Gct of distal radius

1. Giant cell tumorGiant cell tumor
ofof
Distal RadiusDistal Radius

Sumroeng Neti, M.D. (1st class honors)Sumroeng Neti, M.D. (1st class honors)
Orthopedic CenterOrthopedic Center
Bumrungrad International HospitalBumrungrad International Hospital

2. EpidemiologyEpidemiology
-5% of bone tumors5% of bone tumors
-Age: Age: 20-40 20-40 yearsyears
-Slightly female predominantSlightly female predominant

3. LocaIizationLocaIization
-Epiphysis/metaphysisEpiphysis/metaphysis lesion lesion
-eccentrically locatedeccentrically located
uDistal femur : Distal femur : most common sitemost common site
uProximal tibiaProximal tibia
uDistal radiusDistal radius
uSacrumSacrum

4. Clinical presentationClinical presentation
-Progressive pain with mass Progressive pain with mass
-: : most common 80%most common 80%
-Pathologic fracture : 10-30%Pathologic fracture : 10-30%
-Joint effusionJoint effusion

5. Plain radiographPlain radiograph
Tumor effect to bone
- Purely lytic : geographic pattern
- Eccentrically located in the epiphyses
and abut the subchondral bone
Bone response to tumor
- Expansile
- Margin
: Distinct or poorly outlined
: Classically nonsclerotic
: Erosion through the cortex

6. ClassificationClassification
- 15 % latent
- bone maintain
normal contour
- Sharply defined
margin
- 70 % active lesion
- deformity and
expansion of bone
- cortical erosion
- Limited endosteal
response
- 15 % aggressive lesion
- poorly outlined margin
- cortical breakthrough and
soft tissue mass
- pathologic fracture

7. MRIMRI
- To determine the extent of lesion
both within the bone and the soft
tissue
- Usually dark on T1-weight images
and bright on T2 - weight images

8. PathologyPathology
- Multinucleated giant cells ( 40-60 nuclei per cell) in
a sea of mononuclear stromal cell
- Area of storiform spindle cell formation
- Small amount of bone or osteoid

9. Goal of TreatmentGoal of Treatment
1.Tumor removal1.Tumor removal
- - Extended curettage Extended curettage : latent, active: latent, active
- - En Bloc resection : aggressiveEn Bloc resection : aggressive
““Prevent local recurrence”Prevent local recurrence”
2.Restore function : Reconstruction2.Restore function : Reconstruction
- Allograft – Osteochondral allograft- Allograft – Osteochondral allograft
- Arthrodesis- Arthrodesis
- Arthroplasty- Arthroplasty

10. ConventionalConventional
Surgical Treatment Surgical Treatment
GCT of bone
Grade
En Bloc excision
& Reconstruction
Grade 3
Extended curettage
Cement or Bone graft
Grade 1 & 2

11. TreatmentTreatment
Local recurrenceLocal recurrence
•- - Almost happen within first Almost happen within first 22 years years
•- Simple c- Simple curettage and bone grafting urettage and bone grafting
30-40%30-40%
•- - Extended curettage < 10%Extended curettage < 10%
•- - Lung metastasis is 6-time higher in Lung metastasis is 6-time higher in
recurrence caserecurrence case
Extended curettage = curettage + high-speed burr +
adjuvant agents (phenol, liquid nitrogen,etc.)

12. TreatmentTreatment
CurettageCurettage
: realize the importance of creating a : realize the importance of creating a
cortical window at least cortical window at least as large as the as large as the
lesionlesion to prevent leaving residual to prevent leaving residual
tumor cells “ tumor cells “ around the corneraround the corner” ”

13. Filling materialsFilling materials
Bone cement Bone cement
AdvantageAdvantage
- - early limb using early limb using
- early- early recurrence detection recurrence detection
- kill residual tumor cell by - kill residual tumor cell by
heat of polymerizationheat of polymerization
DisadvantageDisadvantage
- - heat-induced degenerative heat-induced degenerative
joint diseasejoint disease
Bone graft Bone graft
AdvantageAdvantage
- - biologic healingbiologic healing
- - preserve bone stockpreserve bone stock
DisadvantageDisadvantage
- - delayed delayed rehabilitationrehabilitation
- - difficult tumor difficult tumor
recurrence detectionrecurrence detection

14. TreatmentTreatment
Adjuvant RxAdjuvant Rx
- 1. 1. PhenolPhenol
- : : concentration should be limited in 5%concentration should be limited in 5%
- 2. 2. Electrocautery or argon beam Electrocautery or argon beam
coagulatorcoagulator
- 3. 3. Liquid nitrogenLiquid nitrogen
- : Disadvantage: Disadvantage
- - - Post – treatment fracture Post – treatment fracture
- - Wound healing problem - Wound healing problem
- - Nerve injury - Nerve injury
- - Difficult to control depth of necrosis- Difficult to control depth of necrosis

15. TreatmentTreatment
In the In the expendable bonesexpendable bones
- distal ulna- distal ulna
- proximal radius, fibula- proximal radius, fibula
En Bloc resectionEn Bloc resection
 reduce the risk of recurrence

16. TreatmentTreatment
Inoperable lesionInoperable lesion
- Spine - Spine
- pelvis - pelvis
RadiationRadiation
A. Chakravarti MD et al JBJS 1999
: 20 patients underwent a single course of megavoltage
radiation (40- 70 gray )  tumor had not progress 17/20
: no radiation-induced malignancy (Mean F/U 9.3 yrs)

17. Lung metastasisLung metastasis
- 3- 3% of patients% of patients
- - Slowly grow, stationary or resolve Slowly grow, stationary or resolve
in some lesionsin some lesions
- - May be surgically resectedMay be surgically resected
- - Mortality rate Mortality rate from pulmonary from pulmonary
metastasis : metastasis : 10-15%10-15%

18. F/U planF/U plan
- - Clinical and x-rays of local Clinical and x-rays of local
recurrencerecurrence(3-20 yrs)(3-20 yrs) : :
- - mass, painful area mass, painful area
- - CXR PA and lateral viewCXR PA and lateral view
- - CT chest CT chest : : ++
DurationDuration
- - 11
stst
year q 3 months year q 3 months
- - 22
ndnd
year q 6 months year q 6 months
- - then q 6-12 monthsthen q 6-12 months

19. Case # 1Case # 1

27. Dx : GCT of Dx : GCT of Distal RadiusDistal Radius
stage III : Aggressivestage III : Aggressive
Rx : En Bloc resectionRx : En Bloc resection
+ osteochondral allograft+ osteochondral allograft
with good resultwith good result

28. Reconstruction of the distal Reconstruction of the distal
radius with use of an radius with use of an
osteoarticular allograftosteoarticular allograft
Mankin HJ et alMankin HJ et al – – JBJS(A)JBJS(A) 19981998
24 patients between 1974-199224 patients between 1974-1992
F/U 10.9 years (2.1-22.3) F/U 10.9 years (2.1-22.3)
8/24 need revision8/24 need revision
•7/8 arthrodesis : 4 #’s, 1 recurrence 7/8 arthrodesis : 4 #’s, 1 recurrence
•1/8 amputation1/8 amputation
Average ROMAverage ROM
•Dorsi/volar flexion : 36/21Dorsi/volar flexion : 36/21
•Radial/ulnar deviation : 16/15Radial/ulnar deviation : 16/15
•Supination/pronation : Supination/pronation : 58/7258/72

29. Reconstruction of the distal Reconstruction of the distal
radius with use of an radius with use of an
osteoarticular allograftosteoarticular allograft
Mankin HJ et alMankin HJ et al – – JBJS(A)JBJS(A)
19981998
associated with associated with
•a low rate of recurrence of the tumora low rate of recurrence of the tumor
•moderately high rate of revisionmoderately high rate of revision
•little pain in association with common activitieslittle pain in association with common activities
•good function, and a moderate range of motiongood function, and a moderate range of motion
Osteoarticular allograftsOsteoarticular allografts are an option for are an option for
reconstruction of the distal radiusreconstruction of the distal radius

30. Case # 2Case # 2
35 year – old Thai male35 year – old Thai male

43. 4 months postop.4 months postop.

44. 8 months postop.8 months postop.

45. 1 year & 1 month postop.1 year & 1 month postop.

46. 1 year & 6 month postop.1 year & 6 month postop.

47. 1 year & 8 month postop.1 year & 8 month postop.

48. Dx : GCT of Dx : GCT of Distal RadiusDistal Radius
stage III : Aggressivestage III : Aggressive
Rx : En Bloc resectionRx : En Bloc resection
+ osteochondral allograft+ osteochondral allograft
with allograft collapsewith allograft collapse

49. Case # 3Case # 3
21 year – old female21 year – old female
S/P wide resection S/P wide resection
+ allograft arthrodesis+ allograft arthrodesis

50. 1 year postop.1 year postop.

51. 3 year postop.3 year postop.

60. Dx : GCT of Dx : GCT of Distal RadiusDistal Radius
stage III : Aggressivestage III : Aggressive
11
stst
Rx : En Bloc resection Rx : En Bloc resection
+ osteochondral allograft+ osteochondral allograft
with allograft fracture, nonunionwith allograft fracture, nonunion
22
ndnd
Rx : Free vascularized fibular Rx : Free vascularized fibular
bone graftbone graft

61. Vascularized fibular graft for Vascularized fibular graft for
reconstruction of the wrist reconstruction of the wrist
after excision of GCTafter excision of GCT
Ono H et alOno H et al – – Plast Reconstr Surg.Plast Reconstr Surg.19971997
7 patients of GCT of distal radius7 patients of GCT of distal radius
radiographic evidence of bone radiographic evidence of bone
union at the host-graft junctions union at the host-graft junctions
in all casesin all cases
No local recurrenceNo local recurrence
There were six good and one There were six good and one
excellent functional results excellent functional results

62. Case # 4Case # 4
52 year – old female52 year – old female

70. After curettageAfter curettage

71. After burringAfter burring

72. After phenol & alcoholAfter phenol & alcohol

73. After cementingAfter cementing

76. 1 year 2 months postop.1 year 2 months postop.

77. 1 year 9 months postop.1 year 9 months postop.

78. 1 year 9 months postop.1 year 9 months postop.

79. Dx : GCT of Dx : GCT of Distal RadiusDistal Radius
stage III : Aggressivestage III : Aggressive
Rx : Extended curettageRx : Extended curettage
(+ phenol) & bone cement(+ phenol) & bone cement
[ No recurrence within 2 years][ No recurrence within 2 years]

80. Treatment of GCT of boneTreatment of GCT of bone
: a comparison of : a comparison of
curettage and wide resectioncurettage and wide resection
Liu HS et alLiu HS et al – – Changgeng Yi Xue Za Zhi. 1998Changgeng Yi Xue Za Zhi. 1998
27 patients 27 patients
11 patients : extended curettage + cement11 patients : extended curettage + cement
16 patients : wide resection+ reconstruction16 patients : wide resection+ reconstruction
F/U 50 months F/U 50 months
Excellent functional resultsExcellent functional results
•extended curettage + cement = 80 %extended curettage + cement = 80 %
•wide resection+ reconstruction = 13 %wide resection+ reconstruction = 13 %
Local control rateLocal control rate
•extended curettage + cement = 90.9 %extended curettage + cement = 90.9 %
•wide resection+ reconstruction = 93.75 %wide resection+ reconstruction = 93.75 %

81. Treatment of GCT of boneTreatment of GCT of bone
: a comparison of : a comparison of
curettage and wide resectioncurettage and wide resection
Liu HS et alLiu HS et al – – Changgeng Yi Xue Za Zhi. 1998Changgeng Yi Xue Za Zhi. 1998
Infection rateInfection rate
•extended curettage + cement = 0/11extended curettage + cement = 0/11
•wide resection+ reconstruction = 3/16wide resection+ reconstruction = 3/16
CONCLUSION:CONCLUSION:
•better functional result after curettage better functional result after curettage
and packing with cement than following and packing with cement than following
wide resectionwide resection
•recommend curettage and cement recommend curettage and cement
packing for giant cell tumor of bone packing for giant cell tumor of bone
whenever it is technically feasiblewhenever it is technically feasible

83. Currently recommended Currently recommended
Surgical TreatmentSurgical Treatment
GCT of bone
Grade
En Bloc excision
& Reconstruction
Grade 3
c marked destruction
Extended curettage
Cement or Bone graft
-
Grade 1, 2, 3
s marked destruction-

84. Reconstruction forReconstruction for
Distal RadiusDistal Radius

85. Reconstruction forReconstruction for
Distal RadiusDistal Radius
Preserve RC & DRUJPreserve RC & DRUJ
Preserve DRUJPreserve DRUJ
No motion preservedNo motion preserved
Osteochondral Osteochondral
allograft allograft or or
autograftautograft
Fusion wristFusion wrist + +
•AllograftAllograft
•AutograftAutograft
VascularizedVascularized
Non – vascularizedNon – vascularized
One bone forearmOne bone forearm

86. Thank you Thank you
for for
your attentionyour attention