De Backer, Adelard

Sys, Gwen

Vanhoenacker, Filip

Vanhove, Wim

Verniers, Lucas

English

Ghent University Academic Bibliography

Case 15826 Aggressive Giant Cell tumour of the MetacarpalLucas Verniers (1), Adelard De Backer (2), Wim Vanhove (3), Gwen Sys (3), Filip Vanhoenacker(4, 5, 6)(1) Ghent University, Medical Student, Corneel Heymanslaan 10, 9000 Ghent, Belgium(2) General Hospital Sint-Lucas, Department of Radiology, Groenebriel 1, 9000 Ghent, Belgium(3) Ghent university, Department of Orthopaedics, Corneel Heymanslaan 10, 9000 Ghent, Belgium(4) AZ Sint-Maarten Duffel-Mechelen, Department of Radiology, Leopoldstraat 2, 2800 Mechelen,Belgium(5) Ghent University Hospital, Department of Radiology, Corneel Heymanslaan 10, 9000 Ghent,Belgium(6) Antwerp University Hospital, Department of Radiology, Wilrijkstraat 10, 2650 Edegem,BelgiumUZ Ghent; Corneel heymanslaan 10 9000 Ghent, Belgium; Email:lucas.verniers@ugent.be  Musculoskeletal System Section: 2018, Jul. 4 Published: 54 year(s), femalePatient:Clinical HistoryA 54-year-old female presented with a 2-month history of insidious onset of swelling and pain atthe left thumb. Initial conservative treatment failed. Physical examination confirmed swelling at the1st carpometacarpal (CMC) joint and a limited abduction. The patient was otherwise well with nohistory of prior malignancy.Imaging FindingsPlain radiographs demonstrated an expansile osteolytic lesion in the proximal epiphysis anddiaphysis of the left 1st metacarpal bone (MC1). The cortex appeared markedly thinned. There wasno surrounding sclerosis nor periosteal reaction (Fig. 1). CT confirmed a large lytic lesion with softtissue attenuation, cortical thinning and destruction (Fig. 2). MR imaging showed bone marrowreplacement with distal epiphyseal sparing. The lesion was of low signal intensity (SI) onT1-weighted images (WI) and intermediate to high SI on T2-WI. Moderate enhancement andsoft-tissue extension was noted on contrast-enhanced images (Fig. 3). Bone scintigraphydemonstrated increased radionuclide uptake but absence of multifocality (Fig. 4). Surgical biopsyand subsequent histopathological examination revealed Giant Cell Tumour (GCT). PreoperativeImaging (Fig. 5-6) 3 months later preceding MC1 resection (Fig. 7) and cement grafting (Fig. 8)showed marked increase of the lesion size. Histopathological findings of the resection specimenconfirmed GCT without malignant degeneration.DiscussionGCT of bone is a benign, but locally aggressive lesion with a tendency for local recurrence afterresection. Metastasis is rare. Histologically, it is composed of multinucleated giant cells within astroma of mononuclear cells. GCT account for approximately 5% of all primary bone tumours [1,2]. It predominantly occurs between 20 and 50 years of age with a female predominance [1, 3, 4].GCT of the bone commonly occur in the epi-metaphyseal region of long bones. The distal femur,proximal tibia and distal radius are commonly involved, with the spine and sacrum being lessinvolved [3, 5]. The bones of the hand and foot are rarely involved, with a reported frequency ofabout 2% of all GCT. Metacarpal involvement is extremely rare [5].Clinical presentation is usually nonspecific including pain, swelling, limited range of motion andpathological fractures [1, 5]. On conventional radiographs and CT, GCT is typically seen as an eccentric, epi-metaphysealosteolytic lesion, with well-defined non-sclerotic border and extension underneath the subchondralarticular bone [1-3, 5-7]. GCT may also show aggressive features consisting of, poorly demarcatedmargins, cortical thinning and destruction and soft tissue extension [5]. CT may be useful inevaluating cortical bone integrity, absence of matrix mineralization and demonstration of pathologicfracture [2, 4]. GCT of the hand tends to be less eccentric and more centrally located [7]. MR imaging can help determine the precise intramedullary and soft-tissue extent of the lesion [7].Generally, GCT has a low-to-intermediate signal on T1-WI and a heterogeneous-high signal onT2-WI [2-4, 7]. However, due to intra-tumoural hemosiderin or fibrosis, the signal may be low onT2-WI [2]. The lesion enhances after intravenous gadolinium contrast administration, reflecting theincreased vascular supply [6]. Bone scintigraphy may detect multifocality [4].Extensive curettage or resection is the treatment of choice of GCT of the hand bones [2, 6, 7]. Thecombination of intraoperative cryogenic agents or methyl-methacrylate packing and resection hasresulted in a recurrence rate of less than 10% [6]. For maintenance of the CMC function, resectionis followed by bone reconstruction using an autogenous bone graft or allograft [2].Although histology is mandatory for a definitive diagnosis, analysis of imaging characteristics of alesion can be helpful in suggesting the correct diagnosis of a GCT. Epiphyseal extension and thelow SI on T2-WI on MRI are useful signs in imaging characterization of aggressive GCT even atrare localizations such as the metacarpal.Written informed patient consent for publication has been obtained.Final DiagnosisGiant cell tumour of the bone.Differential Diagnosis ListAneurysmal Bone Cyst, Expansile lytic acrometastases, Osteosarcoma, Chondroblastoma ,Chondrosarcoma, Brown tumour , PlasmocytomaFiguresFigure 1 Plain radiographPlain radiograph of the left thumb shows an expansile osteolytic lesion in the proximalepiphysis of the metacarpal bone with diaphyseal extension. The cortex appears markedlythinned and is focally destructed. © De Backer A, Department of Radiology, AZ Sint-Lucas, Ghent, Belgium Area of Interest: Musculoskeletal bone;  Imaging Technique: Plain radiographic studies;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 2 CT findingsA. Sagittal reformatted image confirmed a large lytic lesion, marked thinning of the cortexand cortical destruction. © De Backer A, Department of Radiology, AZ Sint-Lucas, Ghent, Belgium Area of Interest: Musculoskeletal bone;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; B. Axial contrast-enhanced CT image shows enhancement of the intramedullary soft tissuelesion. © De Backer A, Department of Radiology, AZ Sint-Lucas, Ghent, Belgium Area of Interest: Musculoskeletal bone;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 3 MR imaging findings.A. Coronal T1-WI shows bone marrow replacement in the diaphysis and proximal epiphysis.© De Backer A, Department of Radiology, AZ Sint-Lucas, Ghent, Belgium Area of Interest: Musculoskeletal bone;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; B. Axial T2-WI shows heterogeneous, intermediate to high SI of the lesion with intralesionalfoci of low signal intensity. © De Backer A, Department of Radiology, AZ Sint-Lucas, Ghent, Belgium Area of Interest: Musculoskeletal bone;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; C. Coronal contrast-enhanced T1-WI with fat suppression demonstrates moderate lesionenhancement and soft-tissue extension. © De Backer A, Department of Radiology, AZ Sint-Lucas, Ghent, Belgium Area of Interest: Musculoskeletal bone;  Imaging Technique: MR-Diffusion/Perfusion;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 4 Bone scintigraphyBone scintigraphy demonstrates increased radionuclide uptake and central photopenia. Thisfinding is known as the "doughnut" sign. © De Backer A, Department of Radiology, AZ Sint-Lucas, Ghent, Belgium Area of Interest: Musculoskeletal bone;  Imaging Technique: Nuclear medicine conventional;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 5 Plain radiograph (3 months later)Plain radiograph performed three months later. There is marked increase of the size,expansion and cortical breakthrough of the lesion. © De Backer A, Department of Radiology, AZ Sint-Lucas, Ghent, Belgium Area of Interest: Musculoskeletal bone;  Imaging Technique: Plain radiographic studies;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 6 MRI findings (3 moths later)A. MR findings performed three months after initial MR examination. Axial T1-WI showsfurther tumour growth. Bone marrow replacement is of heterogeneously low signal intensity.© De Backer A, Department of Radiology, AZ Sint-Lucas, Ghent, Belgium Area of Interest: Musculoskeletal bone;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; B and C: On axial and coronal fat suppressed T2-WI an intermediate to high SI is seen withintralesional areas of low signal intensity. There is no extension into the CMC andmetacarpophalangeal joint © De Backer A, Department of Radiology, AZ Sint-Lucas, Ghent, Belgium Area of Interest: Musculoskeletal bone;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; B and C: On axial and coronal fat suppressed T2-WI an intermediate to high SI is seen withintralesional areas of low signal intensity. There is no extension into the CMC andmetacarpophalangeal joint © De Backer A, Department of Radiology, AZ Sint-Lucas, Ghent, Belgium Area of Interest: Musculoskeletal bone;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; D. On axial contrast-enhanced T1-WI with fat suppression demonstrates heterogeneousenhancement of the lesion and its soft tissue extension. © De Backer A, Department of Radiology, AZ Sint-Lucas, Ghent, Belgium Area of Interest: Musculoskeletal bone;  Imaging Technique: MR-Diffusion/Perfusion;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 7 Intra-operativeA. Operative view of first metacarpal. © Planckaert G, UZ Ghent, Ghent, Belgium Area of Interest: Musculoskeletal soft tissue;  Imaging Technique: Experimental;  Procedure: Intraoperative;  Special Focus: Neoplasia; B. Resection specimen measuring 5.4 cm. © Planckaert G, UZ Ghent, Ghent, Belgium Area of Interest: Musculoskeletal bone;  Imaging Technique: Experimental;  Procedure: Intraoperative;  Special Focus: Neoplasia; Figure 8 Post-operativePost-operative plain radiograph of the left thumb. The resection cavity is filled with methylacrylate bone cement. © De Backer A, Department of Radiology, AZ Sint-Lucas, Ghent, Belgium Area of Interest: Musculoskeletal bone;  Imaging Technique: Plain radiographic studies;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; References[1] Sobti A, Agrawal P, Agarwala S, Agarwal M (2016) Giant Cell Tumor of Bone - An OverviewThe Archives of Bone and Joint Surgery 4(1):2-9.[2] Matev B, Georgiev H, Georgiev G (2012) Giant cell tumor of the fourth metacarpal: case reportand literature review Journal ofRadiotherapy and Medical Oncology 18:73-77.[3] Jin AK, Park JS, Park SY, et al (2011) Aggressive Behavior of a Giant Cell Tumor Involvingthe Metacarpal Bone During Pregnancy: Case Report Journal of the Korean Radiological Society64(5):509-513.[4] Pereira HM, Marchiori E, Severo A (2014) Magnetic resonance imaging aspects of giant-celltumours of bone Journal of Medical Imaging and Radiation Oncology 58(6):674-8.[5] Chakarun CJ, Forrester DM, Gottsegen CJ, Patel DB Jr (2013) Giant cell tumor of bone: review,mimics, and new developments in treatment Radiographics 33(1):197-211.[6] Roy S, Mukherjee S, Mahata M, Datta J, Das TK (2016) Giant cell tumor in first metacarpalbone: A rare entity International Journal of Medical Science and Public Health 5:1049-1051.[7] McEnery KW, Raymond AK (1999) Giant cell tumor of the fourth metacarpal American Journalof Roentgenology 172(4):1092.CitationLucas Verniers (1), Adelard De Backer (2), Wim Vanhove (3), Gwen Sys (3), Filip Vanhoenacker(4, 5, 6)(1) Ghent University, Medical Student, Corneel Heymanslaan 10, 9000 Ghent, Belgium(2) General Hospital Sint-Lucas, Department of Radiology, Groenebriel 1, 9000 Ghent, Belgium(3) Ghent university, Department of Orthopaedics, Corneel Heymanslaan 10, 9000 Ghent, Belgium(4) AZ Sint-Maarten Duffel-Mechelen, Department of Radiology, Leopoldstraat 2, 2800 Mechelen,Belgium(5) Ghent University Hospital, Department of Radiology, Corneel Heymanslaan 10, 9000 Ghent,Belgium(6) Antwerp University Hospital, Department of Radiology, Wilrijkstraat 10, 2650 Edegem,BelgiumUZ Ghent; Corneel heymanslaan 10 9000 Ghent, Belgium; Email:lucas.verniers@ugent.be (2018,Jul. 4)  Aggressive Giant Cell tumour of the Metacarpal {Online}URL: http://www.eurorad.org/case.php?id=15826

Aggressive giant cell tumour of the metacarpal

Verniers, Lucas000110654465919027244674365A3680-F0EE-11E1-A9DE-61C894A0A6B4

Vanhove, WimUZGent001980113439801001072010972680820423FE2770E8-F0ED-11E1-A9DE-61C894A0A6B4

Sys, GwenGE38UZGent0019873036648010016640130000-0002-5308-7846F68679BA-F0ED-11E1-A9DE-61C894A0A6B4

Vanhoenacker, FilipGE328020010176270000-0002-7253-12013ACFE6BA-F0EE-11E1-A9DE-61C894A0A6B4

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Aggressive giant cell tumour of the metacarpal

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