Radiography
Findings
The most important radiographic findings of giant cell tumor are the location of the tumor, its lytic nature, and the lack of a host response.
Typically, giant cell tumors are expansile, osteolytic, radiolucent lesions without sclerotic margins and usually without a periosteal reaction. Septa may be seen in the lesion in 33-57% of patients (see Image below and Image 10 in Multimedia); these represent nonuniform growth of the tumor rather than true septa. The tumors are typically in the range of 5-7 cm in diameter when they are discovered.
Anteroposterior radiograph shows a septate lytic lesion in the subarticular location of the proximal femur. After curettage of the giant cell tumor, infection developed, and the insertion of antibiotic beads was required.
Most giant cell tumors (85%) occur in the long bones; approximately 50% are located in the bones around the knee. Location is important in the diagnosis of giant cell tumor. Most tumors are eccentric and are seen in a subarticular location (see Image below and Image 11 in Multimedia); however, the tumor originates in the metaphysis, and the common epiphyseal involvement is the result of the patient's skeletal maturity. Early lesions may lie solely in the metaphysis. A narrow zone of transition with a lack of sclerosis at its margins is a distinctive finding and strongly suggestive of the diagnosis. When sclerosis of the tumor margins is present, it is seldom complete. Periosteal reactions are not usually seen; the lack of a host-reactive response is typical of giant cell tumors.
Anteroposterior radiograph of the left wrist shows an expanded lytic lesion in the subarticular position of the distal ulna, which is typical for a giant cell tumor (see Image below).
Coronal CT scan of a giant cell tumor of the distal ulna (same patient as Image above). The radiographic findings showed an expanded subarticular lesion.
Giant cell tumors in the spine are uncommon and account for only 5% of giant cell tumors. The sacrum is the most common location. Patients with these tumors tend to be slightly younger than those with tumors in the appendicular skeleton. The location in the vertebrae can vary, but the tumor most commonly involves the vertebral body. On radiographs, the tumors may be seen in areas of destruction of the vertebral body with invasion of the posterior elements. The tumor can cause vertebral collapse and spinal cord compression, especially when it involves the posterior elements.
Degree of Confidence
The degree of confidence is high for radiography in the appendicular skeleton. In the spine, the degree of diagnostic confidence is not high, as giant cell tumors usually cannot be differentiated from other types of tumors. Tumors in the sacrum are recognizable, and these may be diagnosed on the basis of their appearance and location.
False Positives/Negatives
Unusual forms of certain tumors may mimic giant cell tumors.
Telangiectatic or fibrogenic variants of osteosarcoma may not produce visible ossifications or calcifications. These variants may be eccentric and may extend to the subarticular surface, mimicking a giant cell tumor.
Malignant fibrous histiocytomas occur in a similar age group and can also mimic a giant cell tumor.
Brown tumors of hyperparathyroidism are well known in the differential diagnosis of giant cell tumors.
Chondroblastomas may be mistaken for giant cell tumors because of their subarticular location; however, careful review of the radiographs usually reveals that the epicenter lies in the epiphysis rather than in the metaphysis. The presence of chondroid calcifications further supports the diagnosis of chondroblastoma.
Aneurysmal bone cysts may be only slightly expansile in the early stages, and they can extend to the subarticular cortex, mimicking a giant cell tumor. These cysts usually occur in younger patients. Approximately 29% of aneurysmal bone cysts are reported to be associated with some other solid bone lesion, 39% of which are giant cell tumors.
Computed Tomography
Findings
CT findings are similar to radiographic findings (see Images below and Image 12 in Multimedia) for giant cell tumor of bone.
Anteroposterior radiograph of the left wrist shows an expanded lytic lesion in the subarticular position of the distal ulna, which is typical for a giant cell tumor (see Image below).
Coronal CT scan of a giant cell tumor of the distal ulna (same patient as Image above). The radiographic findings showed an expanded subarticular lesion.
Marginal sclerosis, cortical destruction, and soft-tissue masses (see Image below and Image 13 in Multimedia) are seen more clearly on CT scans than on radiographs. Fluid-fluid levels are occasionally seen but are not specific.6
Coronal CT scan of the skull shows a giant cell tumor arising from the temporal bone. The large extraosseous component that extends into the middle cranial fossa is well visualized on images obtained by using a soft-tissue window.
Degree of Confidence
The degree of confidence is high when CT is used in conjunction with radiography. CT does not usually add much diagnostic information to the radiographic results. CT scans are more useful in complex-shaped bones, such as the vertebrae or pelvic bones, because the details of the lesion may not be depicted well on radiographs (see Images below and Images 14-16 in Multimedia). CT is also useful in surgical planning.
CT scan of the L3 vertebra shows a giant cell tumor causing the vertebral body to expand and extending into the spinal canal.
Axial CT scan of the skull base shows a giant cell tumor arising from the left temporal bone.
CT scan shows the full extent of a giant cell tumor in the left ilium. Septa are seen in the lesion.
Magnetic Resonance Imaging
Findings
On T1-weighted images, giant cell tumors may show heterogeneous or homogeneous signal intensity characteristics. The signal intensity is usually low or intermediate, but areas of high signal-intensity, caused by recent hemorrhage, may be noted.7
On T2-weighted images, heterogeneous low-to-intermediate signal intensity is seen in solid areas of the tumor (see Image below and Image 17 in Multimedia). Areas of low signal intensity may be exaggerated on T2-weighted spin-echo images, and these may be even more exaggerated on gradient-echo weighted images because of the presence of hemosiderin. Hemosiderin is detected in more than 63% of giant cell tumors, and its presence is probably the result of extravasated red blood cells coupled with the phagocytic function of the tumor cells.
T2-weighted coronal MRIs of the wrist show a giant cell tumor located in a subarticular position in the distal radius. The lesion is heterogeneous and hyperintense.
Cystic areas are common and are seen as areas of high signal intensity on T2-weighted images. Fluid-fluid levels may be seen (see Image below and Image 18 in Multimedia). Peritumoral edema is uncommon in the absence of a fracture. The tumor is usually heterogeneously enhancing with the intravenous administration of contrast material.
T2-weighted axial MRI of the knee shows multiple fluid-fluid levels in a giant cell tumor of the distal femur.
Degree of Confidence
The degree of confidence of MRI is high for imaging the appendicular skeleton. The MRI findings for giant cell tumors of the lower spine may overlap with those of other tumors, such as osteoblastoma, aneurysmal bone cyst, and metastasis.
MRI is sensitive for the detection of soft-tissue changes, intra-articular extension, and marrow changes. MRI is the best method for assessing subchondral breakthrough and the extension of tumor into an adjacent joint. Its diagnostic accuracy is high, especially when MRIs are interpreted in conjunction with plain radiographs.
False Positives/Negatives
In the spine, tumors such as osteoblastoma, aneurysmal bone cyst, and metastasis may be found in the same location as giant cell tumors, and they may have overlapping MRI characteristics.
Nuclear Imaging
Findings
Uptake in giant cell tumors is usually diffuse in all phases. The degree of uptake is not correlated with the grade of the tumor or the malignancy. Bone scanning is not usually required in the evaluation of a giant cell tumor, except for the rare case in which multicentric giant cell tumors are suspected.
Degree of Confidence
The degree of confidence is low with nuclear medicine studies. Giant cell tumors cannot be confidently differentiated from other tumors and diseases by using bone scans alone.
False Positives/Negatives
Tracer uptake is not specific for giant cell tumors.
Angiography
Findings
Angiography is not usually required in the evaluation of a giant cell tumor. Neovascularity is demonstrated in 80% of giant cell tumors, along with an intense, inhomogeneous capillary blush. Unfortunately, overlap in the angiographic features of malignant bone tumors, benign tumors, and nonneoplastic lesions precludes the use of angiography in making the differential diagnosis.
Although angiography can be used to assess the intraosseous and extraosseous extent of a tumor, which is useful in planning surgery, MRI has largely replaced angiography in surgical planning.
Preoperative embolization may be performed as a surgical adjunct to diminish bleeding and facilitate resection in highly vascular tumors. Complete removal of a tumor’s extraosseous component is mandatory to prevent local recurrence (see Image below and Image 19 in Multimedia), which may be difficult in a highly vascularized tumor.
Anteroposterior radiograph of the right humerus. A giant cell tumor located in the proximal humerus was treated with curettage and the cavity was filled with cement.
Surgery is usually performed soon after embolization, before collateral vessels form (see Image below and Image 20 in Multimedia). The arterial supply to a tumor can also be embolized in patients who are not candidates for surgery. In these patients, the aim is palliative pain relief.
Preembolization angiogram of the right lower limb (left) shows a hypervascular giant cell tumor located at the lateral aspect of the distal femur. After embolization of the feeder artery to the tumor, the image (right) shows markedly reduced tumor vascularity.
Degree of Confidence
Angiographic features are not diagnostic of giant cell tumor.
More on Giant Cell Tumor |
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 Imaging: Giant Cell Tumor |
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References
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Further Reading
Related eMedicine topics:
Giant Cell Tumor (Orthopedic Surgery)
Paget Sarcoma
Benign Skull Tumors
Skull Base Tumors
Bone Metastases
Keywords
giant cell tumor, osteoclastoma, multinucleated giant cells, Paget disease, aneurysmal bone cysts, osteoclastlike giant cells
