall survival rates at 18 months (99.2%) and 24 months (99.2%) compared to radiotherapy (91.5%; 89.6%) and SAE (92.5%; 89.4%) (p = 0.019, I² = 8%; p = 0.004, I² = 23%). Mortality was higher in patients receiving SAE (20.9%) or radiotherapy (13.6%) compared to denosumab (0.8%) (p < 0.001), but deaths mostly occurred for unrelated diseases. Conclusions: Denosumab, radiotherapy, and SAE are safe and effective for inoperable SGCTs. Clinical and radiological outcomes are mostly comparable, but denosumab may provide superior tumor control.

Diaphyseal giant cell tumor with multiple relapses in a skeletally immature patient: a case report

Giant cell tumor (GCT) is an aggressive osteolytic lesion mostly affecting the meta-epiphyses of long bones at skeletal maturity. Occurrence of the GCT in diaphysis is a rare entity in adult and exceptionally rare in pediatric population. This is the only third diaphyseal case reported in pediatric population. We report a case of recurrent diaphyseal GCT in a skeletally immature patient of 15-year-old male at the right radius after previous resection with plate and screw fixation. Upon optimal investigations, en-bloc resection of the tumor with radial resection and ulna centralization with wrist arthrodesis was done for a campanacci stage III GCT. The patient had an uneventful recovery without recurrence for 2 years and 2 months following surgery. The main challenge relies on accurate diagnosis due to uncommon location that hinders adequate treatment plan, therefore diagnosis should be solely based on histopathology findings.

Giant cell tumor arising from the anterior arc of the rib: an extremely rare site in an adolescent girl

BACKGROUND

Giant cell tumor is a rare and locally aggressive neoplasm of the long bones in children. Rib is the least frequently affected site, seen in less than 1% of all cases and most of them occur at the posterior arc.

CASE

A 12-year-old girl presented with swelling and slight pain on the left inferior-anterior chest wall for two years. Physical examination revealed a giant, hard and fixed mass on the left chest wall. Hematological and biochemical test results were in normal limits but slight elevation of alkaline phosphatase level. Computed tomography of the chest showed a large expansive mass and lytic lesion with internal calcification arising from the anterior part of the 7th rib. En-bloc resection was performed including the 6th-8th ribs and a small part of the diaphragm. The pathological evaluation revealed giant cell tumor of bone.

CONCLUSIONS

Herein, we aim to emphasize that giant cell tumor should be considered in the differential diagnosis of chest wall tumors in childhood whereby en-bloc resection and close follow up would be paramount.

Clinical and radiological outcomes of combined modular prothesis and cortical strut for revision proximal femur in giant cell tumor of bone patients

BACKGROUND

Femoral bone deficiency is a challenging problem in revision proximal femoral replacement. The purpose of this study is to evaluate the clinical and radiological outcomes of revision proximal femoral replacement as a salvage treatment for severe bone loss after oncologic proximal replacement surgery in patient with benign giant cell tumor of bone.

METHODS

16 patients (6 men and 10 women) were included in this retrospective study, with a mean age of 46.6 year at the time of revision surgery. All patients underwent revision proximal femoral replacement with the use of modular prosthesis and cortical strut allografts. The modified Harris Hip Score, Short Form 36, and musculoskeletal Tumor Society Score were used for patient evaluation. Regular follow-up was performed to evaluate the recurrence and metastases rate, limb function, and long-term complications of patients.

RESULTS

The average follow-up was 46.3 months (range, 26-75 months), during which there was no local recurrence and metastases of patient. At the latest follow-up, the mean modified Harris Hip Score was 70.6 points, which was significantly improved compared with that of preoperative (p < 0.05). The final follow-up results of Short Form 36, Musculoskeletal Tumor Society Score, and limb-length discrepancy were also significantly improved compared to that of preoperative (p < 0.05). At the latest follow-up, the implanted femoral stems were all stable and all cortical strut allografts were also incorporated to their own bone.

CONCLUSION

Using modular prosthesis and cortical strut allografts in revision, proximal femur replacement is an acceptable procedure for relatively young patient with severe proximal femoral bone loss after oncologic surgery with benign giant cell tumor of bone. More attentions should be paid to reduce the risk of complications in these complex reconstructions.

Recurrent Giant Cell Tumor of Distal Radius with Pulmonary Metastasis: A Case Report

Introduction

Giant cell tumor (GCT) is a rare, locally aggressive tumor of bone characterised by the presence of abundant giant cells. GCT has a tendency for recurrence, occurring in approximately a quarter of cases. GCT very rarely metastasize, with metastasis to lungs being reported in approximately 1% of GCTs.

Case Presentation

A 48 year -year-old gentleman noticed a swelling around his left wrist. Radiograph showed a lytic lesion in the distal radius having typical soap bubble appearance. He underwent left distal radius curettage and bone cement placement. The histopathological examination of excised tissue confirmed the diagnosis of GCT. Patient then had recurrence of the tumor 6 months after the surgery. He underwent left distal radius resection, fibular grafting, and wrist arthrodesis. Resected tissue on histopathological examination showed features consistent with GCT. One year later, patient noticed multiple swellings in the region of his left wrist. On examination, there were multiple bony hard, non-tender swellings over the distal forearm. Radiographs revealed a lytic lesion in the fibular strut graft with breach of the cortex. Patient was diagnosed to have recurrence for GCT for the second time. Chest radiograph and Computed Tomography (CT) scan of the thorax revealed multiple canon ball lesions in bilateral lungs, suggesting a metastasis of GCT. The patient, however, did not have any respiratory complaints. We then performed an excision of the tumor, removal of plate and k-wire, and applied a wrist spanning external fixator. Histopathological examination confirmed a recurrence of GCT. The patient was not willing for metastasectomy. The patient was followed up for a period of 18 months. We found no clinical, radiological evidence of recurrence. The metastatic lesions in the lungs were not found to have increased in number or size, while the patient remained asymptomatic.

Conclusion

Giant cell tumours are benign, however, they have a propensity for recurrence. Recurrent GCT are more likely to lead to pulmonary metastasis, and thus warrant pulmonary evaluation. Pulmonary metastasis has a favourable outcome with only half the cases having progression.