Summary: A 28-year-old white woman fell from a step and landed on an outstretched
hand. She presented with persistent pain and swelling over her left
ring ﬁnger metacarpophalangeal joint.
Giant cell tumor of the left ring ﬁnger metacarpal bone
Radiography of the left hand revealed a lytic expansile epiphyseal
lesion in the head of the ring ﬁnger metacarpal bone. The lesion caused
cortical destruction and tiny septations with poorly visualized matrix.
There was associated widening of the third and forth meta carpal spaces, which suggested a soft tissue component (Figure 1).
resonance imaging (MRI) showed a subarticular expansile lesion in the
head of the ring ﬁnger metacarpal bone. On T1-weighted imaging, the
lesion exhibited a inhomogeneous low signal intensity lesion. On short
tau inversion recovery imaging, it had inhomogeneous high signal
intensity. There was cortical destruction with soft tissue invasion that
almost touched the middle ﬁnger metacarpal bone (Figure 2, A and B).
The middle ﬁnger metacarpal bone showed the normal contour and signal.
The extensor tendons were effaced and exhibited the normal signal,
surrounded with the abnormal bright signal that involved subcutaneous
fat. The overlying skin was normal. On the palmar side there was a tiny
normal soft tissue plane between the ﬂexor tendons and the expansile
process. The ﬂexor tendons were normal. The subcutaneous fat on this
image appeared normal. The mass on the ulnar side touched the little
ﬁnger metacarpal bone, which had normal contour and signal (Figure 2C). A
whole-body bone scan and spot ﬁlms of the hands showed a single lesion
in the skeleton located in the left hand (Figure 3).
Microscopic examination showed a tumor composed of numerous multi-nucleated giant cells admixed with the mononucleated stromal cells. The
mono nucleated stromal cells were oval-shaped and lacked atypia, and
their nuclei displayed features similar to those present within the
giant cells (Figure 4).
Giant cell tumors comprise 4% to 5% of primary bone tumors and 18.2%
of benign bone tumors. They usually occur in the 20- to 40-year-old age
group (60% to 70% of tumors), although they may appear in older patients
and in younger patients who have not yet ceased growing. The frequency
of giant cell tumors is greater in women than in men. Giant cell tumors
predominate in the long tubular bones (75% to 90% of cases). The distal
portions of the femur, radius, and the proximal portion of the tibia are
the most characteristic sites of involvement (approximately 50% of
cases). Approximately 5% of giant cell tumors localize in the small
bones of the hands or feet; more commonly, they are found in the hands.
Although usually benign, 5% to 10% of these tumors are malignant. As in
this case, 10% of patients have a pathological fracture. The
predominant clinical features are nonspeciﬁc and include local swelling,
warmth, and radiating pain.1 The symptoms may go on for
months before becoming severe enough to demand clinical attention. Acute
onset of pain is frequently associated with fractures, bringing the
tumor to clinical attention.2
The pathology involves a
predominance of giant cells, although this is not speciﬁc for the
diagnosis. They are among mononuclear stromal cells, and fusion of the
mononuclear cells leads to formation of the giant cells. They both have
similar-appearing nuclei, a feature that aids in excluding other
diagnoses.2 There is eosinophilic, granular cytoplasm
surrounding the regularly outlined nuclei. Rarely are mitotic ﬁgures
found within the giant cells. There may be bands of ﬁbrous tissue that
have no giant cells present or osteoid foci within a fracture callus. Up
to 40% of giant cell tumors show evidence of vascular invasion, a
feature that is present in our case.3
The ﬁrst step in
evaluation involves plain radiographs, on which there is a
characteristic appearance. An eccentric, osteolytic lesion that is
sub-articular in location is often seen. Giant cell tumors commonly
appear radiolucent and do not show periosteal reaction.1 If
the tumor is complicated by a fracture, there may be reactive bone
formation. Some tumors may show areas of infarct or intravascular tumor
emboli. Septa sometimes are seen and are caused by uneven tumor growth.
Variation in appearance warrants more in-depth examination. A computed
tomography (CT) scan shows ﬁndings similar to those seen on plain ﬁlms
and often does not reveal additional information. MRI has a high
diagnostic accuracy, especially if correlated with ﬁndings from X-ray
and/or CT scanning.4 MR images can display the intraosseous,
intra-articular, and soft tissue extension of the tumor. Typically,
there is a large encapsulated soft tissue mass with low-to-intermediate
signals on T1-weighted images. A T2-weighted image exhibits a homogeneous
enhancement of medium-to-high intensity signal. Findings will depend on
the amount of cystic, necrotic, or hemorrhagic material present. There
may be inhomogeneous signal intensity or a poorly outlined tumor when
this content is found.5
Deﬁnitive diagnosis is made
with a biopsy. A patient who has a giant cell tumor should undergo a
whole-body bone scan because 40% of patients will have giant cell tumors
in other areas of the body. The differential diagnosis includes an
eurysmal bone cysts, chondroblastoma, chondromyxoid ﬁbroma, giant cell
reparative granuloma, nonossifying ﬁbroma, Langerhans’ cell
histiocytosis, synovial sarcoma, and high-grade central osteosarcoma.
These lesions have similar radiographic appearances.3,5
treatment of choice for most giant cell tumors is intralesional
“extended” curettage. Curettage alone is associated with recurrence in
almost 50% of cases. To avoid recurrence, physicians have added adjuvant
treatments such as liquid nitrogen, phenol, and high-speed burring.6 One study showed that the use of bisphosphonates may help reduce recurrence.7 After
tumor removal, the space can be ﬁlled with polymethylmethacrylate
cement or bone graft. Using cement with curettage allows weight-bearing
quickly, but a recurrence can easily develop around the cement. Bone
grafts may provide better movement and use of the joint area.6 In
small bones, giant cell tumors tend to show a permeative growth
pattern. This feature makes a complete evacuation of the tumor difﬁcult
using only curettage. An en bloc resection with a bone graft has been
recommended. When giant cell tumors recur and are benign, it usually is
not fatal. With recurrence, it is imperative to do a detailed curettage
with adjuvant therapy or joint-sparing surgery, if possible. With any
giant cell tumor, follow-up on a regular basis is necessary.1
Giant cell tumors are relatively common bone tumors that are usually
seen at the end of long bones in patients ≤40 years of age. They usually
have grown to a large size upon discovery. They often show no host
immune response and no matrix. Our case presents giant cell tumor in a
rare location with internal trabeculation and aggressive features in a
patient with a history of trauma. A healing pathologic fracture through
an enchondroma or aneurysmal bone cyst can have a similar radiographic
appearance and create diagnostic uncertainty. An additional
consideration in this case would include the malignant alteration of
enchondroma to chondrosarcoma, but this has not been reported in this
location to our knowledge. Particular attention should be made to
patients with fractures because this is a common presentation for giant
cell tumors. It is important to evaluate both the clinical and
radiologic ﬁndings, and proceed with a biopsy. As with this case,
treatment is appropriate removal of the tumor. Recurrent tumor is always
of concern and can be reduced by certain techniques.7
- Szendröi M. Giant-cell tumor of bone. J Bone Joint Surg Br. 2004; 86:5-12.
Murphey MD, Nomikos GC, Flemming DJ, et al. From the archives of AFIP.
Imaging of giant cell tumor and giant cell reparative granuloma of bone:
Radiologic-pathologic correlation.RadioGraphics. 2001;21:1283-1309.
- Manaster BJ, Doyle AJ. Giant cell tumors of bone. Radiol Clin North Am. 1993;31:299-323.
- Biscaglia R, Bacchini P, Bertoni F. Giant cell tumor of the bones of the hand and foot. Cancer. 2000; 88: 2022-2032.
Resnick D, Kyriakos M, Greenway G. Tumors and tumor-like lesions of
bone: Imaging and pathology of speciﬁc lesionsIn: Resnick D, ed. Diagnosis of Bone and Joint Disorders. 4th ed. Philadelphia, PA: Saunders; 2002:3939-3962.
DeGroot H. Giant cell tumor of bone. Available on line:
www.bonetumor.org/tumors/pages/page106.html.PostedApril 6, 2003.
Accessed August 2005.
- Chang SS, Suratwala SJ, Jung KM, et al. Bisphosphonates may reduce recurrence in giant cell tumor by inducing apoptosis. Clin Orthop Relat Res. 2004;426:103-109.