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Giant Cell Tumor Imaging

  • Author: Wilfred CG Peh, MD, MHSc, MBBS, FRCP(Glasg), FRCP(Edin), FRCR; Chief Editor: Felix S Chew, MD, MBA, MEd  more...
 
Updated: Dec 02, 2015
 

Overview

Giant cell tumor of the bone is a relatively uncommon tumor that is characterized by the presence of multinucleated giant cells. This type of tumor is usually regarded as benign. In most patients, giant cell tumors have an indolent course, but they can recur locally in as many as 50% of cases. Metastasis to the lungs may occur. The radiologic features of giant cell tumors are demonstrated in the images below.

Lateral radiograph of the L3 vertebra shows a gian Lateral radiograph of the L3 vertebra shows a giant cell tumor as a lytic lesion in the vertebral body, with expansion of the bone and internal septa.
CT scan of the abdomen shows an expanding mass tha CT scan of the abdomen shows an expanding mass that arose from one of the left ribs. The histologic findings indicated that the mass was a giant cell tumor.

Cooper first reported giant cell tumors in the 18th century; in 1940, Jaffe and Lichtenstein defined giant cell tumor more strictly to distinguish it from other tumors. Giant cell tumors usually occur de novo but may also occur as a rare complication of Paget disease of the bone.[1, 2]

Most giant cell tumors occur in the long bones (see the images below), and almost all are located at the articular end of the bone. Metaphyseal involvement may occur in skeletally immature patients. Common sites include the proximal tibia, distal femur, distal radius, and proximal humerus, although giant cell tumors have also been reported to occur in the pubic bone, calcaneus, and feet.

Anteroposterior radiograph shows a septate lytic l 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.
Anteroposterior radiograph of the left wrist shows 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.

Giant cell tumors may also occur in the vertebrae (as seen in the image below). Giant cell tumors are 3-4 times as common in the sacrum as they are in the rest of the spine. Sacral tumors may be so extensive that they involve the entire sacrum. Rarely, the tumor may extend across the sacroiliac joint to involve the adjacent ilium or may extend across the L5-S1 disk to involve the posterior elements of the L5 vertebra.

CT scan of the L3 vertebra shows a giant cell tumo CT scan of the L3 vertebra shows a giant cell tumor causing the vertebral body to expand and extending into the spinal canal.

The location of giant cell tumors within the spine can vary, and the most commonly involved areas are the vertebral body and the vertebral arch. Rarely, giant cell tumors develop in the ribs, as the CT (computed tomography) scan below demonstrates.

CT scan of the abdomen shows an expanding mass tha CT scan of the abdomen shows an expanding mass that arose from one of the left ribs. The histologic findings indicated that the mass was a giant cell tumor.

Giant cell tumors typically occur in adults aged 20-40 years. Patients often complain of pain and swelling at the affected site. Pathologic fracture (seen in the images below) is present in 10% of patients.

Anteroposterior radiograph of the right shoulder s Anteroposterior radiograph of the right shoulder shows a pathologic fracture through a giant cell tumor in the proximal humerus. The tumor involves both the epiphysis and the metaphysis.
Anteroposterior radiograph of the knee shows a pat Anteroposterior radiograph of the knee shows a pathologic fracture through a giant cell tumor in the distal femur. The tumor extends to the subarticular surface of the femur.

Vertebral giant cell tumors may extend into the spinal canal and compress the spinal cord, resulting in neurologic symptoms. Giant cell tumors are rarely multicentric. This condition should be considered when patients present with giant cell tumors in the hands, because the incidence of tumors in the small bones of the hand and sacrum is increased. Multicentric tumors are seen below.[3, 4, 5, 6, 7, 8]

Anteroposterior radiograph of the pelvis shows mul Anteroposterior radiograph of the pelvis shows multicentric giant cell tumors. Giant cell tumors are demonstrated in the left ilium and in the greater trochanter of the left femur.

Preferred examination

The radiographic appearance of giant cell tumors is often characteristic. Magnetic resonance imaging (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 extension of tumor into an adjacent joint. The diagnostic accuracy of MRI is high, especially when MRIs are interpreted in conjunction with plain radiographs. CT scans and bone scans are usually less useful than are other examinations.[6, 7, 9, 10, 11, 12]

On radiographs, typical giant cell tumors are usually easily distinguished from other bone tumors. Giant cell tumors are lytic, subarticular, and eccentric, and they are often lacking a sclerotic rim; however, unusual variants may make the radiographic diagnosis difficult.

The disadvantages of MRI are its relatively high cost and limited availability. In addition, some patients experience claustrophobia during the examination and may require sedation. MRI is also contraindicated in patients with cardiac pacemakers, orbital foreign bodies, and noncompatible aneurysmal clips.

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Radiography

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, found in the image below, may be seen in the lesion in 33-57% of patients; 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.[9]

Anteroposterior radiograph shows a septate lytic l 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 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 the first 2 images below); however, the tumor originates in the metaphysis, and the common epiphyseal involvement is the result of the patient's skeletal maturity (see the third image below).

Anteroposterior radiograph of the knee shows a pat Anteroposterior radiograph of the knee shows a pathologic fracture through a giant cell tumor in the distal femur. The tumor extends to the subarticular surface of the femur.
Anteroposterior radiograph of the left wrist shows 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.
Anteroposterior radiograph of the right shoulder s Anteroposterior radiograph of the right shoulder shows a pathologic fracture through a giant cell tumor in the proximal humerus. The tumor involves both the epiphysis and the metaphysis.

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.

Giant cell tumors in the spine (seen below) 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.

Lateral radiograph of the L3 vertebra shows a gian Lateral radiograph of the L3 vertebra shows a giant cell tumor as a lytic lesion in the vertebral body, with expansion of the bone and internal septa.

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.[13]

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.

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Computed Tomography

CT findings are similar to radiographic findings for giant cell tumor of bone. The CT-scan characteristics of giant cell tumors are demonstrated in the images below.

CT scan of the abdomen shows an expanding mass tha CT scan of the abdomen shows an expanding mass that arose from one of the left ribs. The histologic findings indicated that the mass was a giant cell tumor.
Coronal CT scan of a giant cell tumor of the dista Coronal CT scan of a giant cell tumor of the distal ulna. The radiographic findings showed an expanded subarticular lesion.
Coronal CT scan of the skull shows a giant cell tu 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.
CT scan of the L3 vertebra shows a giant cell tumo 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 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 tumo CT scan shows the full extent of a giant cell tumor in the left ilium. Septa are seen in the lesion.

Marginal sclerosis, cortical destruction, and soft-tissue masses are seen more clearly on CT scans than on radiographs. Fluid-fluid levels are occasionally seen but are not specific.[14]

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. CT is also useful in surgical planning.

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Magnetic Resonance Imaging

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.

On T2-weighted images, heterogeneous low to intermediate signal intensity is seen in solid areas of the tumor (see the image below). 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.[15]

T2-weighted coronal MRIs of the wrist show a giant 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, as in the image below. 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 f 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 in imaging the appendicular skeleton is high for MRI. The modality is sensitive in 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 osteoblastomas and aneurysmal bone cysts, as well as metastases, may be found in the same location as giant cell tumors, and they may have overlapping MRI characteristics.

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Nuclear Imaging

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.[10, 13]

The degree of confidence is low for nuclear medicine studies. Giant cell tumors cannot be confidently differentiated from other tumors and diseases by using bone scans alone.[16]

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Angiography

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.

Preembolization angiogram of the right lower limb 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.

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 it in surgical planning.

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Contributor Information and Disclosures
Author

Wilfred CG Peh, MD, MHSc, MBBS, FRCP(Glasg), FRCP(Edin), FRCR Clinical Professor, Yong Loo Lin School of Medicine, National University of Singapore; Senior Consultant and Head, Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Alexandra Health, Singapore

Wilfred CG Peh, MD, MHSc, MBBS, FRCP(Glasg), FRCP(Edin), FRCR is a member of the following medical societies: American Roentgen Ray Society, British Institute of Radiology, International Skeletal Society, Radiological Society of North America, Royal College of Physicians, Royal College of Radiologists

Disclosure: Nothing to disclose.

Coauthor(s)

Tony WH Shek, MBBS FRCPA, FHKCPath, FHKAM, Honorary Clinical Assistant Professor, Department of Pathology, University of Hong Kong

Disclosure: Nothing to disclose.

Specialty Editor Board

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Murali Sundaram, MBBS FRCR, FACR, Professor of Radiology and Consulting Staff, Cleveland Clinic Lerner College of Medicine of CWRU

Murali Sundaram, MBBS is a member of the following medical societies: American College of Radiology, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, International Skeletal Society, Radiological Society of North America, Society of Skeletal Radiology

Disclosure: Nothing to disclose.

Chief Editor

Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, Vice Chairman for Academic Innovation, Section Head of Musculoskeletal Radiology, University of Washington School of Medicine

Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Additional Contributors

Giuseppe Guglielmi, MD Associate Professor of Radiology, Department of Radiology, Scientific Institute Hospital

Disclosure: Nothing to disclose.

Acknowledgements

Lesley-Ann Goh, MBBS, FRCR Consultant, Department of Diagnostic Radiology, National University Hospital

Disclosure: Nothing to disclose.

References
  1. Gebhart M, Vandeweyer E, Nemec E. Paget''s disease of bone complicated by giant cell tumor. Clin Orthop. 1998 Jul. (352):187-93. [Medline].

  2. Hoch B, Hermann G, Klein MJ, Abdelwahab IF, Springfield D. Giant cell tumor complicating Paget disease of long bone. Skeletal Radiol. 2007 Apr 14. [Epub ahead of print]. [Medline].

  3. Swanger R, Maldjian C, Murali R, Tenner M. Three cases of benign giant cell tumor with unusual imaging features. Clin Imaging. 2008 Sep-Oct. 32(5):407-10. [Medline].

  4. Salerno M, Avnet S, Alberghini M, Giunti A, Baldini N. Histogenetic characterization of giant cell tumor of bone. Clin Orthop Relat Res. 2008 Sep. 466(9):2081-91. [Medline].

  5. Balke M, Ahrens H, Streitbuerger A, Koehler G, Winkelmann W, Gosheger G, et al. Treatment options for recurrent giant cell tumors of bone. J Cancer Res Clin Oncol. 2009 Jan. 135(1):149-58. [Medline].

  6. Wang CS, Yin QH, Liao JS, Lou JH, Ding XY, Zhu YB. Giant cell-rich osteosarcoma in long bones: clinical, radiological and pathological features. Radiol Med. 2013 May 28. [Medline].

  7. Zhang Y, Reeve IP, Lewis DH. A case of giant cell tumor of sacrum with unusual pulmonary metastases: CT and FDG PET findings. Clin Nucl Med. 2012 Sep. 37(9):920-1. [Medline].

  8. Wang CS, Lou JH, Liao JS, Ding XY, Du LJ, Lu Y, et al. Recurrence in giant cell tumour of bone: imaging features and risk factors. Radiol Med. 2013 Apr. 118(3):456-64. [Medline].

  9. Shi LS, Li YQ, Wu WJ, Zhang ZK, Gao F, Latif M. Imaging appearance of giant cell tumour of the spine above the sacrum. Br J Radiol. 2015 Jul. 88 (1051):20140566. [Medline].

  10. O'Connor W, Quintana M, Smith S, Willis M, Renner J. The hypermetabolic giant: 18F-FDG avid giant cell tumor identified on PET-CT. J Radiol Case Rep. 2014 Jun. 8 (6):27-38. [Medline].

  11. Adriaensen ME, Zonnenberg BA, de Jong PA. Natural history and CT scan follow-up of subependymal giant cell tumors in tuberous sclerosis complex patients. J Clin Neurosci. 2014 Jun. 21 (6):939-41. [Medline].

  12. Prasad SC, Piccirillo E, Nuseir A, Sequino G, De Donato G, Paties CT, et al. Giant cell tumors of the skull base: case series and current concepts. Audiol Neurootol. 2014. 19 (1):12-21. [Medline].

  13. Gedik GK, Ata O, Karabagli P, Sari O. Differential diagnosis between secondary and tertiary hyperparathyroidism in a case of a giant-cell and brown tumor containing mass. Findings by (99m)Tc-MDP, (18)F-FDG PET/CT and (99m)Tc-MIBI scans. Hell J Nucl Med. 2014 Sep-Dec. 17 (3):214-7. [Medline].

  14. Lanza A, Laino L, Rossiello L, Perillo L, Ermo AD, Cirillo N. Clinical Practice: Giant Cell Tumour of the Jaw Mimicking Bone Malignancy on Three-Dimensional Computed Tomography (3D CT) Reconstruction. Open Dent J. 2008. 2:73-7. [Medline].

  15. Aoki J, Tanikawa H, Ishii K, et al. MR findings indicative of hemosiderin in giant-cell tumor of bone: frequency, cause, and diagnostic significance. AJR Am J Roentgenol. 1996 Jan. 166(1):145-8. [Medline].

  16. Hoshi M, Takada J, Oebisu N, Hata K, Ieguchi M, Nakamura H. Overexpression of hexokinase-2 in giant cell tumor of bone is associated with false positive in bone tumor on FDG-PET/CT. Arch Orthop Trauma Surg. 2012 Nov. 132(11):1561-8. [Medline].

 
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Lateral radiograph of the L3 vertebra shows a giant cell tumor as a lytic lesion in the vertebral body, with expansion of the bone and internal septa.
Anteroposterior radiograph of the right shoulder shows a pathologic fracture through a giant cell tumor in the proximal humerus. The tumor involves both the epiphysis and the metaphysis.
CT scan of the abdomen shows an expanding mass that arose from one of the left ribs. The histologic findings indicated that the mass was a giant cell tumor.
Anteroposterior radiograph of the knee shows a pathologic fracture through a giant cell tumor in the distal femur. The tumor extends to the subarticular surface of the femur.
Anteroposterior radiograph of the pelvis shows multicentric giant cell tumors. Giant cell tumors are demonstrated in the left ilium and in the greater trochanter of the left femur.
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.
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.
Coronal CT scan of a giant cell tumor of the distal ulna. The radiographic findings showed an expanded subarticular lesion.
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.
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.
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.
T2-weighted axial MRI of the knee shows multiple fluid-fluid levels in a giant cell tumor of the distal femur.
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.
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.
Gross appearance of a giant cell tumor in the distal radius. The tumor has a predominance of foam cells, which cause the bright-yellow color.
Typical histologic appearance of giant cell tumor of the bone. Note the uniform distribution of osteoclastlike giant cells in a background of mononuclear cells (stained with hematoxylin and eosin, original magnification X80).
Foci of aneurysmal bone cyst areas are common in giant cell tumors (stained with hematoxylin and eosin, original magnification X80).
Giant cell tumor metastasis to the lung (stained with hematoxylin and eosin, original magnification X20).
 
 
 
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