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CLINICAL IMAGING 1992;16:168-171
ORIGINAL ARTICLES
OSSIFIED SOFT TISSUE RECURRENCE OF GIANT CELL TUMOR OF BONE SHIGERU EHARA, MD, JUN NISHIDA, MD, MASATAKA ABE, MD, YASUSHI KAWATA, MD, HARUKI SAITOH, MD, AND SUSAN V. KATTAPURAM, MD
We report 3 cases of soft tissue recurrence of giant cell tumor of bone. A peripheral rim of ossification in the soft tissue mass is pathognomonic of recurrence in the patients after resection of giant cell tumor. KEY WORDS:
Bone tumors;
Giant
cell tumor; Soft tissue recurrence;
Plain radiography
Local recurrence of giant cell tumor of bone is observed frequently after local excision even in the hands of highly skilled orthopedic surgeons. According to Goldenberg et al., the incidence of local recurrence is approximately 35 percent (2). Usually there is no calcified matrix identified in these recurrent foci, but there are a few reports describing ossified recurrences or metastases 11,3). However, these observations are not widely recognized, and knowledge of it would help in accurate diagnosis and appropriate treatment. CASE REPORTS Case 1 A 65-year-old woman presented with a soft tissue mass in the right popliteal fossa. Twenty-four months ago she underwent curettage of an osteolytic lesion From Iwate Medical University, Morioka, Japan, AkitaNakadohri Hospital, Akita, Japan and Massachusetts General Hospital, Boston, U.S.A. _ Address reprint requests to: Shigeru Ehara, MD, Center for Radiological Science, Iwate Medical University, 19-l Uchimaru, Morioka 020 Japan, Received January 1992; accepted February 1992. 0 1992 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, 0899-7071192/$5.00
New York, NY 10010
in the distal femur with bone grafting. Histological diagnosis was giant cell tumor. Five months ago a subcutaneous nodule was removed from her right thigh, a recurrent tumor with peripheral ossification (Figure 1A).Plain radiography, conventional tomography, and CT showed a soft tissue mass with peripheral ossification adjacent to the previous site of curettage (Figure lB-D). MR depicted the soft tissue mass, but a calcified rim was not detected (Figure 1E). Resection of the mass was performed. Histological examination of this recurrence showed giant cell tumor, again with ossification at the periphery of the lesion (Figure 1F). Case 2 A 33-year-old man presented with a gradually growing mass of his right elbow. When he was 20 years old, he sustained a pathologic fracture through a giant cell tumor of the distal right humerus. Subsequently he underwent curettage of the lesion. When he was 27 years old, he underwent removal of a soft tissue recurrence from his right forearm, the radiological examination of which revealed a peripheral rim of ossification (Figure 2A, B). Six years later, on physical examination a soft tissue mass along the ulnar and posterior aspects of the right proximal forearm was palpable. Ulnar nerve palsy had been noted since the previous resection of the recurrent tumor. Radiological examination showed previous resection of the capitellum and osteolytic lesions in the radial aspect of the distal humerus and the olecranon (Figure 2C). A large soft tissue tumor with a peripheral rim of ossification arising from the lesion in the olecranon extended to the ulnar and posterior aspect of the forearm. MR revealed a heterogenous mass in the soft tissues of the forearm (Figure 2D). Because of an expected poor functional outcome, amputation above
E
.
See figure legend on page 170.
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CLINICAL IMAGING VOL. 16, NO. 3
FIGURE 2. Case 2. (A) Oblique view of the forearm shows a recurrent giant cell tumor revealing peripheral calcification of the lesion (arrows). (B) Brachial arteriography taken in the same projection as Fig. 2A. A hypervascular tumor is noted in the area of the ossification. (C) AP view of the elbow. A lytic-expanding lesion in the olecranon and an adjacent soft tissue mass with peripheral rim of calcification (arrows). Lytic change is also noted in the radial aspect of the distal humerus (arrowheads). (D) Axial Tl weighted image (SE:TR750/TE38). Heterogenous soft tissue mass on the dorsal aspect of the proximal forearm. FIGURE 1. Case 1. (A) Histologic section (H-E stain) of the soft tissue recurrence (1st episode). Ossification is seen in the periphery of the recurrent giant cell tumor. (B) Lateral view of the right knee demonstrating graft in the distal femur. Faint linear calcification is noted along its posterior aspect (arrows). (C) Lateral tomogram demonstrating an extraosseous mass with rim like calcification on the posterior aspect of the graft (arrows). (D) CT scan of the distal femur demonstrating soft tissue mass with peripheral rim of calcification (arrow). (E) Tl weighted sagittal images of the distal femur (SE: TR381 msec/TE30 msec) showing a well-defined soft tissue mass on the posterior aspect of the femur (arrow). Low signal intensity of the periphery of the mass represents ossification or reactive fibrotic change. (F) Histologic section (H-E stain) showing aggregation of giant cells in the fibrous stroma and ossification in the periphery of the lesion. Tumor cells are present in the outer layer of the ossification. These findings are similar to those of Fig 1A.
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FIGURE 3. Case 3. CT scan of the proximal thigh revealing soft tissue nodule with peripheral rim z cm subcutaneous of ossification (arrow).
E
FIGURE 2. (E) Histologic section (H-E stain) of the extraosseous mass of the forearm. Ossification is prominent at the periphery of the lesion.
the elbow was performed. Histological examination revealed recurrent giant cell tumor with a peripheral rim of ossification (Figure ZE). Case
3
A 44-year-old woman underwent resection of a giant cell tumor of the right pubis and ischium. This large mass was relatively homogenous with expansion. Routine follow-up CT performed 11 months later showed a soft tissue mass in the subcutaneous region (Figure 3). There was a rim-like ossification along the periphery. It proved to be a recurrent giant cell tumor.
fication is almost pathognomonic of recurrence. Histological evaluation of our cases showed ossification along the periphery of the lesion with relatively abundant stroma, but not exactly at the margin. In two of our three cases there were two episodes of recurrence, and both had ossified periphery. Current advances in cross-sectional imaging have introduced more sensitive means to detect small soft tissue lesions. MR imaging, performed in two cases of our series, is sensitive to detect soft tissue masses and can delineate the extent of the lesion, but these findings are nonspecific. CT scan is sensitive enough to detect calcification and/or ossification, although its contrast resolution is inferior to MR imaging. We believe plain radiography is still the most cost effective means to monitor changes after resection of giant cell tumors, because it can detect ossified soft tissue recurrence where metallic implants do not degrade the images.
REFERENCES DISCUSSION
Cooper KL, Beabout JW, Dahlin DC. Giant cell tumor: Ossification in soft tissue implants. Radiology 1984;153:597-602.
In 1984 Cooper et al reviewed 1100 cases and identified soft tissue recurrence with a peripheral rim of ossification in 17 cases (1). Such ossification might resemble myositis ossificans, but with the past history of giant cell tumor, the radiologic pattern of ossi-
Goldenberg RR, Campbell CJ, Bonfiglio M. Giant cell tumor of bone: An analysis of two hundred and eighteen cases. J Bone Joint Surg 1970;52A:619-664. Hall FM, Frank HA, Cohen RB, Ezpeleta ML. Ossified pulmonary metastases from giant cell tumor of bone. AJR 1976;127: 1046-1047.
CLINICAL IMAGING 1992;16:168-171
ORIGINAL ARTICLES
OSSIFIED SOFT TISSUE RECURRENCE OF GIANT CELL TUMOR OF BONE SHIGERU EHARA, MD, JUN NISHIDA, MD, MASATAKA ABE, MD, YASUSHI KAWATA, MD, HARUKI SAITOH, MD, AND SUSAN V. KATTAPURAM, MD
We report 3 cases of soft tissue recurrence of giant cell tumor of bone. A peripheral rim of ossification in the soft tissue mass is pathognomonic of recurrence in the patients after resection of giant cell tumor. KEY WORDS:
Bone tumors;
Giant
cell tumor; Soft tissue recurrence;
Plain radiography
Local recurrence of giant cell tumor of bone is observed frequently after local excision even in the hands of highly skilled orthopedic surgeons. According to Goldenberg et al., the incidence of local recurrence is approximately 35 percent (2). Usually there is no calcified matrix identified in these recurrent foci, but there are a few reports describing ossified recurrences or metastases 11,3). However, these observations are not widely recognized, and knowledge of it would help in accurate diagnosis and appropriate treatment. CASE REPORTS Case 1 A 65-year-old woman presented with a soft tissue mass in the right popliteal fossa. Twenty-four months ago she underwent curettage of an osteolytic lesion From Iwate Medical University, Morioka, Japan, AkitaNakadohri Hospital, Akita, Japan and Massachusetts General Hospital, Boston, U.S.A. _ Address reprint requests to: Shigeru Ehara, MD, Center for Radiological Science, Iwate Medical University, 19-l Uchimaru, Morioka 020 Japan, Received January 1992; accepted February 1992. 0 1992 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, 0899-7071192/$5.00
New York, NY 10010
in the distal femur with bone grafting. Histological diagnosis was giant cell tumor. Five months ago a subcutaneous nodule was removed from her right thigh, a recurrent tumor with peripheral ossification (Figure 1A).Plain radiography, conventional tomography, and CT showed a soft tissue mass with peripheral ossification adjacent to the previous site of curettage (Figure lB-D). MR depicted the soft tissue mass, but a calcified rim was not detected (Figure 1E). Resection of the mass was performed. Histological examination of this recurrence showed giant cell tumor, again with ossification at the periphery of the lesion (Figure 1F). Case 2 A 33-year-old man presented with a gradually growing mass of his right elbow. When he was 20 years old, he sustained a pathologic fracture through a giant cell tumor of the distal right humerus. Subsequently he underwent curettage of the lesion. When he was 27 years old, he underwent removal of a soft tissue recurrence from his right forearm, the radiological examination of which revealed a peripheral rim of ossification (Figure 2A, B). Six years later, on physical examination a soft tissue mass along the ulnar and posterior aspects of the right proximal forearm was palpable. Ulnar nerve palsy had been noted since the previous resection of the recurrent tumor. Radiological examination showed previous resection of the capitellum and osteolytic lesions in the radial aspect of the distal humerus and the olecranon (Figure 2C). A large soft tissue tumor with a peripheral rim of ossification arising from the lesion in the olecranon extended to the ulnar and posterior aspect of the forearm. MR revealed a heterogenous mass in the soft tissues of the forearm (Figure 2D). Because of an expected poor functional outcome, amputation above
E
.
See figure legend on page 170.
170
EHARAET AL,
CLINICAL IMAGING VOL. 16, NO. 3
FIGURE 2. Case 2. (A) Oblique view of the forearm shows a recurrent giant cell tumor revealing peripheral calcification of the lesion (arrows). (B) Brachial arteriography taken in the same projection as Fig. 2A. A hypervascular tumor is noted in the area of the ossification. (C) AP view of the elbow. A lytic-expanding lesion in the olecranon and an adjacent soft tissue mass with peripheral rim of calcification (arrows). Lytic change is also noted in the radial aspect of the distal humerus (arrowheads). (D) Axial Tl weighted image (SE:TR750/TE38). Heterogenous soft tissue mass on the dorsal aspect of the proximal forearm. FIGURE 1. Case 1. (A) Histologic section (H-E stain) of the soft tissue recurrence (1st episode). Ossification is seen in the periphery of the recurrent giant cell tumor. (B) Lateral view of the right knee demonstrating graft in the distal femur. Faint linear calcification is noted along its posterior aspect (arrows). (C) Lateral tomogram demonstrating an extraosseous mass with rim like calcification on the posterior aspect of the graft (arrows). (D) CT scan of the distal femur demonstrating soft tissue mass with peripheral rim of calcification (arrow). (E) Tl weighted sagittal images of the distal femur (SE: TR381 msec/TE30 msec) showing a well-defined soft tissue mass on the posterior aspect of the femur (arrow). Low signal intensity of the periphery of the mass represents ossification or reactive fibrotic change. (F) Histologic section (H-E stain) showing aggregation of giant cells in the fibrous stroma and ossification in the periphery of the lesion. Tumor cells are present in the outer layer of the ossification. These findings are similar to those of Fig 1A.
JULY-SEPTEMBER 1992
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171
FIGURE 3. Case 3. CT scan of the proximal thigh revealing soft tissue nodule with peripheral rim z cm subcutaneous of ossification (arrow).
E
FIGURE 2. (E) Histologic section (H-E stain) of the extraosseous mass of the forearm. Ossification is prominent at the periphery of the lesion.
the elbow was performed. Histological examination revealed recurrent giant cell tumor with a peripheral rim of ossification (Figure ZE). Case
3
A 44-year-old woman underwent resection of a giant cell tumor of the right pubis and ischium. This large mass was relatively homogenous with expansion. Routine follow-up CT performed 11 months later showed a soft tissue mass in the subcutaneous region (Figure 3). There was a rim-like ossification along the periphery. It proved to be a recurrent giant cell tumor.
fication is almost pathognomonic of recurrence. Histological evaluation of our cases showed ossification along the periphery of the lesion with relatively abundant stroma, but not exactly at the margin. In two of our three cases there were two episodes of recurrence, and both had ossified periphery. Current advances in cross-sectional imaging have introduced more sensitive means to detect small soft tissue lesions. MR imaging, performed in two cases of our series, is sensitive to detect soft tissue masses and can delineate the extent of the lesion, but these findings are nonspecific. CT scan is sensitive enough to detect calcification and/or ossification, although its contrast resolution is inferior to MR imaging. We believe plain radiography is still the most cost effective means to monitor changes after resection of giant cell tumors, because it can detect ossified soft tissue recurrence where metallic implants do not degrade the images.
REFERENCES DISCUSSION
Cooper KL, Beabout JW, Dahlin DC. Giant cell tumor: Ossification in soft tissue implants. Radiology 1984;153:597-602.
In 1984 Cooper et al reviewed 1100 cases and identified soft tissue recurrence with a peripheral rim of ossification in 17 cases (1). Such ossification might resemble myositis ossificans, but with the past history of giant cell tumor, the radiologic pattern of ossi-
Goldenberg RR, Campbell CJ, Bonfiglio M. Giant cell tumor of bone: An analysis of two hundred and eighteen cases. J Bone Joint Surg 1970;52A:619-664. Hall FM, Frank HA, Cohen RB, Ezpeleta ML. Ossified pulmonary metastases from giant cell tumor of bone. AJR 1976;127: 1046-1047.
