Pediatric Radiology
Metaphyseal Giani-Ceil Tumor in a Girl of 14 1 Bernard Peison, M.D. and Jerrold Feigenbaum, M.D. A case of giant-cell tumor in the radial metaphysis of a 14-year-01d girl is reported . 3.5 % of these tumors are detected in patients younger than 15 years of age , when closure of the cartilaginous growth plate occurs. A significant number of the 14 % of giant-cell tumors detected in patients younger than 20 may originate in a metaphysis during adolescence and become symptomatic qnly after long bone epiphyseal involvement. INDEX TERMS:
Bone Neoplasms' Bones , growth and development
Radiology 118:145 -146, January 1976
THE RADIOLOGICAL, clinical , and histological characI teristics of the adult form of giant-cell tumor of bone have been well established by Jaffe (11), Lichtenstein (16), and others (3, 4, 19, 23). However, there has been some controversy concerning these lesions in the past (1, 7), and also in the more recently recorded opinions of Aegerter (2), whose account encompasses the still unsettled matter of histogenesis (20), Aegerter concludes that a giant-cell tumor is a neoplasm of osteoclasts, and, more reservedly, that it be recognized as a neoplasm . Although there has been a partial reconciling of views regarding 'the adult form of giant-cell tumor, even recently published cases (5, 8) do not bear upon the special characteristics of this lesion in adolescents. We have found only one previously documented case of an adolescent giantcell tumor in the literature (22); this is a similar case occurring in the. radius of a 14-year-old girl. The common defining characteristic in both cases is a giant-cell tumor in the metaphysis of a long bone (the radius) occurring before the disappearance of the cartilaginous growth plate. Case report
Fig. 1 Giant-cell tumor. Note the typical radiolucent lesion in the distalradialmetaphysis (June 20, 1969) after healing of a pathological fracture sustained one month earlier. The tumor is restricted to the metaphysis anddoesnot involve the growthplate.
amination confirmed the clinical impression that the tumor had recurred . The cartilag inous growth plate of the left radius had been replaced by bone, in contrast to the persistence of the plate in the contralateral radius. The terminal 6 cm of the left radius was surgically resected on February 27, 1970, and replaced by a bone graft from the right iliac crest, fusing the left wrist. The diagnosis of recurrent giant-cell tumor of the radius was confirmed . The patient has healed without further
A 14-year-old white girl sustained a fracture through the distal end of the left radius on May 7, 1969. Radiological examination revealed a lesion at the site of the fracture, consistent with a benign osteoblastoma, a unicameral bone cyst, or an aneurysmal bone cyst. The fracture was treated conservat ively and she was admitted four weeks later for surgery. Physical examination revealed that the left forearm was moderately weak and there was enlargement and deformity of the distal radial segment. Radiographs of the left wrist showed a radiolucent expansile lesion In the distal metaphysis of the radius, measuring 3 cm in width and 3.5 cm in length and extending proximally from the growth plate (Fig. 1). A thin shell of SUbperiosteal bone contained the tumor without any apparent extraosseous soft-tissue mass. Subperiosteal new bone extending along the diaphysis from the lesion was attributed to a previous fracture. No sclerotic margin was present. The tumor did not extend across the cartilaginous growth plate Into the epiphysis. No other abnormalities were demonstrated by skeletal survey, and serum clacium, inorganic phosphorus, and alkaline phosphatase values were within normal limits. The patient underwent surgery on June 23, and the left forearm was immobilized in a plaster cast. The patient returned to the hospital with complaints of a recurrent "lump" over the distal metaphysis of the left radius. Radiological ex-
Fig. 2 Grade I giant-cell tumor of the radial metaphysis, composed of uniformly distributed giant cells among the less conspicuous, vaguely syncytial, mononuclear " stromal" cells. (H&E X 200)
1 From Rahway Hospital (B. P., Director of Laboratories; J. F., Department of Orthopedics), Rahway, N. J. Accepted for publication in July 1975. . S5
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complaints and shows no clinical or radiological evidence of tumor recurrence.
Table I:
Giant-Cell Tumors of Bones in Patients Younger Than 20 Yr. of Age
DISCUSSION The differential diagnosis of a giant-cell tumor in the young patient has become widely standardized (15) and must include nonossifying fibroma, chrondromyxoid fibroma, benign chondroblastoma, benign osteoblastoma, aneurysmal bone cyst, unicameral bone cyst, brown tumor, giant-cell repara-' tive granuloma, and pigmented villonodular synovitis eroding bone. These alternatives can be clearly eliminated by the unequivocal histological patterns of the tumor. In this case, the mass was composed of numerous multinuclear giant cells uniformly dlstributed among the less conspicuous, vaguely syncytial, mononuclear "stromal" cells. There was no necrosis or scarring. Neither an osteoid nor a chondroid matrix could be demonstrated in any of the tumor tissue samples (Fig. 2). For descriptive purposes, the mass is classified as a Grade I giant-cell tumor of bone (11). The occurrence of giant-cell tumors in subjects under 20 years of age is documented by statistics drawn from consecutive series (TABLE I). This shows the incidence in patients aged 20 years or less to be approximately 14% (143/1,019). The clinically and radiologically more rneaninqful age separation should occur at 15 years, immediately before closure of the growth plate. Our own statistics (TABLE I) and those of Dahlin (5) and Murphy (19) show a combined incidence of 3.5 % (9/256) in patients under the age of 15. The term "incidence" is generally used when it is the rate of detection which is being assessed. Because these tumors may be asymptomatic and go undetected, it is likely that a significant percentage of the giant-cell tumors found before age 20 may have originated before closure of the growth plate. This echoes the hypothesis of Sherman et al (22), whose reported case came to clinical attention only because of trauma to the affected bone. As long as giant-cell tumors are restricted to the metaphysis by the 9r9wth plate, they are likely to remain asymptomatic. When the growth plate is obliterated, epiphyseal invasion ultimately undermines the subchondral bone, increasing the likelihood of clinical complaints which may lead to radiological detection of the lesion.
REFERENCES 1. Aegerter E, Kirkpatrick JA Jr: Orthopedic Diseases. Philadelphia, Saunders, tst Ed, 1958, pp 505-519 2. Aegerter E, Kirkpatrick JA Jr: Orthopedic Diseases. Philadelphia, Saunders, 3d Ed, 1968, pp 620-636 3. Coley Bl: Neoplasms of Bone. Hoeper, 2d Ed, 1949, pp 196-125 4. Coley Bl, Higinbotham Nl, Kogure T: Giant cell tumor of bone, Am J Surg 96:479-491, Oct 1958 5. Dahlin DC, Cupps RE, Johnson EW Jr: Giant-cell tumor: a study of 195 cases. Cancer 25: 1061-1 070, May 1970 6. Edeiken J, Hodes PJ: Giant cell tumors vs tumors with giant cells. Radiol Clin North Am 1:75-100, Apr 1963 7. Geschickter CF, Copeland MM: Tumors of Bone. Philadel. phia, Lippincott, 3d Ed, 1949, pp 316-320 8. Goldenberg RR, Campbell CJ, Bonfiglio M: Giant-cell tumor of bone. An analysis of two hundred and eighteen cases. J Bone Joint Surg [arit] 52:619-664, Jun 1970 9. Guilleminet M, Picault C: On the subject of 2 cases of giant cell tumors of bone. !-yon Chir 56:613-618, Jul1960 10. Hutter RV, Worcester IN Jr, Francis KC, et al: Benign and malignant giant cell tumors of bone. A clinicopathological analysis of
January 1976
Author/Year Thomson et al., 1955 Murphy et al., 1956 Coley et al., 1958 Guilleminet, 1960 Kojima et al., 1960 Walter, 1960 Schajowicz, 1961 Sherman et al., 1961 Hutter et al., 1962 Edeiken et al., 1963 Mnaymneh et al., 1964 Jonasch, 1965 Merle 0' Aubigne, 1968 Johnson et al., 1969 Goldenberg, 1970 Dahlin, 1970 Johnston (New York Orthopedic Hospital), 1971
No. of Patients Total Age Younger No. of Group Than Ref. Patients (Yr.) 20 Yr.
24 19 4 9 15 25 21 22 10 6 18 14 17 12 8 5 13
Total No. from consecutive series
34 3i 108 89 29 15 85 1 76 1 41 3 39 24 218 195
16 14-20 10-20 15 16-17 16-17 15-20 15 10-19 20
Metaphyseal Giani-Ceil Tumor in a Girl of 14 1 Bernard Peison, M.D. and Jerrold Feigenbaum, M.D. A case of giant-cell tumor in the radial metaphysis of a 14-year-01d girl is reported . 3.5 % of these tumors are detected in patients younger than 15 years of age , when closure of the cartilaginous growth plate occurs. A significant number of the 14 % of giant-cell tumors detected in patients younger than 20 may originate in a metaphysis during adolescence and become symptomatic qnly after long bone epiphyseal involvement. INDEX TERMS:
Bone Neoplasms' Bones , growth and development
Radiology 118:145 -146, January 1976
THE RADIOLOGICAL, clinical , and histological characI teristics of the adult form of giant-cell tumor of bone have been well established by Jaffe (11), Lichtenstein (16), and others (3, 4, 19, 23). However, there has been some controversy concerning these lesions in the past (1, 7), and also in the more recently recorded opinions of Aegerter (2), whose account encompasses the still unsettled matter of histogenesis (20), Aegerter concludes that a giant-cell tumor is a neoplasm of osteoclasts, and, more reservedly, that it be recognized as a neoplasm . Although there has been a partial reconciling of views regarding 'the adult form of giant-cell tumor, even recently published cases (5, 8) do not bear upon the special characteristics of this lesion in adolescents. We have found only one previously documented case of an adolescent giantcell tumor in the literature (22); this is a similar case occurring in the. radius of a 14-year-old girl. The common defining characteristic in both cases is a giant-cell tumor in the metaphysis of a long bone (the radius) occurring before the disappearance of the cartilaginous growth plate. Case report
Fig. 1 Giant-cell tumor. Note the typical radiolucent lesion in the distalradialmetaphysis (June 20, 1969) after healing of a pathological fracture sustained one month earlier. The tumor is restricted to the metaphysis anddoesnot involve the growthplate.
amination confirmed the clinical impression that the tumor had recurred . The cartilag inous growth plate of the left radius had been replaced by bone, in contrast to the persistence of the plate in the contralateral radius. The terminal 6 cm of the left radius was surgically resected on February 27, 1970, and replaced by a bone graft from the right iliac crest, fusing the left wrist. The diagnosis of recurrent giant-cell tumor of the radius was confirmed . The patient has healed without further
A 14-year-old white girl sustained a fracture through the distal end of the left radius on May 7, 1969. Radiological examination revealed a lesion at the site of the fracture, consistent with a benign osteoblastoma, a unicameral bone cyst, or an aneurysmal bone cyst. The fracture was treated conservat ively and she was admitted four weeks later for surgery. Physical examination revealed that the left forearm was moderately weak and there was enlargement and deformity of the distal radial segment. Radiographs of the left wrist showed a radiolucent expansile lesion In the distal metaphysis of the radius, measuring 3 cm in width and 3.5 cm in length and extending proximally from the growth plate (Fig. 1). A thin shell of SUbperiosteal bone contained the tumor without any apparent extraosseous soft-tissue mass. Subperiosteal new bone extending along the diaphysis from the lesion was attributed to a previous fracture. No sclerotic margin was present. The tumor did not extend across the cartilaginous growth plate Into the epiphysis. No other abnormalities were demonstrated by skeletal survey, and serum clacium, inorganic phosphorus, and alkaline phosphatase values were within normal limits. The patient underwent surgery on June 23, and the left forearm was immobilized in a plaster cast. The patient returned to the hospital with complaints of a recurrent "lump" over the distal metaphysis of the left radius. Radiological ex-
Fig. 2 Grade I giant-cell tumor of the radial metaphysis, composed of uniformly distributed giant cells among the less conspicuous, vaguely syncytial, mononuclear " stromal" cells. (H&E X 200)
1 From Rahway Hospital (B. P., Director of Laboratories; J. F., Department of Orthopedics), Rahway, N. J. Accepted for publication in July 1975. . S5
145
146
BERNARD PEISON AND JERROLD FEIGENBAUM
complaints and shows no clinical or radiological evidence of tumor recurrence.
Table I:
Giant-Cell Tumors of Bones in Patients Younger Than 20 Yr. of Age
DISCUSSION The differential diagnosis of a giant-cell tumor in the young patient has become widely standardized (15) and must include nonossifying fibroma, chrondromyxoid fibroma, benign chondroblastoma, benign osteoblastoma, aneurysmal bone cyst, unicameral bone cyst, brown tumor, giant-cell repara-' tive granuloma, and pigmented villonodular synovitis eroding bone. These alternatives can be clearly eliminated by the unequivocal histological patterns of the tumor. In this case, the mass was composed of numerous multinuclear giant cells uniformly dlstributed among the less conspicuous, vaguely syncytial, mononuclear "stromal" cells. There was no necrosis or scarring. Neither an osteoid nor a chondroid matrix could be demonstrated in any of the tumor tissue samples (Fig. 2). For descriptive purposes, the mass is classified as a Grade I giant-cell tumor of bone (11). The occurrence of giant-cell tumors in subjects under 20 years of age is documented by statistics drawn from consecutive series (TABLE I). This shows the incidence in patients aged 20 years or less to be approximately 14% (143/1,019). The clinically and radiologically more rneaninqful age separation should occur at 15 years, immediately before closure of the growth plate. Our own statistics (TABLE I) and those of Dahlin (5) and Murphy (19) show a combined incidence of 3.5 % (9/256) in patients under the age of 15. The term "incidence" is generally used when it is the rate of detection which is being assessed. Because these tumors may be asymptomatic and go undetected, it is likely that a significant percentage of the giant-cell tumors found before age 20 may have originated before closure of the growth plate. This echoes the hypothesis of Sherman et al (22), whose reported case came to clinical attention only because of trauma to the affected bone. As long as giant-cell tumors are restricted to the metaphysis by the 9r9wth plate, they are likely to remain asymptomatic. When the growth plate is obliterated, epiphyseal invasion ultimately undermines the subchondral bone, increasing the likelihood of clinical complaints which may lead to radiological detection of the lesion.
REFERENCES 1. Aegerter E, Kirkpatrick JA Jr: Orthopedic Diseases. Philadelphia, Saunders, tst Ed, 1958, pp 505-519 2. Aegerter E, Kirkpatrick JA Jr: Orthopedic Diseases. Philadelphia, Saunders, 3d Ed, 1968, pp 620-636 3. Coley Bl: Neoplasms of Bone. Hoeper, 2d Ed, 1949, pp 196-125 4. Coley Bl, Higinbotham Nl, Kogure T: Giant cell tumor of bone, Am J Surg 96:479-491, Oct 1958 5. Dahlin DC, Cupps RE, Johnson EW Jr: Giant-cell tumor: a study of 195 cases. Cancer 25: 1061-1 070, May 1970 6. Edeiken J, Hodes PJ: Giant cell tumors vs tumors with giant cells. Radiol Clin North Am 1:75-100, Apr 1963 7. Geschickter CF, Copeland MM: Tumors of Bone. Philadel. phia, Lippincott, 3d Ed, 1949, pp 316-320 8. Goldenberg RR, Campbell CJ, Bonfiglio M: Giant-cell tumor of bone. An analysis of two hundred and eighteen cases. J Bone Joint Surg [arit] 52:619-664, Jun 1970 9. Guilleminet M, Picault C: On the subject of 2 cases of giant cell tumors of bone. !-yon Chir 56:613-618, Jul1960 10. Hutter RV, Worcester IN Jr, Francis KC, et al: Benign and malignant giant cell tumors of bone. A clinicopathological analysis of
January 1976
Author/Year Thomson et al., 1955 Murphy et al., 1956 Coley et al., 1958 Guilleminet, 1960 Kojima et al., 1960 Walter, 1960 Schajowicz, 1961 Sherman et al., 1961 Hutter et al., 1962 Edeiken et al., 1963 Mnaymneh et al., 1964 Jonasch, 1965 Merle 0' Aubigne, 1968 Johnson et al., 1969 Goldenberg, 1970 Dahlin, 1970 Johnston (New York Orthopedic Hospital), 1971
No. of Patients Total Age Younger No. of Group Than Ref. Patients (Yr.) 20 Yr.
24 19 4 9 15 25 21 22 10 6 18 14 17 12 8 5 13
Total No. from consecutive series
34 3i 108 89 29 15 85 1 76 1 41 3 39 24 218 195
16 14-20 10-20 15 16-17 16-17 15-20 15 10-19 20
