Giant cell tumor of bone in children and adolescents

Giant cell tumor of bone and secondary osteoarthritis

Giant cell tumor of bone is a commonly encountered aggressive epiphyseal bone tumor, most often treated surgically. The natural history and presentation are classically described but the histopathology is poorly understood. Intralesional curettage is the mainstay of treatment, but there is significant variation in the use of adjuvant and cavity filling modalities. No gold standard has been agreed upon for treatment, and a variety of techniques are currently in use. Given its location, secondary osteoarthritis is a known long-term complication. This review examines the natural history of giant cell tumors, treatment options and complications, and subsequent development of osteoarthritis. Arthroplasty is usually indicated for secondary osteoarthritis although data is limited on its efficacy. Further directions will likely center on improved pharmacological treatments as well as improved arthroplasty techniques.

Pediatric oral pathology in Saudi Arabia: A 10-year retrospective study at an academic dental hospital

Introduction

Pediatric oral pathology encompasses a wide range of diseases and conditions affecting the oral cavity in children. In this study we conducted an analysis on a dataset from one academic center in Saudi Arabia to investigate the prevalence of various oral lesions in pediatric patients.

Methods

To conduct this study we analyzed oral pathology reports of pediatric patients (age range: 0-18 years) who underwent biopsies at our institution's oral pathology laboratory between January 2012 and December 2022. The data we collected included demographic information and diagnostic findings. Statistical analysis was performed to determine the prevalence rates of and associations between different variables.

Results

The study analyzed a total of 183 pediatric cases with oral pathologies. The most common conditions observed were mucocele (12 %), periapical granuloma (7.7 %), dentigerous cyst (6.6 %), and radicular cyst (6.6 %). Some conditions showed variations in prevalence based on age and gender. For example, mucoceles were more prevalent among patients who were 6-12 years of age and female.

Conclusion

This retrospective study provides valuable insights into the prevalence and demographic characteristics of pediatric oral pathologies. By understanding the prevalence of conditions in this population and recognizing differences in distribution compared with those cited in other studies, we highlighted the importance of considering regional and demographic influences. Further prospective studies are needed to investigate factors that may contribute to these variations.

The Evaluation and Management of Lung Metastases in Patients with Giant Cell Tumors of Bone in the Denosumab Era

Giant cell tumor of bone (GCTB) is characterized by uncertain biological behavior due to its local aggressiveness and metastasizing potential. In this study, we conducted a meta-analysis of the contemporary literature to evaluate all management strategies for GCTB metastases. A combination of the terms "lung metastases", "giant cell tumor", "bone", "treatment", and "oncologic outcomes" returned 133 patients meeting our inclusion criteria: 64 males and 69 females, with a median age of 28 years (7-63), at the onset of primary GCTB. Lung metastases typically occur at a mean interval of 26 months (range: 0-143 months) after treatment of the primary site, commonly presenting as multiple and bilateral lesions. Various treatment approaches, including surgery, chemotherapy, radiotherapy, and drug administration, were employed, while 35 patients underwent routine monitoring only. Upon a mean follow-up of about 7 years (range: 1-32 years), 90% of patients were found to be alive, while 10% had died. Death occurred in 25% of patients who had chemotherapy, whereas 96% of those not treated or treated with Denosumab alone were alive at a mean follow-up of 6 years (range: 1-19 years). Given the typically favorable prognosis of lung metastases in patients with GCTB, additional interventions beyond a histological diagnosis confirmation may not be needed. Denosumab, by reducing the progression of the disease, can play a pivotal role in averting or delaying lung failure.

Giant cell tumor of bone in the pediatric population: a retrospective study highlighting cases of metaphyseal only location and increased local recurrence rates in skeletally immature patients

OBJECTIVE

To describe the presentation of giant cell tumors (GCT) of the bone in the pediatric population to (1) improve the differential diagnosis of pediatric bone tumors and (2) identify the origin of GCT. Understanding the origin of bone tumors assists in establishing appropriate diagnoses and recommending treatment options. This is particularly important in children, where evaluating the need for invasive procedures is balanced with the desire to avoid overtreatment. GCT have historically been considered epiphyseal lesions with potential metaphyseal extension. Therefore, GCT may be inappropriately excluded from the differential diagnosis of metaphyseal lesions in the skeletally immature.

MATERIALS AND METHODS

We identified 14 patients from 1981 to 2021 at a single institution who had histologic confirmation of GCT and were less than 18 years old at diagnosis. Patient characteristics, tumor location, surgical treatment, and local recurrence rates were collected.

RESULTS AND CONCLUSIONS

Ten (71%) patients were female. Eleven (78.6%) were epiphysiometaphyseal (1 epiphyseal, 4 metaphyseal, 6 epiphysiometaphyseal). Five patients had an open adjacent physis, of which three (60%) had tumors confined solely to the metaphysis. Of the five patients with open physis, four (80%) developed local recurrence while only one patient (11%) with a closed physis had local recurrence (p value = 0.0023). Our results illustrate that for the skeletally immature, GCT can (and in our results more commonly did) occur in the metaphyseal location. These findings suggest that GCT should be included in the differential diagnosis of primary metaphyseal-only lesions in the skeletally immature.

A Rare Giant Cell Tumour in the Distal Radius of a Seven-Year-Old Girl: A Case Report

A giant cell tumour (GCT) is a benign and locally aggressive tumour that is usually observable in a skeletally mature patient involving the end of long bones. The reported incidence of this tumour in a skeletally immature patient is extremely rare. However, we report one such case in the distal radius of a seven-year-old female patient. Having presented with painful swelling of the right distal forearm, she underwent clinical and radiological examination, and a diagnosis of distal radius GCT was made. The tumour was treated with curettage, fibular graft, and synthetic bone graft. This case report shows the importance of including GCT in children as a differential diagnosis. This tumour may have a good prognosis if diagnosed and treated early.

Diagnostic value of H3F3A mutation and clinicopathological features of giant cell tumours in non-long bones

Aims

A histone H3F3A (H3.3) mutation involving a substitution in H3.3 G34 recently has been reported in GCTB within the frequency range (from 69 % to 96 %) and is a helpful diagnostic indicator of GCTB. However, the relationship between H3F3A mutations and the clinicopathological feature of GCTB involving non-long bones (irregular bones and small bones) is unclear.

Methods and results

H3F3A mutations were observed in a cohort of specimens (230 samples of GCTB) using immunohistochemistry and Sanger sequencing. The relationship between H3F3A mutations and the clinicopathological characteristics of patients with GCTB occurring in the non-long bones of the appendicular skeleton was investigated. No significant difference between H3F3A mutations in GCTB arising in non-long bones and the classic sites was found (P = 0.483). GCTB in non-long bones occurred more common in female (31/49, 63.3 %) than in male patients (P = 0.016). GCTB with H3.3 G34L/V/R mutation occurred more often in younger patients compared with those with H3.3 G34W mutation (P = 0.009). The majority of GCTB with soft tissue extension developed in irregular bones but not in small bones (P = 0.061). The H3.3 G34L/V/R mutations rate (7/45) in the non-long bones was significantly higher than that in long bones. The recurrence rate of the GCTB in long bones and non-long bones was 23.3 % (45/193) including 43 cases with local recurrene and 2 cases with lung metastasis. No recurrence occurred in cases with G34V/L/R mutations.

Conclusions

H3F3A was an effective diagnostic marker for GCTB of the non-long bones. The younger patients with GCTB of the non-long bones harboured H3.3 G34L/V/R mutations and may had a female preference and rarely recurrent.

A systematic review of multicentric giant cell tumour with the presentation of three cases at long-term follow-up

Aims

We performed a systematic literature review to define features of patients, treatment, and biological behaviour of multicentric giant cell tumour (GCT) of bone.

Methods

The search terms used in combination were “multicentric”, “giant cell tumour”, and “bone”. Exclusion criteria were: reports lacking data, with only an abstract; papers not reporting data on multicentric GCT; and papers on multicentric GCT associated with other diseases. Additionally, we report three patients treated under our care.

Results

A total of 52 papers reporting on 104 patients were included in the analysis, with our addition of three patients. Multicentric GCT affected predominantly young people at a mean age of 22 years (10 to 62), manifesting commonly as metachronous tumours. The mean interval between the first and subsequent lesions was seven years (six months to 27 years). Synchronous lesions were observed in one-third of the patients. Surgery was curettage in 63% of cases (163 lesions); resections or amputation were less frequent. Systemic treatments were used in 10% (n = 14) of patients. Local recurrence and distant metastases were common.

Conclusion

Multicentric GCT is rare, biologically aggressive, and its course is unpredictable. Patients with GCT should be followed indefinitely, and referred promptly if new symptoms, particularly pain, emerge. Denosumab can have an important role in the treatment. Cite this article: Bone Joint J 2022;104-B(12):1352–1361.

Comprehensive treatment outcomes of giant cell tumor of the spine: A retrospective study

There is no consensus on a treatment strategy for spinal giant cell tumor of bone (GCTB) because of the difficulty in their treatment. Treatment options often include the use of the controversial denosumab, an antibody therapy aimed at tumor shrinkage, different curettage techniques, resection, or a combination of these therapies. The current study aimed to identify treatment methods associated with favorable outcomes in patients with spinal GCTB. We retrospectively reviewed 5 patients with spinal GCTB, including patients with tumors of the sacrum, treated at our hospital between September 2011 and November 2020. Two men and 3 women were included in the study. The median follow-up period was 74 months (range: 14-108 months). We surveyed the tumor site, treatment method, denosumab use, and outcomes. The median age was 17 years (range: 17-42 years). There were 2 cases of sacral GCTB and 1 case each of lumbar, cervical, and thoracic vertebral GCTB. The comorbidities observed included hepatitis, malignant lymphoma, atopic dermatitis, and asthma. The treatment method included zoledronic acid after embolization and denosumab, denosumab only, curettage and posterior fusion, and curettage resection after embolization and anterior and posterior fusion. Denosumab was used in all cases. Three patients were continuously disease-free, 1 patient with no evidence of disease, and 1 patient alive with disease. Aggressive treatment, especially surgical treatment, may lead to good results in spinal GCTB.

A Rationale for the Activity of Bone Target Therapy and Tyrosine Kinase Inhibitor Combination in Giant Cell Tumor of Bone and Desmoplastic Fibroma: Translational Evidences

Giant cell tumor of bone (GCTB) and desmoplastic fibroma (DF) are bone sarcomas with intermediate malignant behavior and unpredictable prognosis. These locally aggressive neoplasms exhibit a predilection for the long bone or mandible of young adults, causing a severe bone resorption. In particular, the tumor stromal cells of these lesions are responsible for the recruiting of multinucleated giant cells which ultimately lead to bone disruption. In this regard, the underlying pathological mechanism of osteoclastogenesis processes in GCTB and DF is still poorly understood. Although current therapeutic strategy involves surgery, radiotherapy and chemotherapy, the benefit of the latter is still debated. Thus, in order to shed light on these poorly investigated diseases, we focused on the molecular biology of GCTB and DF. The expression of bone-vicious-cycle- and neoangiogenesis-related genes was investigated. Moreover, combining patient-derived primary cultures with 2D and 3D culture platforms, we investigated the role of denosumab and levantinib in these diseases. The results showed the upregulation of RANK-L, RANK, OPN, CXCR4, RUNX2 and FLT1 and the downregulation of OPG and CXCL12 genes, underlining their involvement and promising role in these neoplasms. Furthermore, in vitro analyses provided evidence for suggesting the combination of denosumab and lenvatinib as a promising therapeutic strategy in GCTB and DF compared to monoregimen chemotherapy. Furthermore, in vivo zebrafish analyses corroborated the obtained data. Finally, the clinical observation of retrospectively enrolled patients confirmed the usefulness of the reported results. In conclusion, here we report for the first time a molecular and pharmacological investigation of GCTB and DF combining the use of translational and clinical data. Taken together, these results represent a starting point for further analyses aimed at improving GCTB and DF management.

Characteristics of Giant Cell Tumor of the Bone in Pediatric Patients: Our 18-Year, Single-Center Experience

A giant cell tumor (GCT) of the bone is characteristically found in skeletally mature patients. The tumor is rare in pediatric patients, and incidence reported in literature varies from 1.8% to 10.6%. We performed a retrospective study addressing symptoms, treatment, and outcome in pediatric patients who were diagnosed with GCT between March 1997 and January 2015 at our hospital. Fourteen (11.1%) of 126 surgically treated patients with histologically proven GCT were <19 years of age. We confirmed skeletal maturity using magnetic resonance imaging (MRI). Fourteen patients from 8 to 19 years old were identified. Sixteen lesions (76.2%) were found in long bones and 5 lesions (23.8%) in short bones. The most common site was around the knee in 8 patients (38%). GCTs mostly occur at the epi-metaphysis in 11 patients (52.3%). Regardless of the openness of epiphyseal plate, we observed GCT of bone in the epiphysis. Further study will be needed to prove the association between the presence of epiphyseal plate and location of tumor. Three patients (21.4%) had multicentric lesions, and four patients (28.5%) had local recurrence. Multicentric giant cell tumor and local recurrence occur more often in pediatric patients. The characteristics of GCT in pediatric patients do not differ from what is reported for GCT in adults.

Giant Cell Tumors of Bone in Patients Aged 18 Years Old or Younger: Imaging Features and Tumor Characteristics

Objective

The majority of giant cell tumors of bone (GCTB) occur in adult patients, especially between the ages of 20 and 40. This study aims to investigate the imaging features of GCTBs in pediatric patients and compare their characteristics with adult cases.

Methods

Fifty-seven cases of patients aged 18 years old or younger were retrospectively analyzed, accounting for 12.8% of GCTBs in the First Affiliated Hospital of Zhengzhou University from 2001 to 2019. One hundred twenty-six adult patients (19 years of age and older) with GCTB occurring in long tubular bones were also included in this study. The following clinical information was identified from the medical records: age, sex, and follow-up data. Imaging features were reviewed by two musculoskeletal radiologists. Patient characteristics and imaging features between the two groups were compared.

Results

A total of 57 patients (32 females, 25 males) were included in the study. The patients’ ages ranged from 9 to 18 (median = 17 y). The majority of tumors occurred in tubular bones (n = 38, 66.7%) and the pelvis (n = 8, 14.0%). Imaging features were identified in GCTB cases occurring in the long tubular bones. Compared with adult GCTB patients, pediatric GCTB patients had a larger superior–inferior (SI) diameter (P = 0.005) and smaller left-to-right diameter/SI diameter ratio (P = 0.001). Epiphyseal involvement was relatively less common in pediatric patients with GCTBs than in adult patients (P = 0.009). The median age of patients without epiphyseal involvement was lower than the median age of patients with epiphyseal involvement (11 vs 17 y).

Conclusion

GCTB in the pediatric age group is rare. This study has found that, in pediatric patients with GCTBs, the epiphysis is relatively less involved, and the tumor is more likely to grow longitudinally. These findings are helpful in the diagnosis of GCTBs in the pediatric population.

Giant Cell Tumor of Bone in Patients under 16 Years Old: A Single-Institution Case Series

Simple Summary

Giant cell tumor of the bone is a locally aggressive, rarely metastasizing tumor that accounts for about 5% of bone tumors; it generally occurs in patients between 20 and 45 years old. Sporadic cases (less than 140) have been described as occurring in the first two decades of life. A histone 3.3 (H3.3) gene, H3F3A, has been recently identified in as many as 96% of giant cell tumors of bone. These mutations are useful in the differential diagnosis of giant cell tumor of bone with its mimickers. The immunohistochemical expression of H3F3A resulted comparable to molecular analysis as reported in a recent investigation. In the present study, we describe our series of giant cell tumors of bone in pediatric patients <16 years old.

Abstract

Background: Giant cell tumor of bone is a locally aggressive, rarely metastasizing tumor that accounts for about 5% of bone tumors and generally occurs in patients between 20 and 45 years old. A driver mutation in the histone 3.3 (H3.3) gene H3F3A has been identified in as many as 96% of giant cell tumors of bone. The immunohistochemical expression of H3F3A H3.3 G34 expression was found in 97.8% of cases. In the present study, we describe our series of cases of giant cell tumor of bone in pediatric patients <16 years old. Methods: All cases of giant cell tumor of bone in pediatric patients <16 years old treated in our institute between 1982 and 2018 were reviewed. Immunohistochemistry and/or molecular analysis for H3F3A gene mutations was performed to confirm the diagnosis. A group of aneurysmal bone cysts in patients <16 years old was used as a control group. Results: Fifteen cases were retrieved. A pronounced female predominance (93%) was observed. A pure metaphyseal central location occurs in 2 skeletally immature patients. Conclusions: Giant cell tumor of bone should be distinguished from its mimickers due to differences in prognosis and treatment. Immunohistochemical and molecular detection of H3F3A gene mutation represents a reliable diagnostic tool.

Giant Cell Tumor: Changing Behavior from Intraorbital to Intraosseous Mass

Purpose

To present a patient with giant cell tumor (GCT) of the orbit by changing behavior from an intraorbital mass to an intraosseous tumor.

Methods

A 16-year-old boy presented with pain, swelling, erythematous of the left upper and lower eyelids, proptosis, and diplopia. Ophthalmic examination revealed chemosis, conjunctival injection, limited elevation, depression as well as abduction in the left eye.

Results

Multislice computed tomography scan (CT scan) of the orbit and paranasal sinuses showed a hyperdense, oval, extraconal mass with bone erosion. Magnetic resonance imaging of the orbit showed an inferior lateral isointense, oval, extraconal mass that had indented the globe. The patient underwent superior lateral orbitotomy, and the orbital mass was excised. Two months later, the patient developed proptosis, severe chemosis, and eyelid erythema in the same eye. CT scan showed an intraosseous mass in the lateral wall of the orbit that had pushed the globe anteromedially. Intraosseous tumor was resected, and the lateral orbital wall was drilled during the second surgery. GCT was diagnosed based on pathological survey.

Conclusion

Following the resection of the orbital GCT, the tumor behavior may change to an intraosseous lesion.

Giant cell tumor of bone at the proximal epiphysis of humerus in a skeletally immature patient: A case report

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Giant cell tumor of bone (GCTB) at proximal humerus in skeletally immature (SI) patients is rare.

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MRI and clinical evaluation are paramount for the GCTB diagnosis.

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Tumor resection with cementation and adjuvant therapy is described as GCTB treatment.

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GCTB should be suspected in all SI cases with enlarged proximal humerus lesions.

Introduction

Giant cell tumor of bone (GCTB) in skeletally immature (SI) patients are rare benign lesions that have locally aggressive growth pattern and high risk of recurrence. The presence of GCTB at the proximal epiphysis of humerus in SI patients has never been described in literature.

Presentation of case

This report shows the case of a 10-year-old SI male who presented with a GCTB at the proximal epiphysis of humerus that was treated with curettage, cement and adjuvant therapy.

Discussion

The presence of a lytic growing lesion at the proximal humerus in a SI patient should alert clinicians to consider GCTB in their differential diagnosis. The management of GCTB in SI patients is challenging for orthopaedic surgeons. Tumor resection with cementation and adjuvant therapy has been described as a method rationale to prevent the recurrence and preserve the joint function in SI patients with GCTB at the proximal epiphysis of humerus. Clinicians should continue to monitor these patients with radiographic imaging for possible recurrence, metastasis or growth plate injury.

Conclusion

Tumor resection with cementation and adjuvant therapy offers a treatment alternative to prevent the recurrence and preserve the joint function in SI patients with GCTB at the proximal epiphysis of humerus. The use of a prothesis in a SI patient should avoided if possible, to prevent implant-related complications and damage to the growth plate.

Mechanisms of Cytotoxicity of Chemical Agents to Giant Cell Tumors: An In Vitro Study

Background

Various chemical agents have been used as an adjuvant treatment for giant cell tumor (GCT). However, the comparative effect of these chemicals remains unclear.

Methods

Multinucleated and spindle cells from cultured GCT patients, characterized by Nanog and Oct4 expression with RT-PCR, were directly administered, in vitro, with concentrations of 1%, 3%, and 5% of H₂O₂ and 75%, 85%, and 95% of ethanol for 10 minutes and concentrations of 0.003%, 0.005%, 0.01%, 0.03%, 0.1%, and 0.3% of H₂O₂ for 5 minutes and were incubated for 24 hours. Cell morphology, cell viability, and flow cytometry after various concentrations of H₂O₂ and ethanol exposure were assessed.

Results

H₂O₂ in all concentrations caused loss of cell viability. The number of viable cells after H₂O₂ exposure was related to the concentration-dependent effect. The initial viable spindle-shaped cell, multinucleated giant cell, and round-epithelioid cell had morphological changes into fragmented nonviable cells after exposure to H₂O₂. Flow cytometry using Annexin V showed cell death due to necrosis, with the highest concentration amounting to 0.3%.

Conclusion

Administering local chemical adjuvants of H₂O₂ in vitro caused loss of viable GCT cells. The number of viable cells after H₂O₂ exposure was related to the concentration-dependent effect, whereas reducing concentration of H₂O₂ may cause loss of viability and morphology of cultured GCT cells with the apoptotic mechanism.

Can p63 serve as a biomarker for diagnosing giant cell tumor of bone? A systematic review and meta-analysis

BACKGROUND

Tumor protein p63 (p63) has been reported to be highly expressed in giant cell tumor of bone (GCTB). Whether p63 can be treated as a diagnostic marker for GCTB remains unclear.

OBJECTIVE

We conducted a meta-analysis to evaluate the applicability of p63 in diagnosing GCTB.

DESIGN AND SETTING

Systematic review and meta-analysis carried out in a public hospital, Hong Kong, China.

METHODS

We searched PubMed, EMBASE and the Cochrane Library from inception to April 30, 2019. Literature in English or Chinese about the differential diagnosis of GCTB using p63 were included. -Animal experiments, reviews, correspondence, case reports, expert opinions and editorials were excluded. Studies were also excluded if they did not provide sufficient information to construct a 2 × 2 contingency table. We calculated individual and pooled sensitivities and specificities. We used I² as an indicator of heterogeneity.

RESULTS

Out of 88 records identified, 8 articles on 788 GCTB patients fulfilled the inclusion criteria and were included in the present analysis. Bivariate analyses yielded a pooled mean sensitivity of 0.87 (95% confidence interval, CI, 0.72-0.95) and specificity of 0.71 (95% CI, 0.56-0.82) for using p63 as a biomarker in diagnosing GCTB. The area under the receiver operating characteristic curve was 0.86 (95% CI, 0.82-0.88).

CONCLUSION

p63 is a helpful indicator in diagnosing GCTB due to its high sensitivity and specificity. -Nonetheless, the results need to be carefully interpreted based on other diagnostic methods such as imaging.

SYSTEMATIC REVIEW REGISTRATION

164115 (PROSPERO registration number).

Can Giant Cell Tumor of the Bone Occur in the Skeletally Immature?

Giant cell tumor (GCT) of the bone is a benign, locally aggressive neoplasm that has a high tendency for local recurrence. It usually has a higher incidence in the third decade of life. This is a retrospective review of a case with histologic confirmation of GCT in a skeletally immature patient involving the metatarsal bone, which is a rare site. At our institution, 1.3% of skeletally immature patients had GCT of the bone. From an extensive literature review, only four cases of GCT of the metatarsal bone in the skeletally immature were identified. Giant cell tumor in a skeletally immature patient can be confused for an aneurysmal bone cyst because of similar radiologic findings. Giant cell tumor of the bone can occur in an immature skeleton and should be sought out as a differential diagnosis despite being rare.

Processing Techniques for Scanning Electron Microscopy Imaging of Giant Cells from Giant Cell Tumors of Bone

Giant cell tumor (GCT) of bone is a common benign lesion that causes significant morbidity due to the failure of modern medical and surgical treatment. Surface ultra-structures of giant cells (GCs) may help in distinguishing aggressive tumors from indolent GC lesions. This study aimed to standardize scanning electron microscopic (SEM) imaging of GC from GCT of bone. Fresh GCT collected in Dulbecco's Modified Eagle Medium was washed to remove blood, homogenized, or treated with collagenase to isolate the GCs. Mechanically homogenized and collagenase-digested GCs were imaged on SEM after commonly used drying methodologies such as air-drying, tetramethylsilane (TMS)-drying, freeze-drying, and critical point-drying (CPD) for the optimization of sample processing. The collagenase-treated samples yielded a greater number of isolated GC and showed better surface morphology in comparison to mechanical homogenization. Air-drying was associated with marked cell shrinkage, and freeze-dried samples showed severe cell damage. TMS methodology partially preserved the cell contour and surface structures, although the cell shape was distorted. GC images with optimum surface morphology including membrane folding and microvesicular structures on the surface were observed only in collagenase-treated and critical point-dried samples. Collagenase digestion and critical point/TMS-drying should be performed for optimal SEM imaging of individual GCs.

Giant cell tumor of bone: Unusual features of a rare tumor

Giant cell tumor of bone is a benign tumor with an aggressive behavior. Its typical subarticular location and high recurrence risk can be associated with significant morbidity. Although benign, it can rarely metastasize especially to the lungs. Also, it can be multicentric in less than 1% of patients. Late malignant transformation, although rare, can occur with a very poor prognosis. This series reports on these unusual and challenging features and management considerations of giant cell tumor of bone. This retrospective study included review of the medical records of patients with a confirmed histopathological diagnosis of giant cell tumor of bone. A total of 25 patients (16 females and 9 males) with a mean age of 34.5 years were included; 22 had primary tumors, while 3 were referred with recurrent tumors. Pain was the most common presenting symptom. Most patients had grade III tumors. Tumors around the knee were the most common. Multicentric tumors were detected in three patients. Twenty-three patients (20 primary giant cell tumor of bone and 3 with recurrence) received treatment. Most patients (15/23) were treated with intralesional curettage with or without adjuvants. Seven patients had wide excision. Recurrence was seen in 45% (9/20) of primary giant cell tumor of bone especially with difficult anatomical locations. Most recurrences occurred more than 4 years after treatment. Pulmonary nodules were detected in four patients; two of them showed resolution during follow-up. One patient developed secondary sarcoma transformation with a fatal outcome. Giant cell tumor of bone was more common in females. Long bones were more affected, especially around the knee. Intralesional curettage was the most frequently used treatment. Recurrence was associated with inadequate tumor resection (especially in difficult anatomical location), younger age, male gender, and advanced local tumor grade. Denosumab can be used in the treatment of pulmonary metastasis, multicentric and recurrent giant cell tumor of bone. Due to late recurrence and malignant transformation, a prolonged follow-up is warranted.

Clinical features and prognostic factors of pediatric spine giant cell tumors: report of 31 clinical cases in a single center

BACKGROUND CONTEXT

Giant cell tumors (GCTs) of the bone are benign but locally aggressive. Pediatric spine giant-cell tumors (PSGCTs) have been infrequently reported in the literature because of the rarity of the disease.

PURPOSE

The purpose of this study was to define the overall occurrence rate of PSGCTs among all spinal GCTs in our center and investigate the clinical features and prognostic factors of this rare disease.

STUDY DESIGN

A retrospective review.

PATIENT SAMPLE

Thirty-one PSGCT patients, screened from 226 patients with spine GCTs who received treatment in our center between 1998 to 2017.

OUTCOME MEASURES

The clinical symptoms, neurologic status, radiologic manifestations, treatment, outcome, and complications were recorded and analyzed.

METHODS

The postoperative recurrence-free survival (RFS) rate was estimated by the Kaplan-Meier method. Factors with p values ≤.1 were subjected to multivariate analysis for RFS by proportional hazard analysis, among which p values ≤.05 were considered statistically significant.

RESULTS

A total of 31 (31 of 226, 13.7%) PSGCTs patients (9 male and 22 female) were included in the study, with a mean age of 15.9 years and a mean follow-up period of 85.1 (median 84.0; range 12-221) months. The majority of patients (80.6 %) were 14-18 years of age. Recurrence was detected in 12 (38.7%) of the 31 patients. Univariate and multivariate analyses suggested that Jaffe grade II-III was an adverse prognostic factor for RFS, while total spondylectomy and bisphosphonate treatment were positive prognostic factors.

CONCLUSIONS

Total en bloc spondylectomy (TES) is associated with excellent prognosis for PSGCTs, and total piecemeal spondylectomy is a viable alternative if total en bloc spondylectomy is unfeasible. Long-term bisphosphonate administration could significantly reduce the recurrence risk of PSGCTs. Denosumab treatment is recommended, especially for advanced PSGCTs. Jaffe grade II-III is an adverse prognostic factor for recurrence.

An Unusual Presentation of Giant Cell Tumor of the Tibia in a Skeletally Immature Patient

INTRODUCTION

Giant cell tumors (GCTs) are locally aggressive tumors that principally affect the epiphysis of long bones. Histologically, these tumors consist of three types of cells: Osteoclast-like multinucleated giant cells, round mononuclear cells resembling mononucleocytes, and spindle-shaped round fibroblast-like stromal cells. Radiographically, the tumors appear osteolytic and radiolucent without a sclerotic border. The tumor rarely occurs in pediatric age group. Its incidence in pediatric patients varies from 1.8 to 7.5%.

CASE REPORT

A 15-year-old girl presented to us with the complaints of pain in the left knee of 3months' duration and inability to squat. Radiographic imaging was done which showed lytic lesion involving the proximal tibia and showing cortical destruction. The lesion was graded as a Campanacci Grade 3 tumor. The patient was taken up for surgery and an extended curettage was performed, and the cavity was packed with bone cement. The patient was asymptomatic at the end of 18-month follow-up and was continuing her normal daily activities.

CONCLUSION

GCT of the bone is extremely rare in skeletally immature patients. This particular case highlights the need for keeping the diagnosis of GCT at the periphery of one's vision when dealing with pediatric patients presenting with osteolytic lesion at the epimetaphysis of long bones.

Histologic Spectrum of Giant Cell Tumor (GCT) of Bone in Patients 18 Years of Age and Below: A Study of 63 Patients

Although the majority of giant cell tumors (GCTs) of the bone occur in adult patients, occasionally they arise in the pediatric population. In this setting they may be mistaken for tumors more commonly seen in this age group, including osteosarcoma, aneurysmal bone cyst, and chondroblastoma. All cases of primary GCT of the bone arising in patients 18 years and below were retrieved from our institutional archives and examined with emphasis on the evaluation of various morphologic patterns. Clinical/radiologic records were reviewed when available. Analysis for H3F3A/H3F3B mutations was performed in a subset of cases. Sixty-three (of 710) patients treated at our institution for GCT were 18 years of age and below. The following morphologic patterns were identified: fibrosis (31 cases, 49%), reactive-appearing bone (26, 41%), cystic change (7, 11%), foamy histiocytes (6, 10%), secondary aneurysmal bone cyst (3, 5%), and cartilage (2, 3%). Infarct-like necrosis was present in 17 tumors (27%), and the mitotic rate ranged from 0 to 35 mitoses/10 high-power fields (median 5 mitoses/10 high-power field). Follow-up information (n=55; 6 mo to 69.6 y; median, 11.6 y) showed 21 patients with local recurrence (38%) and 2 patients with lung metastasis (4%). Polymerase chain reaction with sequencing showed that 5 of 5 tested cases harbored H3F3A mutations. In summary, GCT arising in the pediatric population is rare, representing 9% of GCTs seen at our institution. The morphologic spectrum of these tumors is broad and similar to that seen in patients above 18 years of age. It is important to recognize that matrix formation may be observed in GCT, including reactive-appearing bone and cartilage, as well as areas of fibrosis mimicking osteoid production, to avoid misclassification as osteosarcoma or other giant cell-rich lesions common in children.

Giant Cell Tumor: A Rare Condition in the Immature Skeleton-A Retrospective Study of Symptoms, Treatment, and Outcome in 16 Children

Background. Pediatric giant cell tumor (GCT) of bone is rare and the course of the disease in the immature skeleton is sparsely described. We performed a retrospective study addressing symptoms, treatment, and outcome in children with GCT. Methods. Review of medical records and images of patients with GCT. Patients were detected from our hospital prospective database and those with open epiphyseal cartilages were included. Results. 16 children (75% girls) from 6 to 15 years old were identified. Eight lesions (50%) were in long bones and 4 (25%) in flat bones. One lesion appeared to be purely epiphyseal. All patients had pain as the initial symptom. Local recurrence developed in 2 patients. 14 of 16 patients returned to normal activity with no sequelae. One patient developed anisomelia after surgery. Conclusions. The biological tumor behavior in children does not seem to differ from what is reported in adults. Lesions in flat bones are very unusual, but our data alone do not provide enough evidence to conclude that this is more common in the immature skeleton. Literature review showed only one previous case report describing a purely epiphyseal GCT. Intralesional curettage is appropriate treatment and gives good functional results with acceptable recurrence rates.

Giant Cell Tumor of Bone in Skeletally Immature Patients - A Clinical Perspective

INTRODUCTION

Giant cell tumors of skeleton are very rare in pediatric and adolescent population. Here we report two cases-one a fifteen year old child with swelling distal humerus and another a case of a thirteen year old child with pain and swelling proximal tibia.

CASE REPORT

A fifteen year old child presented to department of orthopedics of our institute with complaint of difficulty in moving upper limb and swelling distal humerus. Another patient who was a 13 years old male had painful ambulation and swelling in upper tibia. MRI followed by core needle biopsy was done in both the patients confirming the mass to be giant cell tumor which is quite rare in this age group. First patient was managed by wide excision and total elbow replacement and second one by curettage, cementation and augmentation with plate-screw construct.

CONCLUSION

Giant cell tumour of skeleton is highly uncommon in pediatric age group. It should be considered as one of the differential diagnosis of epiphyseo metaphyseal lesions in pediatric population in spite of its rarity.

Rapidly growing giant cell tumor of bone in a skeletally immature girl

Giant cell tumor of bone (GCTB) in skeletally immature patients is rare, and little is known regarding how fast GCTB can grow. We report a case of a 10-year-old skeletally immature girl with pathologically proven GCTB with obvious growth plate invasion that showed surprisingly rapid growth over only 14 days. A radiograph of the left knee revealed well-circumscribed, geographic bone destruction at the distal metaphysis of the femur with a focal cortical defect, suggesting a pathologic fracture. No abnormal mineralization or periosteal reaction was seen. A CT without contrast and an MRI demonstrated a homogeneous lesion with cortical disruption posteriorly and laterally with a slight soft tissue extension. Biopsy showed numerous multinucleated giant cells and spindle-shaped mononuclear cells without any sign of malignancy, suggesting GCTB. However, rapid lesion enlargement and destruction of the surrounding cortex were noted 14 days after biopsy. Considering the amount of bone destruction, traditional treatment of curettage and bone cement would not suffice to sustain structural strength. In addition, considering the patient's age, the tumor location, and the aggressive course, a malignant tumor, especially a giant cell-rich osteosarcoma, could not be excluded. Therefore, en bloc resection, including the growth plate and prosthetic replacement, were performed. Confirmation of GCTB was made from a pathologic evaluation, and a breach to the growth plate was identified. Since very little inflammatory reaction, degenerative change, or aneurysmal, bone, cyst-like change was found, the growth plate invasion was confirmed as due to GCTB extension, not due to the preoperative biopsy.

Giant cell tumour of the femur in a 9-year-old girl, resulting in severe leg length discrepancy

Giant cell tumour of bone (GCTB) is a rare benign tumour noted before physeal closure. GCTB cases in patients younger than 10 years are especially uncommon. The authors report the case of a 9-year-old girl with a GCTB of the distal femur. After initial intralesional excision and curettage of the tumour, local recurrence occurred, which needed two more additional surgeries to treat. The primary tumour and the local relapse invaded the growth plate of the right distal femur, leading to growth disturbance of the femur and requiring leg lengthening using Ilizarov apparatus. Surgeons should note the possibility of this rare condition while treating radiographic lytic lesions even in skeletally immature patients. The occurrence of late limb length discrepancy would be more likely in younger patients.

Giant cell tumor of bone arising in long bones possibly originates from the metaphyseal region

Giant cell tumor of bone (GCTB) is a primary benign bone tumor with a locally aggressive character. Definitive descriptions of the site of origin for this type of tumor are not available. The aim of the present study was to evaluate the site of origin of GCTB of long bones with regards to epiphyseal lines by means of radiographic examination. For that purpose, plain X-ray scans of 71 GCTBs arising in long bones were retrospectively reviewed. The tumor locations were the distal femur in 31 cases, proximal femur in 11 cases, proximal tibia in 13 cases, distal radius in 6 cases, proximal humerus in 5 cases and proximal fibula in 5 cases. The vertical center (VC) of the tumor was determined with X-ray anteroposterior view, and the correlation between the VC and the epiphyseal line, and between the distance from the epiphyseal line to the VC and tumor area or volume were analyzed using a regression model equation based on scatter plot diagrams. The VC of the tumor was located in the metaphyseal region in 57 cases, in the epiphyseal line in 11 cases and in the epiphyseal region in 3 cases. In cases of GCTB located in the distal femur or proximal tibia, significant correlations between the distance from the VC to the epiphyseal line and tumor area or volume were identified. The site of origin of GCTB was estimated to be located in the metaphyseal region. GCTB often occurs in mature patients, which renders it challenging to estimate the true site of origin of this lesion, since the metaphyseal line has disappeared in mature patients. The results of the present study suggest that GCTB possibly originates in the metaphyseal region.

Biological characteristics of a novel giant cell tumor cell line derived from spine

Giant cell tumor of bone(GCTB) is a special bone tumor for it consists of various cell types, and its biological characteristics is different from common benign or malignant neoplasm. In the present study, we report the biological features of a primary Asian GCTB cell line named GCTB28. We analyzed extensive properties of the GCTB28 cells including morphological observations, growth, cell cycle, karyotype, proliferation, proteins expression, surface biomarker verification, and tumorigenicity in nude mice. We found that the stromal cells of GCTB were endowed with self-renewal capacity and played dominant roles in GCTB development. Moreover, we confirmed that GCTB cells can be CD33(-)CD14(-) phenotype which was not in accord with previous study. This study provides an in vitro model system to investigate pathogenic mechanisms and molecular characteristics of GCTB and also provides a useful tool for researching the therapeutic targeting of GCTB.

Exophytic giant-cell tumor of the tibial tubercle

A 23-year-old pregnant woman presented to the orthopedic tumor clinic with gradual onset of left anteriomedial tibial pain for one month and a lytic lesion of the proximal tibia on radiography. MRI showed an exophytic mass of the left tibial tubercle with fluid-fluid levels. The patient underwent surgical excision, and pathology was consistent with giant-cell tumor. This lesion is notable for its exophytic growth pattern and its location at the tibial tubercle. Giant-cell tumors are almost always epiphyseal in location in skeletally mature patients. Although the tibial tubercle is sometimes thought of as metaphyseal, it is an epiphyseal equivalent for bone tumor growth. The role of the patient's pregnancy in the pathophysiology of her tumor is unclear.

Management of Giant Cell Tumour Radius in a Three Year old Child with an Improvised Technique

Giant cell tumours of immature skeleton have a very low incidence and epi-metaphyseal location. We are presenting giant cell tumour distal radius in a skeletally immature patient; an uncontained defect with a large soft tissue component which was managed by wide excision and reconstruction with an improvised technique.

Giant cell tumor of the metacarpal bone in children: free osteoarticular metatarsal transfer: case report

We present a successful total resection of metacarpal bone and nonvascularized joint transfer in a giant cell tumor of the fourth metacarpal bone in a 13-year-old girl. At the 6-year follow-up, a good functional outcome was achieved, with 85° range of motion of the metacarpophalangeal joint and no clinical or radiographic evidence of tumor recurrence and no signs of degeneration of the joint.

[Patellar giant cell tumour: presentation of a case and a review of the literature]

Patellar tumours are rare. They typically appear in young patients, and present with a non-specific pain in the knee. Giant cell tumour (GCT) are benign, but locally aggressive. Although they are usually found around the knee (40-60%), those affecting the patella have been classically described in the literature as uncommon. We describe the case of a 19 year old male complaining of pain in his knee, whose clinical examination suggested a meniscal tear. Plain radiological examination, as well as MRI, revealed a well circumscribed lytic lesion within the patella. The patient underwent arthroscopic surgery, during which an incisional biopsy was performed. Following pathology reports, which confirmed the suspected GCT, definitive surgery was performed. At 56 months after the surgery the patient remains asymptomatic and free of disease.

Giant-cell tumor of the fourth metacarpal bone in children: case report

Giant-cell tumor is a rare benign tumor that generally arises in long bones of the lower extremity in adults. The involvement of the metacarpal bone in children is extremely rare. The authors report the case of an 8-year-old boy admitted for a painless swelling of the posterior surface of the fourth right metacarpal bone. The radiological examination showed an expansile osteolytic lesion with a multilocular appearance. Total resection of the metacarpal bone and reconstruction with free fibular graft was performed. We highlight the rarity of this neoplasm in childhood and discuss epidemiological, clinical, radiological, and therapeutical characteristics of this pathology.

Solitary epiphyseal enchondroma of the proximal femur in a 23-month-old girl

A 23-month-old girl was referred to us because of a right leg limp for 10 days that had not improved despite anti-inflammatory treatment and that did not show signs of infection. Upon examination, gait was in abduction and external rotation of the hip. Plain radiographs showed a solitary lucent lesion of the posteroinferior two thirds of the epiphysis that was hyperintense on T2-weighted magnetic resonance scanning images. We approached the proximal femoral epiphysis using the "trapdoor" technique and excised the lesion by curettage and iliac crest graft. Histologically, the lesion was diagnosed as an enchondroma. We discuss the main causes of lucent epiphyseal lesions in children. Finally, we review the literature on previous reports of patients with solitary epiphyseal enchondromas.

STUDY TYPE

Case report.