Giant cell tumor of bone: clinical and radiographic aspects of 115 cases

Abstracts

OBJECTIVE: To review clinical and radiographic findings in patients with histologically confirmed giant cell tumor of bone. MATERIALS AND METHODS: Clinical and radiological data of 115 patients with giant cell tumor of bone were analyzed. RESULTS: Of the evaluated cases, 57.4% (66) were female and 80% (92) were white. The patients were 30 years old in average and the most common site of the lesions was the distal femoral metaphysis, in 22.6% (26). The most common radiographic aspect was a purely lytic lesion, in 63.7% (51) of the cases. CONCLUSION: Giant cell tumor of bone is not an uncommon tumor, predominant in the white race, with radiological findings well established.

Conventional radiology; Giant cell tumor of bone; Bone neoplasms

OBJETIVO: Analisar os aspectos clínicos e radiográficos em pacientes com diagnóstico de tumor de células gigantes ósseo, confirmado por histopatologia. MATERIAIS E MÉTODOS: Os dados clínicos e radiológicos (quando disponíveis) de 115 pacientes com diagnóstico de tumor de células gigantes ósseo foram analisados no presente estudo. RESULTADOS: Dos casos avaliados, 57,4% (66) eram do sexo feminino e 80% (92) eram da raça branca. A média de idade dos pacientes foi de 30 anos e a topografia mais freqüente das lesões foi a metáfise distal do fêmur, em 22,6% (26) dos casos. O aspecto radiográfico mais comum foi o de lesão puramente lítica, em 63,7% (51) dos casos. CONCLUSÃO: O tumor de células gigantes é uma neoplasia óssea relativamente comum, com predomínio em indivíduos da raça branca e com aspecto radiológico bem definido.

Radiologia convencional; Tumor de células gigantes; Neoplasias ósseas

ORIGINAL ARTICLE

Giant cell tumor of bone: clinical and radiographic aspects of 115 cases^*

Julian Catalan^I; Alexandre Calábria da Fonte^I; Joel Rodrigo Beal Lusa^I; Alex Dias de Oliveira^I; Elisa Soares de Melo^I; Reinaldo Ottero Justino Júnior^I; Tjioe Tjia Min^I; Ana Carolina Mori Lima^I; Carlos Marcelo Gonçalves^II

^IMD Residents at the Center of Treatment and Research Department of Imaging, Hospital do Câncer – A.C. Camargo

^IIMD Radiologist at the Center of Treatment and Research Department of Imaging, Hospital do Câncer – A.C. Camargo

^{Mailing address}

ABSTRACT

OBJECTIVE: To review clinical and radiographic findings in patients with histologically confirmed giant cell tumor of bone.

MATERIALS AND METHODS: Clinical and radiological data of 115 patients with giant cell tumor of bone was analyzed.

RESULTS: Of the evaluated cases, 57.4% (66) were female and 80% (92) were white. The patients were 30 years old in average and the most common site of the lesions was the distal femoral metaphysis, in 22.6% (26). The most common radiographic aspect was a purely lytic lesion, in 63.7% (51) of the cases.

CONCLUSION: Giant cell tumor of bone is not an uncommon tumor, predominant in the white race, with radiological findings well established.

Keywords: Conventional radiology; Giant cell tumor of bone; Bone neoplasms.

INTRODUCTION

The giant cell tumor (GCT) is one of the most common primary bone neoplasms, being in most cases, a benign lesion. The great majority of tumors affect individuals between the second and fourth decades of life, with a discreet female predominance. Pain and local volume increase are the most frequent complaints. Classically, conventional radiographic studies demonstrate a well defined solitary lytic, metaepiphyseal lesion, and the knee bones are more affected. The present study intends to evaluate the clinical and radiographic aspects of 115 cases of this disease diagnosed in our institution.

MATERIALS AND METHODS

In the period from 1980 to 2000, 115 histologically confirmed and diagnosed cases of GCT were studied by means of images files review and data collected in the Radiology Sector Records of the Center of Treatment and Research of the Hospital do Câncer – A.C. Camargo

The examinations have not followed any particular pattern, considering that they were performed along several years in the service routine, with different devices and without definition of an appropriate protocol.

RESULTS

Of 115 patients, 57.4% (66) were female and 42.6% (49) were male. The predominant race in this population was white, with 92 individuals (80%), followed by 14 dark skinned individuals (12.2%), 7 blacks (6.1%), and 2 asians (1.7%).

Average age was 30 years, with 34 patients below 20 years, and 11 patients above 50 years, corresponding to the age ranges where the onset of this entity is less frequent. The youngest patient was four years old and the oldest, 79. (Figure 1).

Clinically, pain and volume increase were the most significant symptoms in 80.8% (93) and in 54% (62) of the patients, respectively. Hematuria, fever and weight loss were symptoms in only one patient each, corresponding to 0.9% of our casuistic.

Local recidivation was diagnosed after treatment in 27.8% (32) of the patients. The most common GCT topography (Figure 2) was the distal metaphysis of the femur (Figure 3), with 22.6% (26) of patients, followed by proximal tibia (Figure 4), with 20% (23), mandible, with 7.8% (9), and proximal metaphysis of the humerus and distal metaphysis of the radius (Figure 5), each with 6.9% (8) of the patients.

Only one of the patients presented disease metastatization and the lung was the affected organ. After the case review by the responsible multidisciplinary team, one has concluded that it was a secondary malignant GCT.

Radiographically, the most frequently observed pattern was the purely lytic metaphyseal lesion, in 63.7% (51) (Figure 6) of the patients. Other more frequent patterns were lytic lesion with insufflation (Figure 7), in 20% (16), and lytic lesion with internal septations (Figure 8), in 13.8% (11) of the patients. Cortical rupture was observed in 11.2% (9) of cases, increase in soft parts in 17.5% (14), periosteal reaction in 7.5% (6) and marginal sclerosis in 6.25% (5) of cases. There was no description of pre-treatment radiographic aspect for 43.7% (35) of the patients.

DISCUSSION

The GCT is a relatively common bone neoplasm, corresponding to about 5%–10% of all the primary bone tumors and 15–25% of the benign bone tumors. It is microscopically characterized by great quantity of giant cells scattered throughout a stroma of mononuclear cells. There is no consensus among the majority of authors regarding the true histogenesis of these lesions, but evidences favor a mesenchymal origin and the hypothesis of mononuclear cells being progenitors of the giant cells that give name to the tumor⁽¹⁾.

There are two GCT malignant variants – one characterized by a stroma with an explicitly malignant aspect, permeated with benign giant cells, known as "primary form", and another in which a sarcomatous proliferation appears inside the lesion previously documented as a benign GCT⁽²⁾. Occasionally, even a GCT with totally benign characteristics may evolve as a distant metastasis⁽³⁾. Only about 69 cases were publicized in the indexed literature up to this moment.

Typically, its onset occurs in the age range between 20 and 50 years, with a discreet prevalence in female patients⁽⁴⁾.

Pain of variable intensity is the predominant symptom, usually associated with volume increase of the affected region.

The classical site of such lesions is of help in the diagnosis since one knows that in more than 85% of times the lesion is situated at up to 1 cm from the subarticular bone. The starting point of this tumor is unknown, but the majority of authors believe that its origin is the metaphyseal side of the epiphyseal plate⁽⁵⁾. In the rare cases in which GCT onset precedes the closing of the growth physis, the lesion tends towards a metaphyseal location⁽⁶⁾. In these cases, it is necessary to ascertain the absence of an aneurysmal bone cyst or a giant cell osteosarcoma⁽³⁾.

Almost half of cases affect regions around the knee, most usually the distal femur. The distal radius and the sacrum also are bones frequently involved. Rarely, these tumor appear on small bones of hands and feet; in these cases, it seems there is a higher incidence of tumoral multicentricity^(3,5).

Radiologically, it is seen as a lytic, eccentric image, with a narrow transition zone to the normal bone, without peripheral sclerosis. This finding is observed in up to 85% of the cases⁽⁴⁾. Large lesions, however, seem to have a central location. Periosteal reaction is radiographically characterized in less than one third of cases. In about half of patients there is a multiloculated aspect secondarily to a prominent trabeculation (in truth, pseudotrabeculation due to a osseous sulcus created by endosteal erosion)⁽⁶⁾. Rarely a tumor produces calcifications, suggesting a diagnosis of osteosarcoma.

A rating system based on the radiographic aspect of the GCT was developed by Campanacci et al.⁽⁷⁾. The grade I tumor presents well defined margins and a thin "halo" of mature bone. The grade II tumor is well delimited, but does not present a sclerotic halo. The grade III lesion has ill-defined borders, suggesting aggressiveness. However, this rating does not seem to have a clinical correlation.

Other imaging diagnosis methods play a significant role in the lesion characterization. The bone scintigraphy demonstrates increased concentration of radiotracer in the lesion (Figure 9) and, in up to 57% of cases, both the "donut sign" and central photopenia are present⁽⁶⁾.

Computed tomography for diagnosing solitary bone lesions is typically used for outlining the cortical alterations in a more accurate way⁽⁸⁾. In the GCT, the CT scan (Figure 10) demonstrates more clearly the cortical expansion or erosion, pseudotrabeculations, absence of mineralizing matrix and eventual pathologic fractures⁽⁹⁾.

The magnetic resonance imaging is considered the most important method for evaluating the bone tumors extent, but is less specific in differential diagnoses⁽¹⁰⁾.

At magnetic resonance images, the GCT presents more commonly as a well-defined lesion, that may be surrounded by a low intensity signal halo, representing both reactive sclerosis and fibrous capsule⁽⁶⁾. Most lesions presents low-intensity signal both in T1 and T2 weighted images (Figure 10), due the presence of hemosiderin deposits and/or high content of collagen^(6,9).This finding may be useful for exclusion of other lesions in an epiphyseal location like subcondral cysts, chondroblastomas and clear cell chondrosarcomas^(6,11). Cystic areas inside the lesion also are frequently characterized by magnetic resonance imaging, and may be consequential to hemorrhages or to secondary aneurysmatic bone cysts formation^(6,9).

A surgical grading system similar to that of Campanacci et al.⁽⁷⁾ was developed by Enneking, also represented by three different grades⁽¹²⁾. The standard treatment ranges from a simple curettage to an extensive resection with different results in several studies. The lesion curettage combined with marginal cauterization and/or use of liquid nitrogen, has shown itself as a reliable treatment method, but large lesions require extensive resection and reconstruction with prosthesis or autologous bone tissue⁽¹³⁾.

GCT local recurrence is more frequently observed in the first three years after treatment. Great series of patients with post-treatment assessment demonstrate indexes of up to 25% of local recidivation, as reported by O'Donnel et al.⁽¹⁴⁾.

CONCLUSION

The giant cell tumor is a relatively common bone neoplasm with well-defined radiological characteristics. Its more common epidemiological and radiological aspects described in literature are similar to those aspects observed in our casuistic.

REFERENCES

Received October 28, 2004.

Accepted after revision May 18, 2005.

• 1. Goldring SR, Roelke MS, Petrison KK, Bhan AK. Human giant cell tumors of bone identification and characterization of cell types. J Clin Invest 1987; 79:483491.
• 2. Grote HJ, Braun M, Kalinski T, et al. Spontaneous malignant transformation of conventional giant cell tumor. Skeletal Radiol 2004;33:169175.
• 3. Unni KK. Giant cell tumor. In: Unni KK, editor. Dahlin's bone tumors: general aspects and data on 11,087 cases. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 1996;263283.
• 4. Mirra JM. Bone tumors: diagnosis and treatment. 2nd ed. Philadelphia, Pa: JB Lippincott, 1980:332356.
• 5. Levine SM, Lambiase RE, Petchprapa CN. Cortical lesions of the tibia: characteristic appearances at conventional radiography. RadioGraphics 2003; 23:157177.
• 6. Murphey MD, Nomikos GC, Fleming DJ, et al. Imaging of giant cell tumor and giant cell reparative granuloma of bone: radiologic-pathologic correlation. RadioGraphics 2001;21:12831309.
• 7. Campanacci M, Giunti A, Olmi R. Giant cell tumors of bone: a study of 209 cases with long-term follow-up in 130. Ital J Orthop Traumatol 1975;1: 249277.
• 8. Resnick D. Tumors and tumor-like lesions of bone: radiographic principles. In: Resnik D, editor. Diagnosis of bone and joint disorders. Philadelphia, Pa: Saunders, 1995;36133627.
• 9. Woertler K. Benign bone tumors and tumor-like lesions: value of cross-sectional imaging. Eur Radiol 2003;13:18201835.
• 10. Berquist TH. Magnetic resonance imaging of primary skeletal neoplasms. Radiol Clin North Am 1993;31:411424.
• 11. Aoki J, Tanikawa H, Ishii K, et al. MR findings indicative of hemosiderin in giant cell tumor of bone: frequency, cause, and diagnostic significance. AJR 1996;166:145148.
• 12. Oda Y, Miura H, Tsuneyoshi M, Iwamoto Y. Giant cell tumor of bone: oncological and functional results of long-term follow-up. Jpn J Clin Oncol 1998;28:323328.
• 13. Su YP, Chen WM, Chen TH. Giant cell tumors of bone: an analysis of 87 cases. Int Orthop 2004;28: 239243.
• 14. Manaster BJ, Doyle AJ. Giant cell tumors of bone. Radiol Clin North Am 1993;31:299323.

*

Study developed at the Center of Treatment and Research, Hospital do Câncer – A.C. Camargo, São Paulo, SP.

Publication Dates

• Publication in this collection
  25 May 2006
• Date of issue
  Apr 2006

History

• Received
  28 Oct 2004
• Accepted
  18 May 2005