J Radiol Sci 2011; 36: 173-176
Giant Cell Tumor in an Immature Skeleton
Pei-Yu Tsai Wen-Sheng Tzeng Clement Kuen-Huang Chen Jinn-Ming Chang
Department of Medical Imaging, Chi-Mei Medical Center, Yong-Kang Campus, Tainan, Taiwan
Abstract
We report a case of giant cell tumor occurring in a 12-year-old girl. Radiographs revealed a radiolucent lesion in
the proximal epi-metaphysis of the right fibula, which was initially diagnosed as an aneurysmal bone cyst. Magnetic
resonance imaging showed an expansile intramedullary lesion with focal multiloculated fluid-fluid levels and also
solid mass in the proximal metaphysis. The latter solid component also extended into the proximal fibular epiphysis.
Following the magnetic resonance imaging, the diagnosis was revised to giant cell tumor with focal aneurysmal bone
cyst changes, which was subsequently confirmed histopathologically following surgery. The unusual occurrence,
location, imaging features, and differential diagnosis of osseous giant cell tumor in the immature skeleton were
discussed.
Giant cell tumor (GCT) of bone is a benign but locally
aggressive lesion that primarily affects the epi-metaphysis
of long bones in adults, especially in their third to fourth
decades of life. The disease diagnosed before skeletal
maturity is extremely rare. We report a case of GCT of
the proximal epi-metaphysis of the right fibula with focal
secondary aneurysmal bone cyst (ABC) in a 12-year-old
girl. MRI helped to establish accurate image diagnosis and
make an surgical planning.
Case report
A 12-year-old girl presented with a painful mass in
her right upper leg that has been noted for months. Physical
examination revealed a tender mass in the lateral aspect
of her right upper leg, along with local heat and decreased
range of motion in the knee joint. Routine radiographs
showed a geographic expansile osteolytic lesion, 2.3 ×
2.4 × 5.8 cm in size, in the proximal metaphysis of the
right fibula. There was no obvious matrix mineralization,
periostitis, focal cortical destruction or extraosseous softtissue mass (Fig. 1). Considering the patient’s age, lesion
location and morphology, the diagnosis based on plain film
radiographs was aneurysmal bone cyst. The differential
diagnoses included simple bone cyst, fibrous dysplasia and
telangiectatic osteosarcoma. A subsequent MRI revealed
focal multiloculation with fluid-fluid levels in the inferior
portion and a solid mass with homogeneous appearance
in the superior portion of the lesion. The solid mass manifested as homogeneous isointensity to muscle on T1WI,
mildly high signal on T2WI, and moderately high signal
on fat-saturated T2WI images. Additionally, a small focal
extension of the lesion to the proximal fibular epiphysis
was demonstrated (Fig. 2). MRI suggested the possibility of
primary bone tumor, especially giant cell tumor, with focal
secondary ABC change.
Under the impression of unusual GCT occurring
in the immature skeleton, intralesional curettage of the
tumor, local adjuvant treatment with alcohol, and bone
graft reconstruction were performed. Microscopically, the
tumor manifested as diffuse sheets of mononuclear cells
Correspondence Author to: Jinn-Ming Chang
Department of Medical Imaging, Chi-Mei Medical Center, Yong-Kang Campus, Tainan, Taiwan
No. 901, Chung-Hwa Road, Yong-Kang, Tainan 710, Taiwan
J Radiol Sci September 2011 Vol.36 No.3
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Giant cell tumor in an immature skeleton
with scanty mitotic figures, multinucleated giant cells, focal
hemorrhage and secondary ABC change. The multinucleated giant cells were positive for CD68. Proliferation rate
determined by ki-67 was less than 10%. The final histology
confirmed a GCT with secondary ABC.
Figure 1
Figure 1. Frontal and lateral radiographs of right knee and upper leg
disclose a well-def ined expansile
osteolytic lesion (black arrows) in the
proximal fibular meta-diaphysis with
cortical thinning but without obvious
matrix mineralization, periostitis, or
extraosseous soft tissue mass. The
bone lesion extends into the proximal
fibular epiphysis (white arrow).
Figure 2
2b
2c
2a
Figure 2. Sagittal T1WI a. T2WI b. and T2WI with fat saturation c. disclose a solid tumor component with homogeneous
isointensity to muscle on T1WI, mildly high signal on T2WI, and moderately high signal on fat-saturated T2WI (thick
arrows) in the metaphysis of proximal fibula. Transphyseal extension of the solid tumor to epiphysis is also noted (arrowheads). The inferior portion of the lesion demonstrates multilocular appearance with fluid-fluid levels (thin arrows) indicating secondary aneurysmal bone cyst formation.
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Giant cell tumor in an immature skeleton
Figure 3
Figure 3. The histologic appearance of
the lesion shows the features of giant
cell tumor comprising diffuse sheets
of ovoid to polygonal or elongated
mononuclear cells along with some
multinucleated giant cells (arrows),
characteristic of giant cell tumor of
bone (H & E, x 400).
Discussion
GCT of bone accounts for 4-8% of primary bone
tumors. It is most commonly seen in patients aged 20 to 40
years. The occurrence of GCT in patients with open growth
plates is rare. The reported incidence of GCT in skeletally
immature patients ranges from 1.8% to 7.5% [1, 2].
In adult patients, the tumor typically affects the
epiphyses of the distal femur, proximal tibia, distal radius,
and proximal humerus [3, 4]. The proximal fibula is less
frequently involved, with reported incidence of about 3-4%
[5]. Approximately 84%–99% of GCT extends to within
one centimeter of subarticular bone [5].
The exact site of origin of GCT is controversial.
Murphy et al and Kransdorf et al described the lesions
almost invariably involve the metaphysis rather than the
epiphysis in skeletally immature patients [5, 6]. It was
therefore hypothesized that, in the vast majority of cases,
GCT of bone originates in the metaphysis and extends into
the epiphysis. The case of our report seems agreeable to this
thesis. However, there was a reported case of GCT isolated
to the epiphysis of distal femur in a 14-year-old girl [7].
GCT demonstrates geographic bone destruction with
no significant surrounding sclerosis or matrix mineralization. About 14% of GCT exhibits secondary ABC
components [5]. In addition to GCT, many other benign
or malignant bone lesions, including chondroblastoma,
fibrous dysplasia, osteoblastoma, chondromyxoid fibroma,
nonossifying fibroma, osteosarcoma, chondrosarcoma,
J Radiol Sci September 2011 Vol.36 No.3
hemangioendothelioma, and metastatic carcinoma, can also
demonstrate secondary ABC change [8, 9]. Among them,
GCT is the most common lesion associated with secondary
ABC.
Routine radiographs of the patient in our case are
characteristic of ABC considering the patient’s age, lesion
location and morphology. Fortunately, MRI depicts the
solid component of the tumor, focal ABC changes, and
epiphyseal extension of the solid tumor. Chondroblastoma,
although commonly seen in the immature skeleton, mainly
affects the epiphyses with a characteristic multilobular
chondral matrix and often internal calcifications. Foci of
osteoid and/or fibrous tissue are invariably seen in fibrous
dysplasia, osteoblastoma, chondromyxoid fibroma, nonossifying fibroma, and telangiectatic osteosarcoma, leading to
focal low or heterogeneous internal signals. Characteristically, telangiectatic osteosarcoma consists of large hemorrhagic or necrotic cavities that compose most (>90%) of
the tumor volume with viable high-grade sarcomatous cells
around the periphery and septations of these spaces [10].
However, in our case, the lesion presented as a predominant soft tissue mass with homogeneous signal intensity
but without periosteal reaction, central cystic change or
necrosis, focal mineralization, cortical breakthrough and
bulging soft tissue mass. The lesion of our case manifested
as homogeneous intermediate to high signal intensity at
upper solid tumor. The diagnosis of GCT was therefore
made following MRI.
In conclusion, in the presence of an expansile osteolytic
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Giant cell tumor in an immature skeleton
lesion in the metaphysis of a tubular bone occurring in an
immature skeleton with open growth plate, giant cell tumor,
although very uncommon, should be considered in the list
of differential diagnoses. Further study, MRI or CT scan,
can help to identify solid tumor components, establish an
accurate imaging diagnosis, and facilitate surgical planning.
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