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Giant cell tumor - Foot and Ankle

Summary

Giant cell tumor is a benign but locally aggressive tumor that can occur in any bone. This tumor is uncommon in the foot.

The incidence is highest in the third decade.
The typical patient has a history of gradually increasing pain. In the foot a mass may be apparent due to the limited soft tissues. Pain from pathological fracture or microfracture may cause the patient to seek treatment.
Plain radiographs show a lytic lesion without matrix mineralization in the characteristic location.
An "extended curettage" performed by mechanical currettage plus the application of adjuvant local treatment, such as liquid nitrogen, phenol, or a high speed burr.
Complete Information on this Tumor
Introduction and Definition: 

Giant cell tumor is a benign but locally aggressive tumor that can occur in any bone. This tumor is uncommon in the foot. The lesions are located in the metaphysis adjacent to the epiphysis or epiphyseal scar. For this reason, the lesions are located proximally in the first metatarsal (as shown here) and distally in the lesser metatarsals due to the location of the epiphysis. The tumor can cross joints and affect several ajdacent bones. In time, the cortex may be expanded and even destroyed. In smaller bones, the lesion can slowly expand the entire bone into a oversized balloon with cartilage on the end.

Giant cell tumor accounts for 5 to 9 percent of all primary bony tumors. Giant cell tumors are usually found in the long bones, most often the distal femur, proximal tibia, and distal radius. Giant cell tumor is a one of the most common primary bone lesions in the distal phalanx. Whether that tumor arises in the epiphysis or distal metaphysis is a matter of controversy, but giant cell tumors only occur after the epiphyseal plates have closed and a diagnosis of GCT in a patient with open growth plates should be questioned.

Giant cell tumor of bone is a benign lesion that is a usually solitary and locally aggressive. It is believed by some to be potentially malignant. In the very rare instances this lesion has the potential for metastasis to the lungs and in these cases the lung lesions may behave in an indolent fashioned and even require no treatment. The authors recommend a chest CT scan for all patients newly diagnosed with GCT.

Incidence and Demographics: 
The incidence is highest in the third decade.
Symptoms and Presentation: 

The typical patient has a history of gradually increasing pain. In the foot a mass may be apparent due to the limited soft tissues. Pain from pathological fracture or microfracture may cause the patient to seek treatment.

X-Ray Appearance and Advanced Imaging Findings: 
Plain radiographs show a lytic lesion without matrix mineralization in the characteristic location. The epicenter is in the metaphysis, and the tumor expands into the epiphysis until it reaches the subchondral bone, which seems to be a partial barrier to further growth.
Differential Diagnosis: 
In the foot, other lytic bone lesions that do not have a prominent matrix include chondromyxoid fibroma, lipoma of bone, unicameral bone cyst, and epithelioid hemangioma. Rare, but worth considering, are malignant lytic tumors like Ewing's sarcoma and lymphoma of bone. In older adults, metastatic lesions can present in the foot.
Preferred Biopsy Technique for this Tumor: 
open
Treatment Options for this Tumor: 
An "extended curettage" is performed by mechanical currettage plus the application of adjuvant local treatment, such as liquid nitrogen, phenol, or a high speed burr. In this way potential microscopic amounts of tumor tissue that may be present in the margins of the curetted cavity are eliminated, and the rate of local recurrence is reduced. After performing the "extended curettage", the cavity is filled with a suitable material, such as morcellized bone graft, bone graft substitute, or polymethylmethacrylate bone cement. Highly expansile primary lesions of the lesser bones of the foot may be excised and the bone may be reconstituted with a structural autograft from the iliac crest with excellent results. Lesions of the phalanges of smaller the lesser toes should be amputated.
Preferred Margin for this Tumor: 
intralesional is adequate for most lesions, expendable or replaceable bones can be excised with a marginal margin
Outcomes of Treatment and Prognosis: 
Local recurrence may be treated by repeat extended curettage, or if local control seems impossible, by wide excision and reconstruction with a bone graft. The heat of polymerization of the PMMA cement may help kill residual tumor cells and lower the rate of local recurrence. Treatment of giant cell tumors is by surgery only. Chemotherapy is not used. Intralesional excision by "extended" curettage is the treatment of choice. Curettage alone is associated with a high recurrence rate, and this can be decreased with the addition of chemical cautery using phenol, multiple freeze-thaw cycles using liquid nitrogen, and treating the walls of the cavity with a high-speed rotary burr. Local recurrence after curettage alone is thought to lead to recurrence in 50% of cases. Recurrence after extended curettage is approximately 10 percent. The tumor cavity may be filled with polymethyl methacrylate cement or bone graft, according to the surgeon's preference. Some believe that the polymethyl methacrylate cement lowers the risk of a local recurrence due to the large amount of heat given off during hardening. Recurrences are normally treated with a second interlesional surgery. Bone graft may allow for more favorable biomechanics of load inthe nearby joint. The early signs of local recurrence may be more difficult to detect in cases treated with bone graft. Lesions that are highly expansile and destructive, or lesions that occur in "expendable" bones such as the proximal fibula (as shown here) may be excised with a wide margin. Multiply recurrent giant cell tumors are also treated with wide resection.