DEPARTMENT OF ORTHOPAEDICS

GOVT.MEDICAL COLLEGETHRISSUR

CASE 1

42yrs old patient Ref from Ottappalam Govt. hospital Pain (L)wrist of 1/12 duration Fullness of the (L)wrist Range of movements: mild restriction

of palmar flexion, ulnar deviation & pronation

Mild weakness of the grip

42yrs old male patient

X-RAY

DIFFERENTIAL DIAGNOSIS

1. GCT2. Infection 3. ABC4. Brown tumour5. Chondroblastoma 6. Unicameral bone cyst7. Chondromyxoid fibroma

OTHER INVESTIGATIONS

Hb -12g% ESR – 8 Chest X-ray-normal Ca ,P – normal S.ALP – 54 S.acid phosphatase – 35u T3,T4,TSH – normal

FNAC - giant cell, spindle cell lesion possibly GCT

MRI

Moderate sized expansile lesion in the distal epiphyseometaphyseal region of (L)radius, eccentrically located, medial exophytic lobulation, no significant enhancement, lesion extends upto the subarticular region of the radius, exophytic component abuts the lateral margin of the ulna causing mild mass effect on the pronator quadratus muscle with mild oedema, no periosteal reaction - suggestive of giant cell tumour

CASE 2

41yr old male patient Pain and swelling (L)wrist > 2/12 Went for massage initially Pain and swelling increased after

massage Range of movements: all movements

painful and restricted Weakness of grip and severe pain

X-RAY

OTHER INVESTIGATIONS

Hb – 10.2g% ESR – 12 Chest X-ray - normal S.Ca, P – normal S.ALP – 80 S.acid phosphatase – 41u Thyroid function – normal

FNAC – suggestive of GCT

MRI

Moderate sized expansile lesion in the distal epimetapahyseal radius(L) eccentrically located , volar and lateral exophytic lobulation, extends upto the subarticular region of the radius, no periosteal reaction- suggestive of GCT

ENNEKING STAGING(PRE-OP)

Stage 1 (latent)-asymptomatic(intracompartmental)

Stage 2(active)-symptomatic(intracompartmental)

Stage 3(aggressive)-extracompartmental

CAMPANACCI GRADING

Campanacci radiological grades (cortical breach)

Grade 1 – intact cortex

Grade 2 – well-defined margins, no radio-opaque rim

Grade 3 – fuzzy borders

Campanacci histological grades(post-op)

Grade 1(typical) Grade 2(aggressive) Grade 3(malignant)

Compactness of stromaMitotic figuresHyperchromatism Giant cells

RECURRENCE AFTER SURGERY

Is there any absolutely predictable correlation between the grading systems and the incidence of local recurrence or metastasis of the giant cell tumour ?

No !!

TREATMENT OPTIONS

Curettage & bone grafting Extended curettage Resection(wide excision) & wrist

arthrodesis(vascularised/nonvascularised fibula)

Resection,Ulnar transposition(one-bone forearm)&wrist arthrodesis

Resection & reconstruction of the wrist with fibular head(fibular head arthroplasty)

JOURNAL OF ORTHO. SUR

Click icon to add picture

2012;4:76-82Dr.Dominic Puthur&Dr.Kishore Puthezhath

EXTENDED CURETTAGE

Curettage supplemented by power burrs & local adjuvants

Local adjuvants: phenol hydrogen peroxide bone cement zinc chloride argon beam cauterization

Dominic puthur,Wilson Iype:GCT-curettage&bone grafting:IJO,41,apr-jun 2007;121-23

MOST AUTHORS AGREE THAT THE COMPLETENESS OF THE CURETTAGE&EXCISION IS THE SINGLE MOST IMPORTANT FACTOR TO PREVENT RECURRENCE.

WHAT DID WE DO?Follows…….

EXPOSURE

EXCISION WITH PQ ENMASSE

CAVITY IN THE DISTAL RADIUS, MOPS SOAKED IN HYDROGEN PEROXIDE

SANDWITCH TECHNIQUE : ILIAC CREST GRAFT + GELFOAM

BONE CEMENTING

RECONSTRUCTION OF GCT WITH MINIMAL SUBCHONDRAL BONE

Sandwitch technique

CLOSURE WITHOUT DRAIN

POST-OP X-RAYS

HISTOPATHOLOGY

Stromal cells - neoplastic Osteoclast like giant cells – cells

responsible for bone destruction Aggressive lesions – compact

stroma,atypism,heterochromatism Benign lesions – more giant cells with

multiple nuclei Malignant cells in plenty - ?

GCT(pathologist)

HISTOPATHOLOGY

CASE 1: GCT WITH MILD ATYPISMCASE 2 : GCT WITH MODERATE ATYPISM

LITERATURE SUPPORT

Cheng etal treated grade 3 lesions with curettage when the tumour did not invade the wrist, >50% cortexinact,extraosseous mass only in one plane

Cheng CY,shih HN-treatment of GCT of distal radius:clin ortho&rel research 2001;383:221-8

Khan etal showed that curettage alone is sufficient for most of the distal radius GCTs

Khan MT,Gray JM-management of distal radius GCTs. Ann R coll surgery Engl 2004;86:18-24

COMPARATIVE TRIAL BY AK GUPTA ETAL. FROM GSVM MEDICAL COLLEGE,KANPUR

YOGESH,AJAY PURI ETAL. TATA MEMORIAL HOSPITAL,MUMBAI

ROLE OF BISPHOSPHONATES

Novel adjuvant therapy for GCTChang,Suratwala etal clin.ortho& relat res 2004;426:103-9

topical/systemic pamidronate or Zoledronate Induce apoptosis of the giant cells Limit tumour progression & prevent bone

destruction Rinsing morsellized bone grafts with

bisphosphonates prevents resorption and reduce the risk of mechanical failure

Kesteris&Aspenberg JBJS(Br)2006;88:993-96

TARTRATE RESISTANT ACID PHOSPAHATASE AS A TUMOUR-MARKER(?!)

Total serum acid phosphatase - tumour size

Akhane T,Isobe K acta ortho 2005;76:1231-3

High preoperative values , normalized after surgery, reappeared with local recurrence

Tartrate resistant acid phosphatase - more specific

IN OUR PATIENTS

Case 1 preoperative acid phosphatase – 35u 5th post-op day - 4.6u

Case 2 preoperative acid phosphatase - 41u 5th post-op day - 5.1u

CONCLUSION

Curettage&graft still a good option

Average recurrence rate of GCT - 32%(whatever be the mode of treatment)

Extended curettage - less recurrence rate

Bisphonates – medical management of GCT

Tumour marker – acid phosphatase

THANK YOU