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Giant cell tumor of metacarpal treated by cryosurgery
Giant cell tumor of metacarpal treated by cryosurgery We report the case of a 44.year-old woman with a giant cell tumor of the fourth metacarpal head of her dominant left hand that was treated with cryoprobe freezing, curettage and hone grafting. Three years after operation the metacarpophalaugeal joint remained normal both functionally and radiologically. The tumor has not recurred. Cryoprobe kiimg of giant cell tumors of the hand can offer effective direct tumor eradication, as well as maintaining normal bone architecture and preserving full function. (J HANDSURG1989;14A:130-4.)
Roy A. Meals, MD, Joseph M. Mirra, MD, and Avi J. Bernstein, MD, Los Angeles, Calif.
Giant cell tumor (GCT) of the hand accounts for 2% of reported GCTs.’ Despite the fact that the GCT is not a sarcoma, its relatively high recurrence rate (40% to 60%)’ coupled with local “aggressiveness” after simple curettage often leads to extensive en bloc excision. In hand lesions en bloc excision versus ray resection is advocated. ’ Reconstruction of the hand after en bloc excision is particularly difficult because of the need to restore joint surface as well as bone and because of dysfunction associated with postoperative scarring. The negative impact of aggressive ablative surgery on hand function and esthetics is indisputable. Cryosurgery offers a mode of treatment that permits both local tumor ablation while leaving adequate structural support to facilitate reconstruction without need for wide excision or amputation. GCT of the large bones, for example, has been shown to be particularly sensitive to this techique.’ To completely necrose a voluminous GCT in large bones by freezing, topical application of liquid nitrogen poured through a funnel is generally necessary.4 For small bones, however, use of a cryoprobe offers the advantages of discretely defining the area to be frozen while minimizing the risk
From the Divisions of Orthopaedic Surgery aad Surgical Pathology, University of California at Los Angeles; and The Jonsson Cancer Center, Los Angeles, Calif. Received for publication Feb. 17, 1988; accepted in revised form May 16, 1988. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Roy A. Meals, MD, Division of Orthopaedic Surgery, ULCA Center for the Health Sciences, Los Angeles, CA 90024-1749.
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THE JOURNAL OF HAND SURGERY
adjacent soft tissues. Thus, cryoprobe surgery offers a particularly attractive technique for this aggressive tumor of the hand. Other modes of therapy that have been well studied include irradiation, curettage and bone grafting, resection, and amputation. Resection appears to offer the lowest recurrence rate and is the presently recommended form of therapy for lesions of the hand.‘x5 Pate1 et al5 have stated, however, that cryosurgery could be a potentially useful alternative to resection, but there is insufficient documentation of its use in the hand. Curettage and bone grafting have recurrence rates as high as 60% and a “malignant” rate stated to be as high as 16%.3 In the first series by Marcove et al.‘, 3 of 25 patients treated with cryosurgery showed residual tumor in a second biopsy.6 In later series recurrence by this method has now been reduced to less than 5%.’ We report a case of GCT within a metacarpal treated successfully by cryoprobe surgery, with full restoration of hand function and 33 months follow-up. to
Case report A 44-year-old female dental office worker was seen initially with complaints of pain and swelling over the dorsum of her dominant left hand for 1 month. The patient noted exquisite tenderness over the affected area several days before examination. She recalled no injury to this area or previous similar symptoms. She had no history of fever, chills, or arthralgias. On physical examination the dorsal aspect of the left hand was swollen and tender over the ring metacarpal. Range of motion for all joints was full and the neurovascular status was intact. Radiographs revealed an expansile, reticulated, osteolytic lesion in the distal aspect of the ring metacarpal coming up to, but not involving, the articular cartilage (Fig. 1). Results of laboratory studies were within normal limits and a bone
Vol. 14A, No. 1 January 1989
Cryosurgery
scan revealed increased activity in the left fourth metacarpal head. Since the radiographic and clinical presentation strongly favored GCT of bone, the options of ray resection versus en bloc excision with metacarpophalangeal joint reconstruction were discussed with the patient. Alternatives for joint reconstruction included autologous metatarsal autograft, metacarpal allograft, or silicone joint implant into a cortical autograft. The advantages and potential disadvantages of cryosurgery were also explained to the patient. With the patient under general anesthesia and pneumatic limb tourniquet, the periosteum of the distal ring metacarpal was exposed dorsally. A Linde cryoprobe (Union Carbide Co., Somerset, N.J.) 5 mm in diameter, with internal circulating liquid nitrogen cooled to - 180“ C was placed over the periosteum of the distal metacarpal head. Three lo-minute freeze-thaw cycles were performed moving the probe 1 cm proximally and distally. The probe was then pushed through the periosteum into the center of the tumor and again allowed to freeze the tissue. On thawing, the lesion was extensively curetted. A brownish tissue was read as conventional GCT on frozen and later permanent pathologic sections (Figs. 2 and 3). Two more freeze-thaw cycles were done passing the probe proximally and distally into the metacarpal shaft. Autologous iliac crest cancellous bone graft was used to fill the defect. After operation, the ring and small finger metacarpophalangeal joints were immobilized for 3 weeks. Mild paresthesias were noted in the ring finger and along the ulnar side of the long finger. These resolved completely by 6 months after operation. Subsequently the patient has remained entirely asymptomatic. Serial radiographs revealed incorporation of bone graft and preservation of joint architecture (Fig. 4). A bone scan and serial chest radiographs over the ensuing 33 months indicated no evidence of lung implantation or other primary lesions. The patient returned to work and resumed full activity 6 weeks after operation. She maintained normal grip strength, range of motion, and appearance of the left hand (Fig. 5).
Discussion Cryosurgery of tumors of the hand has been twice reported. Marcove et aL6 had one proximal phalanx lesion in his series of 52 giant cell tumors that were treated with cryosurgery. In 1984 Gartsman and Ranawat* used cryosurgery in the treatment of an osteoid osteoma of the proximal phalanx. They employed a spray unit to dispense the liquid nitrogen and protected the surrounding tissues with sponges soaked in saline solution. The technique of using a cryoprobe instead of pouring or spraying liquid nitrogen onto the lesion was reported by Mirra et aL9 They successfully treated a GCT of the second cervical vertebra through an anterior oral approach. This lesion was not amenable to the pouring technique because of its remote surgical location and its proximity
to the spinal cord. The cryo-
13 1
Fig. 1. Radiograph in December 1984 shows expansile, lytic, lesion of proximal epiphyseal region of fourth metacarpal with reticulated pattern. Appearance most consistent with GCT.
probe contains a coil, which has circulating liquid nitrogen controlled by an external unit. This technique allows specific and directed freeze-thaw cycles without extensive necrosis of healthy tissues because of spilling or lack of control. Freezing of the spinal cord by this approach was not an expected event, since it is bathed by spinal fluid. Nevertheless, careful monitoring of the cord was accomplished by means of thermocouples. Several techniques have been used to reconstruct a metacarpal after resection for treatment of a GCT. In 1985 Carlow and Suheil” resected en masse an almost identical lesion to the presently reported case and reconstructed the metacarpal with contoured iliac crest bone graft and a silicone rubber implant. In 1984, Henard” reported the use of a contoured calvarium allograft to span the defect between the trapezium and proximal phalanx after resection of the entire first metacarpal for treatment of a GCT. Some thumb motion remained through the trapezio-scaphoid and trapeziotrapezoid joints.
132
Meals, Mirra, and Bernstein
The Journal of HAND SURGERY
Fig. 2. Biopsy of specimens obtained immediately after freezing and curettage showed a lesion
diffusely sprinkled with osteoclast-like giant cells. There was no fibrosis, blood-filled cavities, or matrix production. (Hematoxylin-eosin stain; X 125.)
Fig. 3. High power shows the characteristic, numerous osteoclast-like giant cells between, which
are short, spindly stromal cells. In 10 high-power fields there were three mitoses. Cytologic distortion from freezing was minimal. Features are those of a conventional giant cell tumor of bone. (Hematoxylin-eosin stain; x 250.)
GCT of the hand seems to represent a different lesion than conventional GCT in the rest of the skeleton. There is an 18% incidence of multicentric foci indicating that a bone scan should be a part of the routine work up for these tumors. ’ Overall, they appear in a younger age population and recur more rapidly in the hand than they do in other locations. They also have a shorter duration of symptoms, averaging 6 months or less before di-
agnosis and treatment. ’ Recurrence rate after curettage in the hand is approximately 90%. Radiation therapy is ineffective, with a 20% incidence of radiation sarcoma.” Ray resection appears to offer definitive therapy, however, at the cost of losing a functional finger. ‘35 Cryosurgery is an ideal alternative and is effective if performed correctly.4 Our reasoning behind the use of
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133
Fig. 5. A, Hand in flexion 33 months after operation. B, Hand in extension, same date. Fig. 4. This radiograph taken 27 months after that shown in Fig. 1 demonstrates almost completely normal bony architecture. Except for slight residual widening and minor thinning of cortices, it would be difficult to know that a lesion had been present at the site of the fourth metacarpal.
cryosurgery for the treatment of a GCT in the reported patient was as follows: 1. The lesion was relatively small as compared to GCT of the long bones and could easily be frozen with use of the cryoprobe. 2. Freezing necroses tumor by forming intracellular ice crystals. This is achieved by using three freeze-thaw cycles. The temperature of the tissue that is intended for necrosis must be lowered at least to - 21” Ce4,I3 This can be measured by means of thermocouples or by direct visualization of the rather dramatic iceball that forms as the cryoprobe is applied to the tissue and liquid nitrogen is circulated through its tip. Definite tumor tissue kill has been established to occur up to the distance of 50% of the inner diameter of the visualized ice ball as established by thermocouple measurement.4 3. The lesion was still confined to the bone, theoretically making the task of complete tumor kill even
easier. In the case of a small hand bone, including 4 to 5 mm of normal tissue beyond the tumor visualized on the radiographs should be sufficient to ensure adequate tumor necrosis along its margins. 4. The cortical bone typically reconstitutes itself as evidenced by cases of GCT treated cryosurgically in the long and flat bones. 3,4 This occurs either from migration of viable periosteal cells proximal and distal to the freeze zone, or from the muscle mesenchyme metaplasia forming a new periosteum. Given that the phenomenon of cortical reconstitution occurs by these means, it is unquestionably preferable to retain the original bone stock as compared to metacarpal resection or ray amputation providing the risks are small. 5. Even if the digital nerve axons are frozen and disrupted, regenerating nerve fibers grow down the intact nerve sheaths within a few months, since the vital nerve cell nucleus is located in the dorsal root ganglion. Even if the femoral nerve is frozen close to the groin reestablishment of sensory and motor functions occur within 6 to 12 months.3*4 The peripheral nerves of the hand and feet travel short distances by comparison. Reestablishment of functional nerve conduction should occur in a few months at most, whether a nerve was frozen either inadvertently or intentionally.
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The Journal of HAND SURGERY
Meals, Mirra. and Bernstein
6. Even if the lesion proved to be an aneurysmal bone cyst (the only other and less probable diagnosis given the radiographic features), cryoprobe surgery is an acceptable therapeutic approach, considering that from 30% to 40% of these lesions can recur one or more times. 7. Freeze-thawing of the tumor tissue would not interfere with histologic diagnosis, since freezing preserves cellular detail. Liquid nitrogen is used as part of the conventional technique for frozen section diagnosis. For an in-depth exposition of the indications, methods, advantages, and complications of cryosurgery, the interested reader is referred to a prior publication4 It was decided to freeze the lesion first and a biopsy was done later to reduce the possibility of tumor spillage and recurrence, since the radiographic features were strongly consistent with GCT, and much less so for an aneurysmal bone cyst. Cryosurgery may be appropriate even for lesions that have penetrated the bone. The freezing would have to include all of the soft tissue component as well, which would likely compromise nerve function, at least temporarily, and could raise the risk of infection. Even if there were a recurrence after an attempt to freeze the tumor, an en bloc surgical excision could be accomplished. Since a GCT, which has been thoroughly frozen by proper technique, has a minimal risk of recurrence (around 2% to 5% in the long bones),3 cryotherapy should probably be given first consideration over more mutilating treatments. Marcove et a1.3.’ has been repeating biopsies of treated lesions on a routine basis and performing repeat cryotherapy for positive pathology. We did not believe rebiopsy was indicated in our patient because of the relatively small area involved as compared to lesions in large bones and because of the ability of serial radiographs to show early recurrence when dealing with a bone as small as a metacarpal. Radiographic follow-up examinations on a quarterly basis the first 18 months and on a semiannual basis for an additional 12 to 18 months are recommended since the great majority of recurrences are evident witbin the first 2 years.” I4If healing is excellent and there are no signs of recurrence, such as pain or lytic destruction, there should be no need for concern. Although this is the first fully documented case report of GCT of the hand treated with cryotherapy, its use
as a therapeutic tool has been expounded in numerous
articles at other bony sites with excellent results. The major complication in major weight-bearing bones, such as the distal femur is fracture, but this complication should not be a major factor in relation to the small bones of the hands and feet. REFERENCES
5.
6.
7.
8.
9.
10.
11.
12. 13.
14.
Averill RM, Smitb RJ, Campbell CJ. Giant cell tumors of the bones of the hand. J HANDSURG 1980;5:39-50. Eckardt JJ, Grogan TJ. Giant cell tumor of bone. Clin Grthop 1986;204:45-58. Marcove RC. A 17 year review of cryosurgery in the treatment of bone tumors, Clin Orthop 1982;163:231-4. Mirra JM, Marcove RC, Gold RH. Bone tumors: diagnosis and treatment. Philadelphia: JB Lippincott, 1980: 590605. Pate1 MR, Desai SS, Gordon SL, et al. Management of skeletal giant cell tumors of the phalanges of the hands. J HANDSURG 1987;12A:70-6. Marcove RC, Lyden JP, Huvos AG, Bullough PG. Giant cell tumors treated by cryosurgery. J Bone Joint Surg 1973;55A;1633. Marcove RC, Weis CD, Vaghaiwalla MR, Pearson R. Cryosurgery in the treatment of giant cell tumors of bone: a report of 52 consecutive cases. Clin Orthop 1978;134: 275-89. Gartsman GM, Ranawat CS. Treatment of the osteoid osteoma of the proximal phalanx by use of cryosurgery. J HANDSURG 1984;9A:275-7. Mirra JM, Rand F, Rand R, Calcaterra T, Dawson E. Giant cell tumor of the second cervical vertebra treated by cryosurgery and irradiation. Clin Orthop 1981; 154: 228-33. Carlow SB, Subheil SM. Metacarpal resection with a contoured iliac bone graft and silicone rubber implant for metacarpal giant cell tumor: a case report. J HAND SLJRG 1985;1OA:275-8. Henard DC. Giant cell tumor of the thumb metacarpal in an elderly patient: a case report. J HAND SURG 1984;9A:343-5. Morton J. Giant cell tumor of bone. Cancer 1956;9:101225. Marcove RC, Miller TR. The treatment of primary and metastatic localized bone tumors by cryosurgery. Surg Clin North Am 1969;49:421-30. Persson BM, Wouters HW. Curettage and acrylic cementation in surgery of giant cell tumors of bone. Clin Grthop 1976;120:125-33.
Roy A. Meals, MD, Joseph M. Mirra, MD, and Avi J. Bernstein, MD, Los Angeles, Calif.
Giant cell tumor (GCT) of the hand accounts for 2% of reported GCTs.’ Despite the fact that the GCT is not a sarcoma, its relatively high recurrence rate (40% to 60%)’ coupled with local “aggressiveness” after simple curettage often leads to extensive en bloc excision. In hand lesions en bloc excision versus ray resection is advocated. ’ Reconstruction of the hand after en bloc excision is particularly difficult because of the need to restore joint surface as well as bone and because of dysfunction associated with postoperative scarring. The negative impact of aggressive ablative surgery on hand function and esthetics is indisputable. Cryosurgery offers a mode of treatment that permits both local tumor ablation while leaving adequate structural support to facilitate reconstruction without need for wide excision or amputation. GCT of the large bones, for example, has been shown to be particularly sensitive to this techique.’ To completely necrose a voluminous GCT in large bones by freezing, topical application of liquid nitrogen poured through a funnel is generally necessary.4 For small bones, however, use of a cryoprobe offers the advantages of discretely defining the area to be frozen while minimizing the risk
From the Divisions of Orthopaedic Surgery aad Surgical Pathology, University of California at Los Angeles; and The Jonsson Cancer Center, Los Angeles, Calif. Received for publication Feb. 17, 1988; accepted in revised form May 16, 1988. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Roy A. Meals, MD, Division of Orthopaedic Surgery, ULCA Center for the Health Sciences, Los Angeles, CA 90024-1749.
130
THE JOURNAL OF HAND SURGERY
adjacent soft tissues. Thus, cryoprobe surgery offers a particularly attractive technique for this aggressive tumor of the hand. Other modes of therapy that have been well studied include irradiation, curettage and bone grafting, resection, and amputation. Resection appears to offer the lowest recurrence rate and is the presently recommended form of therapy for lesions of the hand.‘x5 Pate1 et al5 have stated, however, that cryosurgery could be a potentially useful alternative to resection, but there is insufficient documentation of its use in the hand. Curettage and bone grafting have recurrence rates as high as 60% and a “malignant” rate stated to be as high as 16%.3 In the first series by Marcove et al.‘, 3 of 25 patients treated with cryosurgery showed residual tumor in a second biopsy.6 In later series recurrence by this method has now been reduced to less than 5%.’ We report a case of GCT within a metacarpal treated successfully by cryoprobe surgery, with full restoration of hand function and 33 months follow-up. to
Case report A 44-year-old female dental office worker was seen initially with complaints of pain and swelling over the dorsum of her dominant left hand for 1 month. The patient noted exquisite tenderness over the affected area several days before examination. She recalled no injury to this area or previous similar symptoms. She had no history of fever, chills, or arthralgias. On physical examination the dorsal aspect of the left hand was swollen and tender over the ring metacarpal. Range of motion for all joints was full and the neurovascular status was intact. Radiographs revealed an expansile, reticulated, osteolytic lesion in the distal aspect of the ring metacarpal coming up to, but not involving, the articular cartilage (Fig. 1). Results of laboratory studies were within normal limits and a bone
Vol. 14A, No. 1 January 1989
Cryosurgery
scan revealed increased activity in the left fourth metacarpal head. Since the radiographic and clinical presentation strongly favored GCT of bone, the options of ray resection versus en bloc excision with metacarpophalangeal joint reconstruction were discussed with the patient. Alternatives for joint reconstruction included autologous metatarsal autograft, metacarpal allograft, or silicone joint implant into a cortical autograft. The advantages and potential disadvantages of cryosurgery were also explained to the patient. With the patient under general anesthesia and pneumatic limb tourniquet, the periosteum of the distal ring metacarpal was exposed dorsally. A Linde cryoprobe (Union Carbide Co., Somerset, N.J.) 5 mm in diameter, with internal circulating liquid nitrogen cooled to - 180“ C was placed over the periosteum of the distal metacarpal head. Three lo-minute freeze-thaw cycles were performed moving the probe 1 cm proximally and distally. The probe was then pushed through the periosteum into the center of the tumor and again allowed to freeze the tissue. On thawing, the lesion was extensively curetted. A brownish tissue was read as conventional GCT on frozen and later permanent pathologic sections (Figs. 2 and 3). Two more freeze-thaw cycles were done passing the probe proximally and distally into the metacarpal shaft. Autologous iliac crest cancellous bone graft was used to fill the defect. After operation, the ring and small finger metacarpophalangeal joints were immobilized for 3 weeks. Mild paresthesias were noted in the ring finger and along the ulnar side of the long finger. These resolved completely by 6 months after operation. Subsequently the patient has remained entirely asymptomatic. Serial radiographs revealed incorporation of bone graft and preservation of joint architecture (Fig. 4). A bone scan and serial chest radiographs over the ensuing 33 months indicated no evidence of lung implantation or other primary lesions. The patient returned to work and resumed full activity 6 weeks after operation. She maintained normal grip strength, range of motion, and appearance of the left hand (Fig. 5).
Discussion Cryosurgery of tumors of the hand has been twice reported. Marcove et aL6 had one proximal phalanx lesion in his series of 52 giant cell tumors that were treated with cryosurgery. In 1984 Gartsman and Ranawat* used cryosurgery in the treatment of an osteoid osteoma of the proximal phalanx. They employed a spray unit to dispense the liquid nitrogen and protected the surrounding tissues with sponges soaked in saline solution. The technique of using a cryoprobe instead of pouring or spraying liquid nitrogen onto the lesion was reported by Mirra et aL9 They successfully treated a GCT of the second cervical vertebra through an anterior oral approach. This lesion was not amenable to the pouring technique because of its remote surgical location and its proximity
to the spinal cord. The cryo-
13 1
Fig. 1. Radiograph in December 1984 shows expansile, lytic, lesion of proximal epiphyseal region of fourth metacarpal with reticulated pattern. Appearance most consistent with GCT.
probe contains a coil, which has circulating liquid nitrogen controlled by an external unit. This technique allows specific and directed freeze-thaw cycles without extensive necrosis of healthy tissues because of spilling or lack of control. Freezing of the spinal cord by this approach was not an expected event, since it is bathed by spinal fluid. Nevertheless, careful monitoring of the cord was accomplished by means of thermocouples. Several techniques have been used to reconstruct a metacarpal after resection for treatment of a GCT. In 1985 Carlow and Suheil” resected en masse an almost identical lesion to the presently reported case and reconstructed the metacarpal with contoured iliac crest bone graft and a silicone rubber implant. In 1984, Henard” reported the use of a contoured calvarium allograft to span the defect between the trapezium and proximal phalanx after resection of the entire first metacarpal for treatment of a GCT. Some thumb motion remained through the trapezio-scaphoid and trapeziotrapezoid joints.
132
Meals, Mirra, and Bernstein
The Journal of HAND SURGERY
Fig. 2. Biopsy of specimens obtained immediately after freezing and curettage showed a lesion
diffusely sprinkled with osteoclast-like giant cells. There was no fibrosis, blood-filled cavities, or matrix production. (Hematoxylin-eosin stain; X 125.)
Fig. 3. High power shows the characteristic, numerous osteoclast-like giant cells between, which
are short, spindly stromal cells. In 10 high-power fields there were three mitoses. Cytologic distortion from freezing was minimal. Features are those of a conventional giant cell tumor of bone. (Hematoxylin-eosin stain; x 250.)
GCT of the hand seems to represent a different lesion than conventional GCT in the rest of the skeleton. There is an 18% incidence of multicentric foci indicating that a bone scan should be a part of the routine work up for these tumors. ’ Overall, they appear in a younger age population and recur more rapidly in the hand than they do in other locations. They also have a shorter duration of symptoms, averaging 6 months or less before di-
agnosis and treatment. ’ Recurrence rate after curettage in the hand is approximately 90%. Radiation therapy is ineffective, with a 20% incidence of radiation sarcoma.” Ray resection appears to offer definitive therapy, however, at the cost of losing a functional finger. ‘35 Cryosurgery is an ideal alternative and is effective if performed correctly.4 Our reasoning behind the use of
Vol. 14A, No. 1 January 1989
Cryosurgery
133
Fig. 5. A, Hand in flexion 33 months after operation. B, Hand in extension, same date. Fig. 4. This radiograph taken 27 months after that shown in Fig. 1 demonstrates almost completely normal bony architecture. Except for slight residual widening and minor thinning of cortices, it would be difficult to know that a lesion had been present at the site of the fourth metacarpal.
cryosurgery for the treatment of a GCT in the reported patient was as follows: 1. The lesion was relatively small as compared to GCT of the long bones and could easily be frozen with use of the cryoprobe. 2. Freezing necroses tumor by forming intracellular ice crystals. This is achieved by using three freeze-thaw cycles. The temperature of the tissue that is intended for necrosis must be lowered at least to - 21” Ce4,I3 This can be measured by means of thermocouples or by direct visualization of the rather dramatic iceball that forms as the cryoprobe is applied to the tissue and liquid nitrogen is circulated through its tip. Definite tumor tissue kill has been established to occur up to the distance of 50% of the inner diameter of the visualized ice ball as established by thermocouple measurement.4 3. The lesion was still confined to the bone, theoretically making the task of complete tumor kill even
easier. In the case of a small hand bone, including 4 to 5 mm of normal tissue beyond the tumor visualized on the radiographs should be sufficient to ensure adequate tumor necrosis along its margins. 4. The cortical bone typically reconstitutes itself as evidenced by cases of GCT treated cryosurgically in the long and flat bones. 3,4 This occurs either from migration of viable periosteal cells proximal and distal to the freeze zone, or from the muscle mesenchyme metaplasia forming a new periosteum. Given that the phenomenon of cortical reconstitution occurs by these means, it is unquestionably preferable to retain the original bone stock as compared to metacarpal resection or ray amputation providing the risks are small. 5. Even if the digital nerve axons are frozen and disrupted, regenerating nerve fibers grow down the intact nerve sheaths within a few months, since the vital nerve cell nucleus is located in the dorsal root ganglion. Even if the femoral nerve is frozen close to the groin reestablishment of sensory and motor functions occur within 6 to 12 months.3*4 The peripheral nerves of the hand and feet travel short distances by comparison. Reestablishment of functional nerve conduction should occur in a few months at most, whether a nerve was frozen either inadvertently or intentionally.
134
The Journal of HAND SURGERY
Meals, Mirra. and Bernstein
6. Even if the lesion proved to be an aneurysmal bone cyst (the only other and less probable diagnosis given the radiographic features), cryoprobe surgery is an acceptable therapeutic approach, considering that from 30% to 40% of these lesions can recur one or more times. 7. Freeze-thawing of the tumor tissue would not interfere with histologic diagnosis, since freezing preserves cellular detail. Liquid nitrogen is used as part of the conventional technique for frozen section diagnosis. For an in-depth exposition of the indications, methods, advantages, and complications of cryosurgery, the interested reader is referred to a prior publication4 It was decided to freeze the lesion first and a biopsy was done later to reduce the possibility of tumor spillage and recurrence, since the radiographic features were strongly consistent with GCT, and much less so for an aneurysmal bone cyst. Cryosurgery may be appropriate even for lesions that have penetrated the bone. The freezing would have to include all of the soft tissue component as well, which would likely compromise nerve function, at least temporarily, and could raise the risk of infection. Even if there were a recurrence after an attempt to freeze the tumor, an en bloc surgical excision could be accomplished. Since a GCT, which has been thoroughly frozen by proper technique, has a minimal risk of recurrence (around 2% to 5% in the long bones),3 cryotherapy should probably be given first consideration over more mutilating treatments. Marcove et a1.3.’ has been repeating biopsies of treated lesions on a routine basis and performing repeat cryotherapy for positive pathology. We did not believe rebiopsy was indicated in our patient because of the relatively small area involved as compared to lesions in large bones and because of the ability of serial radiographs to show early recurrence when dealing with a bone as small as a metacarpal. Radiographic follow-up examinations on a quarterly basis the first 18 months and on a semiannual basis for an additional 12 to 18 months are recommended since the great majority of recurrences are evident witbin the first 2 years.” I4If healing is excellent and there are no signs of recurrence, such as pain or lytic destruction, there should be no need for concern. Although this is the first fully documented case report of GCT of the hand treated with cryotherapy, its use
as a therapeutic tool has been expounded in numerous
articles at other bony sites with excellent results. The major complication in major weight-bearing bones, such as the distal femur is fracture, but this complication should not be a major factor in relation to the small bones of the hands and feet. REFERENCES
5.
6.
7.
8.
9.
10.
11.
12. 13.
14.
Averill RM, Smitb RJ, Campbell CJ. Giant cell tumors of the bones of the hand. J HANDSURG 1980;5:39-50. Eckardt JJ, Grogan TJ. Giant cell tumor of bone. Clin Grthop 1986;204:45-58. Marcove RC. A 17 year review of cryosurgery in the treatment of bone tumors, Clin Orthop 1982;163:231-4. Mirra JM, Marcove RC, Gold RH. Bone tumors: diagnosis and treatment. Philadelphia: JB Lippincott, 1980: 590605. Pate1 MR, Desai SS, Gordon SL, et al. Management of skeletal giant cell tumors of the phalanges of the hands. J HANDSURG 1987;12A:70-6. Marcove RC, Lyden JP, Huvos AG, Bullough PG. Giant cell tumors treated by cryosurgery. J Bone Joint Surg 1973;55A;1633. Marcove RC, Weis CD, Vaghaiwalla MR, Pearson R. Cryosurgery in the treatment of giant cell tumors of bone: a report of 52 consecutive cases. Clin Orthop 1978;134: 275-89. Gartsman GM, Ranawat CS. Treatment of the osteoid osteoma of the proximal phalanx by use of cryosurgery. J HANDSURG 1984;9A:275-7. Mirra JM, Rand F, Rand R, Calcaterra T, Dawson E. Giant cell tumor of the second cervical vertebra treated by cryosurgery and irradiation. Clin Orthop 1981; 154: 228-33. Carlow SB, Subheil SM. Metacarpal resection with a contoured iliac bone graft and silicone rubber implant for metacarpal giant cell tumor: a case report. J HAND SLJRG 1985;1OA:275-8. Henard DC. Giant cell tumor of the thumb metacarpal in an elderly patient: a case report. J HAND SURG 1984;9A:343-5. Morton J. Giant cell tumor of bone. Cancer 1956;9:101225. Marcove RC, Miller TR. The treatment of primary and metastatic localized bone tumors by cryosurgery. Surg Clin North Am 1969;49:421-30. Persson BM, Wouters HW. Curettage and acrylic cementation in surgery of giant cell tumors of bone. Clin Grthop 1976;120:125-33.