Journal of Orthopaedic Surgery 2014;22(3):427-9
Giant cell tumour of the distal humerus: a case report Atmananda S Hegde, Ravindra M Shenoy, Mahabala P Rai Yenepoya Medical College, Mangalore, India
CASE REPORT ABSTRACT Giant cell tumour of the distal humerus is rare. We report one such case in a 30-year-old man who underwent wide resection of the tumour followed by total elbow arthroplasty using a cemented ‘sloppyhinged’ total elbow prosthesis. At the 18-month follow-up, the patient had pain-free range of motion of 15º to 120º and no evidence of recurrence. Key words: giant cell tumor of bone; humerus
INTRODUCTION Giant cell tumour (GCT) of bone accounts for 4% to 5% of all primary bone tumours and 20% of all benign bone tumours.1 In China, it accounts for 20% of all primary bone tumours.2 GCT of bone is usually solitary and benign but locally aggressive, with 5% of metastasis and 1% to 3% of malignant transformation.2–4 It has a predilection for the epiphyseal/metaphyseal region of the long bones3,4 in people aged 30 to 40 years.5 GCT of bone commonly occurs at the distal femur, proximal tibia, distal radius, and proximal humerus6; its occurrence at the distal humerus is rare.7
In December 2012, a 30-year-old man presented with an 8-month history of pain, swelling, and decreased range of movement of the left elbow without preceding trauma. On examination, there was diffuse fullness around the distal humerus, with increased temperature and tenderness. There was a flexion deformity of 20º, with a painful range of motion of 20º to 90º. Supination and pronation were restricted with pain. Radiographs showed an expansile lytic lesion in the olecranon fossa of the humerus with a ‘soap bubble’ appearance. Magnetic resonance imaging (MRI) showed a well-defined, lesion, with altered signal intensity, involving the meta-epiphysis of the distal humerus and extending to the articular surface with a break in the cortex and displacement of adjacent tendons and muscles. Results of blood tests and chest radiographs were within reference ranges. The patient did not attend for a planned biopsy. Three months later, he presented with a biopsy report from elsewhere that suggested Jaffe grade I GCT of bone. He had increased pain and swelling around the elbow joint with gross restriction of movement. Radiographs showed an expansile lytic lesion with cortical breach and soft tissue shadows. MRI also showed a breach of the articular surface (Fig. 1). Computed tomography of the chest showed no
Address correspondence and reprint requests to: Dr Atmananda S Hegde, Department of Orthopaedics, Yenepoya Medical College, Deralakatte, Mangalore, 575018, India. Email: [email protected]
428 AS Hegde et al.
Journal of Orthopaedic Surgery
Figure 1 Radiographs and magnetic resonance images showing an expansile lytic lesion with cortical breach at the distal humerus.
Figure 3 Histopathological photomicrograph showing uniform mononucleate ovoid cells with multinucleate osteoclast-like giant cells.
Figure 2 En bloc resection of the distal humerus followed by total elbow arthroplasty using a cemented ‘sloppy-hinge’ stainless steel total elbow prosthesis.
evidence of pulmonary metastasis. According to the Enneking staging,8 the tumour was classified as stage IB (low grade, extra compartmental, no metastasis). The patient underwent en bloc resection of the distal humerus followed by total elbow arthroplasty using a cemented ‘sloppy-hinge’ stainless steel total elbow prosthesis (Bakshi, Sis Ortho, Bangalore, India). A high arm tourniquet was used without exsanguination. A posteromedial skin incision was made, and the ulnar nerve was identified and isolated. The tumour was excised with a rim of normal tissues
by sharp dissection without breaching the capsule (Fig. 2). The radial head and olecranon process were removed and the triceps attachment was preserved. The cemented sloppy-hinge total elbow prosthesis was inserted after appropriate broaching and sizing. The tourniquet was released and haemostasis was achieved. The wound was closed in layers over a suction drain. The limb was immobilised in full extension with an above-elbow plaster backslab. Histopathological examination of the specimen confirmed the diagnosis of Jaffe grade I GCT of bone (Fig. 3). Postoperatively, active and active-assisted mobilisation was started after one week. At the 18-month follow-up, the patient had pain-free range of motion of 15º to 120º and no evidence of recurrence (Fig. 4).
Vol. 22 No. 3, December 2014
Figure 4 Radiographs at the 7-month follow-up showing no evidence of recurrence.
DISCUSSION GCT of bone typically shows as an epiphyseal, eccentric, expansile lytic lesion with a ‘soap-bubble’ appearance,9 cortical thinning, and delayed cortical breach. It usually causes ‘expansile remodelling’ of the overlying bone; the cortex is usually intact over the tumour, even if it is markedly attenuated. The tumour may contain small foci of dystrophic mineralisation.10 MRI is useful to assess extracortical
Giant cell tumour of the distal humerus 429
spread and intramedullary extension. The key histomorphologic feature is multinucleated giant cells with up to 100 nuclei that have prominent nucleoli. Surrounding mononuclear and small multinucleated cells have nuclei similar to those in the giant cells; this distinguishes GCT of bone from other osteogenic lesions that have benign osteoclast-type giant cells. Surgery is the treatment of choice. Curettage is usually combined with cementing or bone grafting, or both.11 When there is cortical breach with joint invasion, en bloc resection with joint reconstruction is the treatment of choice. Hemi-articular and total elbow allografts have been used for reconstruction of the defects following tumour excision, but the complication rates are high, and these techniques are reserved as salvage procedures following failed total elbow arthroplasty.12 Wide resection and total elbow arthroplasty enables good functional outcome and lower risk for recurrence.13 Total elbow arthroplasty is a viable option, as it provides good pain relief and functional improvement with lower complication rates.12,14,15 DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Gamberi G, Serra M, Ragazzini P, Magagnoli G, Pazzaglia L, Ponticelli F, et al. Identification of markers of possible prognostic value in 57 giant cell tumors of bone. Oncol Rep 2003;10:351–6. 2. Thomas DM, Skubitz KM. Giant cell tumour of bone. Curr Opin Oncol 2009;21:338–44. 3. Werner M. Giant cell tumour of bone: morphological, biological and histogenetical aspects. Int Orthop 2006;30:484–9. 4. Dickson BC, Li SQ, Wunder JS, Ferguson PC, Eslami B, Werier JA, et al. Giant cell tumor of bone express p63. Mod Pathol 2008;21:369–75. 5. Mendenhall WM, Zlotecki RA, Scarborough MT, Gibbs CP, Mendenhall NP. Giant cell tumor of bone. Am J Clin Oncol 2006;29:96–9. 6. Moser RP Jr, Kransdorf MJ, Gilkey FW, Manaster BJ. From the archives of AFIP. Giant cell tumor of the upper extremity. Radiographics 1990;10:83–102. 7. Kulkarni A, Fiorenza F, Grimer RJ, Carter SR, Tillman RM. The results of endoprosthetic replacement of tumours of the distal humerus. J Bone Joint Surg Br 2003;85:240–3. 8. Enneking WF. A system of staging musculoskeletal neoplasms. Clin Orthop Relat Res 1986;204:9–24. 9. Yochum TR, Rowe LJ. Essentials of skeletal radiology. Lippincott Williams & Wilkins. 10. Moser RP Jr, Kransdorf MJ, Gilkey FW, Manaster BJ. From the archives of the AFIP. Giant cell tumor of the upper extremity. Radiographics 1990;10:83–102. 11. Balke M, Schremper L, Gebert C, Ahrens H, Streitbuerger A, Koehler G, et al. Giant cell tumor of bone: treatment and outcome of 214 cases. J Cancer Res Clin Oncol 2008;134:969–78. 12. Kharrazi FD, Busfield BT, Khorshad DS, Hornicek FJ, Mankin HJ. Osteoarticular and total elbow allograft reconstruction with severe bone loss. Clin Orthop Relat Res 2008;466:205–9. 13. Sait SA, Nithyanath M, Cherian VM. Giant cell tumour of the distal humerus treated with elbow arthroplasty: a case report. Int J Case Rep Images 2012;3:37–40. 14. Tang X, Guo W, Yang R, Tang S, Yang Y. Custom-made prosthesis replacement for reconstruction of elbow after tumor resection. J Shoulder Elbow Surg 2009;18:796–803. 15. Sperling JW, Pritchard DJ, Morrey BF. Total elbow arthroplasty after resection of tumors at the elbow. Clin Orthop Relat Res 1999;367:256–1.
Giant cell tumour of the distal humerus: a case report Atmananda S Hegde, Ravindra M Shenoy, Mahabala P Rai Yenepoya Medical College, Mangalore, India
CASE REPORT ABSTRACT Giant cell tumour of the distal humerus is rare. We report one such case in a 30-year-old man who underwent wide resection of the tumour followed by total elbow arthroplasty using a cemented ‘sloppyhinged’ total elbow prosthesis. At the 18-month follow-up, the patient had pain-free range of motion of 15º to 120º and no evidence of recurrence. Key words: giant cell tumor of bone; humerus
INTRODUCTION Giant cell tumour (GCT) of bone accounts for 4% to 5% of all primary bone tumours and 20% of all benign bone tumours.1 In China, it accounts for 20% of all primary bone tumours.2 GCT of bone is usually solitary and benign but locally aggressive, with 5% of metastasis and 1% to 3% of malignant transformation.2–4 It has a predilection for the epiphyseal/metaphyseal region of the long bones3,4 in people aged 30 to 40 years.5 GCT of bone commonly occurs at the distal femur, proximal tibia, distal radius, and proximal humerus6; its occurrence at the distal humerus is rare.7
In December 2012, a 30-year-old man presented with an 8-month history of pain, swelling, and decreased range of movement of the left elbow without preceding trauma. On examination, there was diffuse fullness around the distal humerus, with increased temperature and tenderness. There was a flexion deformity of 20º, with a painful range of motion of 20º to 90º. Supination and pronation were restricted with pain. Radiographs showed an expansile lytic lesion in the olecranon fossa of the humerus with a ‘soap bubble’ appearance. Magnetic resonance imaging (MRI) showed a well-defined, lesion, with altered signal intensity, involving the meta-epiphysis of the distal humerus and extending to the articular surface with a break in the cortex and displacement of adjacent tendons and muscles. Results of blood tests and chest radiographs were within reference ranges. The patient did not attend for a planned biopsy. Three months later, he presented with a biopsy report from elsewhere that suggested Jaffe grade I GCT of bone. He had increased pain and swelling around the elbow joint with gross restriction of movement. Radiographs showed an expansile lytic lesion with cortical breach and soft tissue shadows. MRI also showed a breach of the articular surface (Fig. 1). Computed tomography of the chest showed no
Address correspondence and reprint requests to: Dr Atmananda S Hegde, Department of Orthopaedics, Yenepoya Medical College, Deralakatte, Mangalore, 575018, India. Email: [email protected]
428 AS Hegde et al.
Journal of Orthopaedic Surgery
Figure 1 Radiographs and magnetic resonance images showing an expansile lytic lesion with cortical breach at the distal humerus.
Figure 3 Histopathological photomicrograph showing uniform mononucleate ovoid cells with multinucleate osteoclast-like giant cells.
Figure 2 En bloc resection of the distal humerus followed by total elbow arthroplasty using a cemented ‘sloppy-hinge’ stainless steel total elbow prosthesis.
evidence of pulmonary metastasis. According to the Enneking staging,8 the tumour was classified as stage IB (low grade, extra compartmental, no metastasis). The patient underwent en bloc resection of the distal humerus followed by total elbow arthroplasty using a cemented ‘sloppy-hinge’ stainless steel total elbow prosthesis (Bakshi, Sis Ortho, Bangalore, India). A high arm tourniquet was used without exsanguination. A posteromedial skin incision was made, and the ulnar nerve was identified and isolated. The tumour was excised with a rim of normal tissues
by sharp dissection without breaching the capsule (Fig. 2). The radial head and olecranon process were removed and the triceps attachment was preserved. The cemented sloppy-hinge total elbow prosthesis was inserted after appropriate broaching and sizing. The tourniquet was released and haemostasis was achieved. The wound was closed in layers over a suction drain. The limb was immobilised in full extension with an above-elbow plaster backslab. Histopathological examination of the specimen confirmed the diagnosis of Jaffe grade I GCT of bone (Fig. 3). Postoperatively, active and active-assisted mobilisation was started after one week. At the 18-month follow-up, the patient had pain-free range of motion of 15º to 120º and no evidence of recurrence (Fig. 4).
Vol. 22 No. 3, December 2014
Figure 4 Radiographs at the 7-month follow-up showing no evidence of recurrence.
DISCUSSION GCT of bone typically shows as an epiphyseal, eccentric, expansile lytic lesion with a ‘soap-bubble’ appearance,9 cortical thinning, and delayed cortical breach. It usually causes ‘expansile remodelling’ of the overlying bone; the cortex is usually intact over the tumour, even if it is markedly attenuated. The tumour may contain small foci of dystrophic mineralisation.10 MRI is useful to assess extracortical
Giant cell tumour of the distal humerus 429
spread and intramedullary extension. The key histomorphologic feature is multinucleated giant cells with up to 100 nuclei that have prominent nucleoli. Surrounding mononuclear and small multinucleated cells have nuclei similar to those in the giant cells; this distinguishes GCT of bone from other osteogenic lesions that have benign osteoclast-type giant cells. Surgery is the treatment of choice. Curettage is usually combined with cementing or bone grafting, or both.11 When there is cortical breach with joint invasion, en bloc resection with joint reconstruction is the treatment of choice. Hemi-articular and total elbow allografts have been used for reconstruction of the defects following tumour excision, but the complication rates are high, and these techniques are reserved as salvage procedures following failed total elbow arthroplasty.12 Wide resection and total elbow arthroplasty enables good functional outcome and lower risk for recurrence.13 Total elbow arthroplasty is a viable option, as it provides good pain relief and functional improvement with lower complication rates.12,14,15 DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Gamberi G, Serra M, Ragazzini P, Magagnoli G, Pazzaglia L, Ponticelli F, et al. Identification of markers of possible prognostic value in 57 giant cell tumors of bone. Oncol Rep 2003;10:351–6. 2. Thomas DM, Skubitz KM. Giant cell tumour of bone. Curr Opin Oncol 2009;21:338–44. 3. Werner M. Giant cell tumour of bone: morphological, biological and histogenetical aspects. Int Orthop 2006;30:484–9. 4. Dickson BC, Li SQ, Wunder JS, Ferguson PC, Eslami B, Werier JA, et al. Giant cell tumor of bone express p63. Mod Pathol 2008;21:369–75. 5. Mendenhall WM, Zlotecki RA, Scarborough MT, Gibbs CP, Mendenhall NP. Giant cell tumor of bone. Am J Clin Oncol 2006;29:96–9. 6. Moser RP Jr, Kransdorf MJ, Gilkey FW, Manaster BJ. From the archives of AFIP. Giant cell tumor of the upper extremity. Radiographics 1990;10:83–102. 7. Kulkarni A, Fiorenza F, Grimer RJ, Carter SR, Tillman RM. The results of endoprosthetic replacement of tumours of the distal humerus. J Bone Joint Surg Br 2003;85:240–3. 8. Enneking WF. A system of staging musculoskeletal neoplasms. Clin Orthop Relat Res 1986;204:9–24. 9. Yochum TR, Rowe LJ. Essentials of skeletal radiology. Lippincott Williams & Wilkins. 10. Moser RP Jr, Kransdorf MJ, Gilkey FW, Manaster BJ. From the archives of the AFIP. Giant cell tumor of the upper extremity. Radiographics 1990;10:83–102. 11. Balke M, Schremper L, Gebert C, Ahrens H, Streitbuerger A, Koehler G, et al. Giant cell tumor of bone: treatment and outcome of 214 cases. J Cancer Res Clin Oncol 2008;134:969–78. 12. Kharrazi FD, Busfield BT, Khorshad DS, Hornicek FJ, Mankin HJ. Osteoarticular and total elbow allograft reconstruction with severe bone loss. Clin Orthop Relat Res 2008;466:205–9. 13. Sait SA, Nithyanath M, Cherian VM. Giant cell tumour of the distal humerus treated with elbow arthroplasty: a case report. Int J Case Rep Images 2012;3:37–40. 14. Tang X, Guo W, Yang R, Tang S, Yang Y. Custom-made prosthesis replacement for reconstruction of elbow after tumor resection. J Shoulder Elbow Surg 2009;18:796–803. 15. Sperling JW, Pritchard DJ, Morrey BF. Total elbow arthroplasty after resection of tumors at the elbow. Clin Orthop Relat Res 1999;367:256–1.
