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Soft Tissue Recurrence Of  Giant Cell Tumour

 Krishnakumar R*

* DNB Trainee,Dept. of Orthopaedics,Medical College,Trivandrum

Address for Correspondence:

Dr. R Krishnakumar Mbbs, D Orth.DNB Trainee, Medical
College, Trivandrum
Parkkanthara Veedu
Nalanchira Po,
Trivandrum, Kerala 695015


J.Orthopaedics 2007;4(4)e3


Cooper and Travers first described giant cell tumor of bone in 1818 (4).  Bloodgood coined he term giant-cell tumor in 1912(1). In 1940   Jaffe et al distinguished giant-cell tumor as a distinct clinical, radiographic, and pathological entity that is separate from other lesions containing giant cells(8). Giant cell tumor of bone is characterized radiographically by a well delineated, eccentric, purely lytic, epiphyseal lesion with the absence of reactive sclerosis and periosteal new bone formation abutting the articular surface. Giant cell tumor of the bone accounts for 4-5% of primary bone tumors and 18.2% of benign bone tumors. The incidence is increased in patients with Paget disease of the bone, in which giant cell tumor is a rare neoplastic complication. Typically, giant cell tumors occur in skeletally mature patients aged 20-40 years. The incidence peaks in those aged 20-30 years. Although intraosseous recurrence of giant cell tumour is a well recognized complication; soft tissue recurrences are rarely encountered

Case Report:

A thirty-five year-old man was presented to our institution because of a  gradualy enlarging soft-tissue mass in the  anterolateral aspect of the proximal part of the right leg for the past six monthsi. Twenty- four months previously, the patient had been  treated by curettage and  packing with polymethylmethacrylate cement  for a giant-cell tumor of the proximal aspect of the right tibia. Physical examination revealed a nontender soft-tissue mass, seven by four centimeters in size,mobile,variable in consistancy from bony hard to soft cystic ; that was palpable in the anterolateral  aspect of the proximal part of the leg. Plain radiographs showed  a soft-tissue mass with more central  ossification and trabeculations  (Figure 1-A). The curetted leison with polymethylmethacrylate cement was intact. Magnetic resonance imaging studies  showed a lobulated well defined hyperintense mass  intending the proximal substance and origin of the peroneus longus and peroneus brevis with loss of intervening fat planes-possibly infiltrating the peroneus brevis on T2-weighted and STIR images.Leison appeared iso to hyperintense to the muscle on T1-weighted images.Hypointense areas suggestive of mineralisd septae were seen within the leison.Hyperintense cystic areas within the leison was also noted(Fig 1B).On contrast study the leison showed heterogeneous enhancement(Fig 1C).The anterior and posterior intermuscular septum and the interosseous membrane appeared normal.The patient was managed with wide resection of the well circumscribed soft-tissue mass, which measured 7 by 4.2 by 4 centimeters and was located in the upper peroneal compartment attached to the peroneus brevis muscle(Fig 1D). Histological analysis demonstrated a recurrent giant-cell tumor(Fig 1E) .






Discussion :

        Intraosseous recurrences of giant cell tumor of bone are common and readily recognized.  O’Donnell et al   reported a 25% rate of local recurrence with thorough curettage and packing with polymethylmethacrylate (14). Radiologic evaluation of recurrence typically reveals new areas of bone destruction at the previous resection margin or resorption of intralesional bone graft material (9,14,15,16,18,22,23).Recurrence of giant-cell tumor after   polymethylmethacrylate placement typically reveals focal lobular destruction of bone about the cement. Soft-tissue recurrences are less common. It is likely related to either implantation at surgery or tumor spread secondary to pathologic fracture. Soft-tissue recurrence may or may not be visible on plain radiographs. Cooper et al. reported seventeen cases of soft-tissue recurrence in their review of 1100 cases of giant-cell tumor (3). A peripheral rim of ossification was noted around sixteen of the recurrent soft-tissue tumors. In the one exception the ossification was more centrally located within the soft-tissue mass.  Other studies (7, 19,21,) have also  reported peripheral rim of ossification around a soft-tissue recurrence of giant-cell tumor including pulmonary metastasis, and this phenomenon is thought to be almost pathognomonic of recurrence. Metaplasia of the tumor cells may be responsible for this capability of pulmonary and soft-tissue deposits to produce osteoid (3).The differential diagnosis to be kept in mind is myositis ossificans. However these recurrences can be differentiated from myositis ossificans by their continued slow growth, their occurrence more than 2 months after surgery, and with time, the ossified mass should increase, rather than decrease in size. The radiographic appearance of the present reported case with more central calcification without peripheral rim of ossification matches that of the lone case reported in the series of Cooper et al.

                 Most giant cell tumours (80%–90%) recur within the first 3 years after initial treatment (6, 11, 12, 13, 17, 18, 22).After treatment, patients with GCT should be evaluated with serial physical examinations and radiography of the involved site and of the chest.  Tumor recurrences have been noted many years after initial treatment, and necessitate long-term surveillance (10, 20). A local soft tissue tumor with a peripheral rim of ossification in a patient with known giant cell tumor of bone is essentially diagnostic of soft tissue recurrence of giant cell tumor.

Reference :

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This is a peer reviewed paper 

Please cite as : Krishnakumar R : Soft Tissue Recurrence Of  Giant Cell Tumour

J.Orthopaedics 2007;4(4)e3





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