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Giant cell tumor of the fourth metacarpal bone
Journal of Clinical Imaging 24 (2000) 139 ± 142
Giant cell tumor of the fourth metacarpal bone GoÈkhan Arslana,*, Kamil Karaalia, Metin CËubuka, Tekinalp Gelenb, Ersin LuÈlecia a
Faculty of Medicine, Department of Radiology, Akdeniz University School of Medicine, Arapsuyu, Antalya 07070, Turkey b Faculty of Medicine, Department of Pathology, Akdeniz University, Antalya 07070, Turkey Received 20 March 2000; accepted 30 May 2000
Abstract Giant cell tumor is among the rare tumors of the bone. We present a case of metacarpal giant cell tumor with radiographic, computed tomographic (CT) and histologic findings, as well as grey scale and Doppler sonographic features. We also present the ``doughnut''-shaped appearance on scintigraphy of the lesion, which has not been shown on a metacarpal giant cell tumor. D 2000 Elsevier Science Inc. All rights reserved. Keywords: Giant cell tumor; Metacarpal; Radiography; Ultrasound; Doppler study; Computed tomography
1. Introduction Giant cell tumors are among the rare tumors of the bone. Their incidence has been reported as approximately 5% of all bone neoplasms [1]. Their usual locations include the ends of long bones (70%), pelvis and spine, especially the sacrum [2]. Involvement of the hand bones is very rare and its incidence has been reported as between 2% and 5% of all giant cell tumors [2,3]. We present a case of metacarpal giant cell tumor with radiographic, grey scale and Doppler sonographic, computed tomographic (CT), scintigraphic, and histologic features. 2. Case report A 60-year-old woman presented with increasing swelling and mild pain in her fourth metacarpal of the left hand for 4 months. Radiography showed an expansile and lytic lesion of the fourth metacarpal, which was located within the middle and distal portions of the bone (Fig. 1). Cortical destruction was also present and it was more apparent on the ulnar side of the bone. On sonographic examination with a 7.5-MHz linear probe, the lesion was a homogenous hypoe* Corresponding author. Tel.: +90-242-227-4343 ext. 35110; fax: +90242-227-4325. E-mail addresses: [email protected], [email protected] (G. Arslan).
choic structure with posterior acoustic enhancement and the bone cortex was seen as a thin echogenic boundary (Fig. 2). On color Doppler sonography, vascular structures were demonstrated mainly at the periphery of the lesion and flow spectrums of the vessels showed low-resistance arterial patterns (Fig. 3a, b). CT revealed an expansile lesion and marked cortical thinning (Fig. 4a). The lesion showed homogenous contrast enhancement and there was no soft tissue involvement (Fig. 4b). On scintigraphic examination, increased uptake was seen. The activity of the lesion was greater at the periphery than at the center (scintigraphic ``doughnut sign''). There was no increased activity in the other bones of the hand (Fig. 5). Posteroanteior chest radiograph and all the laboratory tests, including serum calcium and phosphorus levels, were normal. The lesion was treated with curettage. Histologic examination showed multiple osteoclast-like giant cells within a stroma composed of bland mononuclear cells (Fig. 6). These histologic findings were consistent with giant cell tumor. The patient was followed up for 14 months and there was no symptom or finding suggesting recurrence. 3. Discussion Most giant cell tumors occur in the third and fourth decades of life [2]. The patients usually present with swelling and pain, as in our case. Cortical thinning may lead to pathologic fractures and this may be the initial
0899-7071/00/$ ± see front matter D 2000 Elsevier Science Inc. All rights reserved. PII: S 0 8 9 9 - 7 0 7 1 ( 0 0 ) 0 0 1 8 5 - 6
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G. Arslan et al. / Journal of Clinical Imaging 24 (2000) 139±142
Fig. 3. (A) Color Doppler sonography shows vascular signals mainly from the periphery of the lesion. (B) Doppler flow spectra of the vessels show low-resistance arterial pattern. Fig. 1. Radiography of the left hand shows an expansile and lytic lesion within the fourth metacarpal, located within the middle and distal portions of the bone.
presentation [3]. Giant cell tumors are most commonly located in the epiphysis, extending from the metaphysis.
Fig. 2. Sonographic examination shows a homogenous hypoechoic structure with posterior acoustic enhancement and the bone cortex is seen as a thin echogenic boundary.
Hand involvement is rare and is seen in approximately 2± 5% of all cases [2,3]. In our patient, the lesion was within the fourth metacarpal of the left hand. It appeared as an expansile, lytic lesion on radiograph, which is considered to be typical, but not specific, for giant cell tumors [2,4]. Periost reaction is usually absent in giant cell tumors and it was not present in our case. The radiologic hallmark of this lesion is that it abuts the subchondral bone plate of the adjacent joint [4]. In our case, the subchondral bone near the proximal interphalangeal joint was involved, especially on the ulnar side (Fig. 1). The radiologic differential diagnosis for such lesion includes aneurysmal bone cysts, benign chondroblastoma, non-osteogenic fibroma, hyperparathyroidism, and simple bone cyst [5]. CT can determine the intra- and extraosseous extent of the lesion, and cortical structures are evaluated better than plain films [4]. CT remains superior to magnetic resonance imaging (MRI) in defining thin cortical shells or invasion of the cortex by tumor [6]. Soft tissue involvement can be evaluated in contrast-enhanced scans. In our case, cortical thinning, expansion of the lesion, diffuse enhancement, and absence of soft tissue involvement were demonstrated well with CT. The advantage of MRI over CT is its
G. Arslan et al. / Journal of Clinical Imaging 24 (2000) 139±142
141
Fig. 4. (A) Bone window CT section reveals an expansile lesion and marked cortical thinning. (B) On contrast-enhanced CT, the lesion shows homogenous contrast enhancement and there is no soft tissue involvement.
multiplanar imaging capability and better demonstration of intra-articular extension [6]. We could not perform MRI since it was not available in our institution at the time the patient presented. Giant cell tumors are hypervascular lesions, showing in the majority of the cases with increased uptake on scintigraphy [7]. Scintigraphic evaluation is especially important for the giant cell tumors involving the hand bones because it has been reported that patients with a primary giant cell tumor of the bones of the carpis or hand have an 18% incidence of multicentric disease [4]. In such cases, bone scintigraphy is of value in identifying other sites of skeletal abnormality. In giant cell tumors, uptake usually appears more intense at the periphery than in the center of the tumor and this feature is called ``doughnut''-shaped [8,9]. Although this ``doughnut''shaped uptake on scintigraphy is highly suggestive of giant cell tumor, it is not specific. This pattern may be seen in simple bone cyst, aneurysmal bone cyst, bone infarction, eosinophilic granuloma, active infection, and
trauma [10]. The lesion in our case showed increased uptake on scintigraphy and activity was greater at the periphery than in the center. Therefore, ``doughnut''shaped lesion was present on scintigraphy. To our knowledge, ``doughnut''-shaped appearance on scintigraphy has not been reported in a metacarpal giant cell tumor before. It has been suggested that the ``doughnut'' appearance is due to the normal reparative response of bone on the outer rim, whereas the inner cold area is the tumor mass [11,12]. Decreased activity within the center has been explained by central necrosis by some authors [9]. We examined the lesion by color Doppler US as well as scintigraphy and we observed that the vascularity of the lesion is mainly peripheral. We did not see any finding suggesting central necrosis on US, Doppler US, or contrast-enhanced CT, so we think that central necrosis was not responsible for the ``doughnut'' appearance on scintigraphy. The grey scale and Doppler US features of giant cell tumor that we presented are nonspecific, but have not been described before.
Fig. 5. On scintigraphic examination, increased uptake is seen. The activity of the lesion is greater at the periphery than at the center (scintigraphic ``doughnut sign'').
Fig. 6. Photomicrograph shows numerous multinucleated osteoclast-like giant cells within stroma composed of bland mononuclear cells (hematoxylin and eosin stain, original magnification 20).
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G. Arslan et al. / Journal of Clinical Imaging 24 (2000) 139±142
References [1] Dahlin DC. Giant cell tumor of bone: highlights of 407 cases. AJR Am J Roentgenol 1985;144:955 ± 60. [2] Delbeke D, Habibian MR. Non-inflammatory entities and the differential diagnosis of positive three-phase bone imaging. Clin Nucl Med 1988;13:844 ± 51. [3] Eckardt JJ, Grogan TJ. Giant cell tumor of bone. Clin Orthop 1986;204:45 ± 58. [4] Goodgold HM, Chen DCP, Majd M, Nolan NG, Malawer M. Scintigraphic features of giant cell tumor. Clin Nucl Med 1984;9:526 ± 30. [5] Henard DC. Giant cell tumor of the thumb metacarpal in an elderly patient: a case report. J Hand Surg 1984;9A:343 ± 5. [6] Krasnow AZ, Isitman AT, Collier BD, Bates FT, Hellman RS. Flow study and SPECT imaging for the diagnosis of giant cell tumor of bone. Clin Nucl Med 1988;13:89 ± 92.
[7] Levine E, De Smet AA, Neff JR, Martin NL. Scintigraphic evaluation of giant cell tumor of bone. AJR Am J Roentgenol 1984;143:343 ± 8. [8] McEnery KW, Raymond AK. Giant cell tumor of the fourth metacarpal. AJR Am J Roentgenol 1998;172:1092. [9] O'Reilly M, Chew FS. The scintigraphic features of giant cell tumors in relation to other imaging modalities. Clin Nucl Med 1996;21: 43 ± 8. [10] Tehranzadeh J, Murphy BJ, Mnaymneh W. Giant cell tumor of the proximal tibia: MRI and CT appearance. J Comput Assist Tomogr 1989;13:282 ± 6. [11] Van Nostrand D, Madewell JE, McNiesh LM, Kyle RW, Sweet D. Radionuclide bone scanning in giant cell tumor. J Nucl Med 1986;27:329 ± 38. [12] Veluvolu P, Collier BD, Isitman AT, Carrera GF, Hellman RS, Fry S. Scintigraphic skeletal ``doughnut'' sign due to giant cell tumor of the fibula. Clin Nucl Med 1984;9:631 ± 4.
Giant cell tumor of the fourth metacarpal bone GoÈkhan Arslana,*, Kamil Karaalia, Metin CËubuka, Tekinalp Gelenb, Ersin LuÈlecia a
Faculty of Medicine, Department of Radiology, Akdeniz University School of Medicine, Arapsuyu, Antalya 07070, Turkey b Faculty of Medicine, Department of Pathology, Akdeniz University, Antalya 07070, Turkey Received 20 March 2000; accepted 30 May 2000
Abstract Giant cell tumor is among the rare tumors of the bone. We present a case of metacarpal giant cell tumor with radiographic, computed tomographic (CT) and histologic findings, as well as grey scale and Doppler sonographic features. We also present the ``doughnut''-shaped appearance on scintigraphy of the lesion, which has not been shown on a metacarpal giant cell tumor. D 2000 Elsevier Science Inc. All rights reserved. Keywords: Giant cell tumor; Metacarpal; Radiography; Ultrasound; Doppler study; Computed tomography
1. Introduction Giant cell tumors are among the rare tumors of the bone. Their incidence has been reported as approximately 5% of all bone neoplasms [1]. Their usual locations include the ends of long bones (70%), pelvis and spine, especially the sacrum [2]. Involvement of the hand bones is very rare and its incidence has been reported as between 2% and 5% of all giant cell tumors [2,3]. We present a case of metacarpal giant cell tumor with radiographic, grey scale and Doppler sonographic, computed tomographic (CT), scintigraphic, and histologic features. 2. Case report A 60-year-old woman presented with increasing swelling and mild pain in her fourth metacarpal of the left hand for 4 months. Radiography showed an expansile and lytic lesion of the fourth metacarpal, which was located within the middle and distal portions of the bone (Fig. 1). Cortical destruction was also present and it was more apparent on the ulnar side of the bone. On sonographic examination with a 7.5-MHz linear probe, the lesion was a homogenous hypoe* Corresponding author. Tel.: +90-242-227-4343 ext. 35110; fax: +90242-227-4325. E-mail addresses: [email protected], [email protected] (G. Arslan).
choic structure with posterior acoustic enhancement and the bone cortex was seen as a thin echogenic boundary (Fig. 2). On color Doppler sonography, vascular structures were demonstrated mainly at the periphery of the lesion and flow spectrums of the vessels showed low-resistance arterial patterns (Fig. 3a, b). CT revealed an expansile lesion and marked cortical thinning (Fig. 4a). The lesion showed homogenous contrast enhancement and there was no soft tissue involvement (Fig. 4b). On scintigraphic examination, increased uptake was seen. The activity of the lesion was greater at the periphery than at the center (scintigraphic ``doughnut sign''). There was no increased activity in the other bones of the hand (Fig. 5). Posteroanteior chest radiograph and all the laboratory tests, including serum calcium and phosphorus levels, were normal. The lesion was treated with curettage. Histologic examination showed multiple osteoclast-like giant cells within a stroma composed of bland mononuclear cells (Fig. 6). These histologic findings were consistent with giant cell tumor. The patient was followed up for 14 months and there was no symptom or finding suggesting recurrence. 3. Discussion Most giant cell tumors occur in the third and fourth decades of life [2]. The patients usually present with swelling and pain, as in our case. Cortical thinning may lead to pathologic fractures and this may be the initial
0899-7071/00/$ ± see front matter D 2000 Elsevier Science Inc. All rights reserved. PII: S 0 8 9 9 - 7 0 7 1 ( 0 0 ) 0 0 1 8 5 - 6
140
G. Arslan et al. / Journal of Clinical Imaging 24 (2000) 139±142
Fig. 3. (A) Color Doppler sonography shows vascular signals mainly from the periphery of the lesion. (B) Doppler flow spectra of the vessels show low-resistance arterial pattern. Fig. 1. Radiography of the left hand shows an expansile and lytic lesion within the fourth metacarpal, located within the middle and distal portions of the bone.
presentation [3]. Giant cell tumors are most commonly located in the epiphysis, extending from the metaphysis.
Fig. 2. Sonographic examination shows a homogenous hypoechoic structure with posterior acoustic enhancement and the bone cortex is seen as a thin echogenic boundary.
Hand involvement is rare and is seen in approximately 2± 5% of all cases [2,3]. In our patient, the lesion was within the fourth metacarpal of the left hand. It appeared as an expansile, lytic lesion on radiograph, which is considered to be typical, but not specific, for giant cell tumors [2,4]. Periost reaction is usually absent in giant cell tumors and it was not present in our case. The radiologic hallmark of this lesion is that it abuts the subchondral bone plate of the adjacent joint [4]. In our case, the subchondral bone near the proximal interphalangeal joint was involved, especially on the ulnar side (Fig. 1). The radiologic differential diagnosis for such lesion includes aneurysmal bone cysts, benign chondroblastoma, non-osteogenic fibroma, hyperparathyroidism, and simple bone cyst [5]. CT can determine the intra- and extraosseous extent of the lesion, and cortical structures are evaluated better than plain films [4]. CT remains superior to magnetic resonance imaging (MRI) in defining thin cortical shells or invasion of the cortex by tumor [6]. Soft tissue involvement can be evaluated in contrast-enhanced scans. In our case, cortical thinning, expansion of the lesion, diffuse enhancement, and absence of soft tissue involvement were demonstrated well with CT. The advantage of MRI over CT is its
G. Arslan et al. / Journal of Clinical Imaging 24 (2000) 139±142
141
Fig. 4. (A) Bone window CT section reveals an expansile lesion and marked cortical thinning. (B) On contrast-enhanced CT, the lesion shows homogenous contrast enhancement and there is no soft tissue involvement.
multiplanar imaging capability and better demonstration of intra-articular extension [6]. We could not perform MRI since it was not available in our institution at the time the patient presented. Giant cell tumors are hypervascular lesions, showing in the majority of the cases with increased uptake on scintigraphy [7]. Scintigraphic evaluation is especially important for the giant cell tumors involving the hand bones because it has been reported that patients with a primary giant cell tumor of the bones of the carpis or hand have an 18% incidence of multicentric disease [4]. In such cases, bone scintigraphy is of value in identifying other sites of skeletal abnormality. In giant cell tumors, uptake usually appears more intense at the periphery than in the center of the tumor and this feature is called ``doughnut''-shaped [8,9]. Although this ``doughnut''shaped uptake on scintigraphy is highly suggestive of giant cell tumor, it is not specific. This pattern may be seen in simple bone cyst, aneurysmal bone cyst, bone infarction, eosinophilic granuloma, active infection, and
trauma [10]. The lesion in our case showed increased uptake on scintigraphy and activity was greater at the periphery than in the center. Therefore, ``doughnut''shaped lesion was present on scintigraphy. To our knowledge, ``doughnut''-shaped appearance on scintigraphy has not been reported in a metacarpal giant cell tumor before. It has been suggested that the ``doughnut'' appearance is due to the normal reparative response of bone on the outer rim, whereas the inner cold area is the tumor mass [11,12]. Decreased activity within the center has been explained by central necrosis by some authors [9]. We examined the lesion by color Doppler US as well as scintigraphy and we observed that the vascularity of the lesion is mainly peripheral. We did not see any finding suggesting central necrosis on US, Doppler US, or contrast-enhanced CT, so we think that central necrosis was not responsible for the ``doughnut'' appearance on scintigraphy. The grey scale and Doppler US features of giant cell tumor that we presented are nonspecific, but have not been described before.
Fig. 5. On scintigraphic examination, increased uptake is seen. The activity of the lesion is greater at the periphery than at the center (scintigraphic ``doughnut sign'').
Fig. 6. Photomicrograph shows numerous multinucleated osteoclast-like giant cells within stroma composed of bland mononuclear cells (hematoxylin and eosin stain, original magnification 20).
142
G. Arslan et al. / Journal of Clinical Imaging 24 (2000) 139±142
References [1] Dahlin DC. Giant cell tumor of bone: highlights of 407 cases. AJR Am J Roentgenol 1985;144:955 ± 60. [2] Delbeke D, Habibian MR. Non-inflammatory entities and the differential diagnosis of positive three-phase bone imaging. Clin Nucl Med 1988;13:844 ± 51. [3] Eckardt JJ, Grogan TJ. Giant cell tumor of bone. Clin Orthop 1986;204:45 ± 58. [4] Goodgold HM, Chen DCP, Majd M, Nolan NG, Malawer M. Scintigraphic features of giant cell tumor. Clin Nucl Med 1984;9:526 ± 30. [5] Henard DC. Giant cell tumor of the thumb metacarpal in an elderly patient: a case report. J Hand Surg 1984;9A:343 ± 5. [6] Krasnow AZ, Isitman AT, Collier BD, Bates FT, Hellman RS. Flow study and SPECT imaging for the diagnosis of giant cell tumor of bone. Clin Nucl Med 1988;13:89 ± 92.
[7] Levine E, De Smet AA, Neff JR, Martin NL. Scintigraphic evaluation of giant cell tumor of bone. AJR Am J Roentgenol 1984;143:343 ± 8. [8] McEnery KW, Raymond AK. Giant cell tumor of the fourth metacarpal. AJR Am J Roentgenol 1998;172:1092. [9] O'Reilly M, Chew FS. The scintigraphic features of giant cell tumors in relation to other imaging modalities. Clin Nucl Med 1996;21: 43 ± 8. [10] Tehranzadeh J, Murphy BJ, Mnaymneh W. Giant cell tumor of the proximal tibia: MRI and CT appearance. J Comput Assist Tomogr 1989;13:282 ± 6. [11] Van Nostrand D, Madewell JE, McNiesh LM, Kyle RW, Sweet D. Radionuclide bone scanning in giant cell tumor. J Nucl Med 1986;27:329 ± 38. [12] Veluvolu P, Collier BD, Isitman AT, Carrera GF, Hellman RS, Fry S. Scintigraphic skeletal ``doughnut'' sign due to giant cell tumor of the fibula. Clin Nucl Med 1984;9:631 ± 4.