eMedicine Specialties > Orthopedic Surgery > Neoplasms

Giant Cell Tumor: Workup

Author: Valerae O Lewis, MD, Associate Professor, Chief, Section of Orthopedic Oncology, MD Anderson Cancer Center
Coauthor(s): Terrance Peabody, MD, Professor, Department of Surgery, Chief, Section of Orthopedic Surgery and Rehabilitative Medicine, University of Chicago; A Kevin Raymond, MD, Associate Professor, Department of Pathology, Section Head of Orthopedic Pathology, University of Texas MD Anderson Cancer Center
Contributor Information and Disclosures

Updated: Apr 2, 2009

Workup

Imaging Studies

  • Radiographically, these lesions are lucent and eccentrically located within the bone (see Image 2). GCTs can appear aggressive and are often characterized by extensive local bony destruction, cortical breakthrough, and soft-tissue expansion (see Image 3). When located in the epiphysis, GCTs generally extend to the articular surface (see Image 4). Although radiographs of GCTs demonstrate a narrow zone of transition, GCTs generally lack the dense peripheral sclerosis seen in nonossifying fibromas. Mineralization of the primary lesion is rare. However, when GCTs occur in the soft tissue (metastasis or local recurrence), peripheral calcifications are common (see Image 5).
Distribution of giant cell tumors according to ag...

Distribution of giant cell tumors according to age and sex of the patient. Six patients had multicentric disease.

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Distribution of giant cell tumors according to ag...

Distribution of giant cell tumors according to age and sex of the patient. Six patients had multicentric disease.


Giant cell tumor. Anteroposterior radiograph of t...

Giant cell tumor. Anteroposterior radiograph of the distal femur reveals an expansile lytic metaphyseal-epiphyseal lesion.

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Giant cell tumor. Anteroposterior radiograph of t...

Giant cell tumor. Anteroposterior radiograph of the distal femur reveals an expansile lytic metaphyseal-epiphyseal lesion.


Giant cell tumor. Lateral radiograph of the same ...

Giant cell tumor. Lateral radiograph of the same distal femur as in Image 2 in Multimedia reveals an expansile lytic metaphyseal-epiphyseal lesion.

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Giant cell tumor. Lateral radiograph of the same ...

Giant cell tumor. Lateral radiograph of the same distal femur as in Image 2 in Multimedia reveals an expansile lytic metaphyseal-epiphyseal lesion.


Giant cell tumor. Anteroposterior radiograph of t...

Giant cell tumor. Anteroposterior radiograph of the distal radius reveals an aggressive lesion characterized by extensive local bony destruction, cortical breakthrough and significant soft-tissue expansion.

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Giant cell tumor. Anteroposterior radiograph of t...

Giant cell tumor. Anteroposterior radiograph of the distal radius reveals an aggressive lesion characterized by extensive local bony destruction, cortical breakthrough and significant soft-tissue expansion.


Giant cell tumor. Lateral radiograph of the same ...

Giant cell tumor. Lateral radiograph of the same distal radius as in Image 4 in Multimedia reveals an aggressive lesion characterized by extensive local bony destruction, cortical breakthrough and significant soft-tissue expansion.

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Giant cell tumor. Lateral radiograph of the same ...

Giant cell tumor. Lateral radiograph of the same distal radius as in Image 4 in Multimedia reveals an aggressive lesion characterized by extensive local bony destruction, cortical breakthrough and significant soft-tissue expansion.

  • Campanacci et al proposed a grading system for GCTs that is based on the radiographic appearance of the tumors.34 The Campanacci grading system is similar to that proposed by Enneking for benign bone tumors.48
    • A grade 1 lesion (latent) has a well-defined margin and an intact cortex.
    • A grade 2 lesion (active) has a relatively well-defined margin but no radiopaque rim, and the cortex is thinned and moderately expanded.
    • A grade 3 lesion (aggressive) has indistinct borders and cortical destruction).3,34
    • No correlation exists between the grading systems and the incidence of local recurrence or metastases.
  • MRI often is performed to delineate the extent of the neoplasm.
    • In the typical GCT, the signal intensity is homogeneous, and the lesion is well circumscribed.
    • The lesions have low signal intensity on T1-weighted images and intermediate signal intensity on T2-weighted images (see Image 6).
  • CT scans of the lesion reveal an absence of bone and intralesional mineralization.

Histologic Findings

On gross inspection, these lesions are characteristically chocolate brown, soft, spongy, and friable. Yellowish-to-orange discoloration due to hemosiderin may be present. Cystic cavities within the tumor are common. Often, these cavities are blood filled (see Image 8). Examination of resected specimen reveals a variable degree of cortical expansion and disruption. Despite the cortical disruption, the periosteum remains intact (see Image 9).19

Giant cell tumor. Anteroposterior radiograph of t...

Giant cell tumor. Anteroposterior radiograph of the distal tibia demonstrates extension of the lesion to the articular surface.

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Giant cell tumor. Anteroposterior radiograph of t...

Giant cell tumor. Anteroposterior radiograph of the distal tibia demonstrates extension of the lesion to the articular surface.


Giant cell tumor. Lateral radiograph of the same ...

Giant cell tumor. Lateral radiograph of the same distal tibia as in Image 7 in Multimedia demonstrates extension of the lesion to the articular surface.

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Giant cell tumor. Lateral radiograph of the same ...

Giant cell tumor. Lateral radiograph of the same distal tibia as in Image 7 in Multimedia demonstrates extension of the lesion to the articular surface.


Histologically, the lesions tend to be cellular (see Image 10). Although the multinucleated giant cell is the characteristic cell type, these lesions have a background network of stromal mononuclear cells. The mononuclear cells are plump and round, oval, or spindle shaped. They may have prominent mitotic activity, but cellular atypia is rare (see Image 11). The degree of mitotic activity has no prognostic significance.

Multinucleated giant cells, as the name suggests, have numerous centrally located nuclei as opposed to the peripherally located nuclei of Langerhans -type giant cells seen in atypical infections (see Image 12). The nuclei tend to be compact and oval and contain prominent nucleoli. These are similar in appearance to those of the surrounding stromal cells, and the giant cell often appears to be a syncytium of these stromal cells.59,60

Giant cell tumor. Sagittal MRI of the same distal...

Giant cell tumor. Sagittal MRI of the same distal tibia as in Images 7-8 in Multimedia demonstrates extension of the lesion to the articular surface.

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Giant cell tumor. Sagittal MRI of the same distal...

Giant cell tumor. Sagittal MRI of the same distal tibia as in Images 7-8 in Multimedia demonstrates extension of the lesion to the articular surface.


Anteroposterior radiograph of a wrist arthrodesis...

Anteroposterior radiograph of a wrist arthrodesis performed for a giant cell tumor. Soft tissue recurrence is present. Note the peripheral mineralization about the soft-tissue recurrence (arrow).

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Anteroposterior radiograph of a wrist arthrodesis...

Anteroposterior radiograph of a wrist arthrodesis performed for a giant cell tumor. Soft tissue recurrence is present. Note the peripheral mineralization about the soft-tissue recurrence (arrow).


Giant cells generally are distributed throughout the lesion. The concentration of multinucleated giant cells varies considerably from tumor to tumor. Some tumors have many multinucleated giant cells, whereas others have a few giant cells nestled in swirls of spindle-shaped stromal cells (see Image 13). The concentration of multinucleated giant cells is not related to the incidence of local recurrence or metastases. In some lesions, giant cells invade the small perforating vessels (see Image 14). This intravascular invasion can be found in approximately 5% of cases. This invasion, although appearing aggressive, is not correlated with the prognosis.26

Sagittal T1-weighted MRI shows a giant cell tumor...

Sagittal T1-weighted MRI shows a giant cell tumor with low signal intensity.

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Sagittal T1-weighted MRI shows a giant cell tumor...

Sagittal T1-weighted MRI shows a giant cell tumor with low signal intensity.


Giant cell tumor. CT scan of the distal femur rev...

Giant cell tumor. CT scan of the distal femur reveals an absence of matrix within the lesion.

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Giant cell tumor. CT scan of the distal femur rev...

Giant cell tumor. CT scan of the distal femur reveals an absence of matrix within the lesion.


At histologic analysis, the differential diagnosis includes brown tumors of
hyperparathyroidism; aneurysmal bone cysts; and, rarely, chondroblastoma,
osteoblastoma, or osteosarcoma.

In an attempt to relate the histologic features with the clinical course, several histologic grading systems have been developed. The earliest was devised by Jaffe et al in 1940. In grade I at the benign end of the spectrum, giant cells are numerous, mononuclear cells are rare, and mitotic activity is absent. In grade II, mononuclear stromal cells are numerous, and moderate atypia and mitotic activity is seen. In grade III, giant cells are few and small, atypia and pleomorphism are common, and mitotic activity is frequent.

However, this grading system has no prognostic significance.3,61,9,62 In an attempt to improve the prognostic relevance of the histologic grading system, several authors have modified the staging system of Jaffe et al.26 Generally, these staging systems include sarcomatous lesions as grade III lesions. Unfortunately, these modified systems, like that of Jaffe et al, are of little value in predicting patient outcomes.

More on Giant Cell Tumor

Overview: Giant Cell Tumor
Workup: Giant Cell Tumor
Treatment: Giant Cell Tumor
Follow-up: Giant Cell Tumor
Multimedia: Giant Cell Tumor
References
Further Reading
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Keywords

giant cell tumor, GCT, bone tumor, benign bone tumor, giant cell tumor of bone, osteoclastoma, bone grafting, intralesional curettage

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Contributor Information and Disclosures

Author

Valerae O Lewis, MD, Associate Professor, Chief, Section of Orthopedic Oncology, MD Anderson Cancer Center
Valerae O Lewis, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: AAOS NOW None Editorial Board; WOA None Board of Directors - Treasurer; Stryker Inc. Grant/research funds None

Coauthor(s)

Terrance Peabody, MD, Professor, Department of Surgery, Chief, Section of Orthopedic Surgery and Rehabilitative Medicine, University of Chicago
Terrance Peabody, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, and Phi Beta Kappa
Disclosure: Nothing to disclose.

A Kevin Raymond, MD, Associate Professor, Department of Pathology, Section Head of Orthopedic Pathology, University of Texas MD Anderson Cancer Center
Disclosure: Eli Lilly  Consulting fee I am a member of an a advisory board.; Novartis Honoraria Speaking and teaching

Medical Editor

Lynn A Crosby, MD, FACS, Chief of Shoulder Division, Professor, Department of Orthopedic Surgery, Wright State University School of Medicine
Lynn A Crosby, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American College of Surgeons, American Fracture Association, American Medical Association, American Medical Tennis Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Arthroscopy Association of North America, Mid-America Orthopaedic Association, and Orthopaedic Research Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Sean P Scully, MD, PhD, Professor, Department of Orthopedics, University of Miami
Sean P Scully, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, International Society on Thrombosis and Haemostasis, and Society of Surgical Oncology
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
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