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Giant cell tumor of the patella
GIANT CELL TUMOR OF THE PATELLA* CASE MAX Assistant
REPORT
A.
Professor of Orthopedic
LEVINE,
LOS ANGELES,
T
of presentation case is made because of the giant ceII tumor HE
M.D.
Surgery, CoIlege of nledical Evangelists
the folIowing of the rarity in the patella.
CALIFORNIA
and Chuinard.2 Their addition made it the fifteenth reported case. It is interesting to note that in the cases
FIG. I. LateraI roentgenogram shows Iarge cystic defect in the patelIa. Note the near break through at the articular surface of the pateIIa.
In addition this case is interesting because of the earhness of the Iesion. Very few cases have so far been reported with as IittIe invoIvement of the pateHa. The most compIete review of the Iiterature was abIy presented by S. Arthur Linde.l At that time he added a case to thirteen aIready reported. The Iast case of giant ceI1 tumor of the pateIIa was reported by DiIIehunt * From the Orthopedic
Departments,
reviewed by Linde, that reported by DiIIehunt and Chuinard, as we11 as the case that is being presented by the author, trauma had been a predominate factor. CASE REPORT M. L., Jr. a white maIe, thirty-one years old, was seen at the offxe ApriI 6, 1942. His chief pain over the compIaints were, moderate
College of MedicaI Evangelists, 286
and Cedars of Lebanon HospitaI.
NEW
SERIESVOL. LXII,
No.
2
Levine-Tumor
medial aspect of the right knee and severe pain on pressure of the right “ knee cap. ” Duration was approximately one year, shortly following
of
PateIIa
American
Journal
of Surgery
287
as well as the capsular surfaces of the patella were in tact and no evidence of any disorder was noted, except for a “derby hat” feeling
FIG. 2. Gross specimen. Section showing the multiloculated cystic defect invoIving approximately two-thirds of the marrow.
a fall on his knee while playing bal1. The patient stated that even slight pressure on his knee always caused considerable discomfort. Physical examination was essentially negative except for the right lower extremity. Atrophy of the right thigh was one-half inch. The right knee was s/4 of an inch greater in circumference than that of the left. The right calf presented three-fourths of one inch atrophy. There was no limitation of motion except for the last ten degrees of passive hyperflexion which was also painful. No patellar asymmetry or enlargement could be noted with the naked eye. Anteroposterior and lateral view radiographs of the right knee were taken which revealed an irregular cystic lesion occupying approximately two-thirds of the patella. (Fig. I .) Excision of the patella was advised, however, the patient was not admitted to the Cedars of Lebanon Hospital until June 18, 1942. A sterile twenty-four hour preparation of the right upper extremity was done. This was followed by the operation of the right knee on June 19, 1942. Through a paramedian incision, the right knee joint was exposed. The articular
of the anterior surface. This was due to the extreme thinning of this surface by the tumor. With a scalpel the cortex was entered and the tumor was noted to occupy at least twothirds of the patella. The entire patella was excised. The capsular ligaments were approximated with chromic mattress and purse-string sutures. The repair was well tested with fortyfive degree passive knee ffexion. Further closure was completed and the right leg was placed in a plaster of paris cylinder cast extending from the groin to the ankle. The pathological report by Dr. Reuben Strauss stated that the specimen consisted of a patella, apparently from an adult. The articular surface presented nothing remarkable and the anterior aspect showed evidence of dissection. There was a small defect, 13 by 8 mm. on the anterior aspect which appeared to be an artefact. The edges of the defect were sharp. It communicated with a cystic defect involving the marrow. On section there was a multiloculated cystic defect involving approximately two-thirds of the marrow. These locules were lined by a smooth, grayish-white membrane which showed considerable reddish-brown dis-
288
American Journal of Surgery
coIoration. eIsewhere
Levine-Tumor
The cancehous bone of the marrow was normal in appearance and
consistency. (Fig. 2.)
of PateIIa
NOVEMBER. rgd,
osteoclasts. This tumor tissue was moderately In the area moderate amount of vascular. osteoid tissue could also be seen and some
microphotograph showing numerous giant ~11s resembling osteoclasts scattered among a relatively large amount of tumor tissue composed of spindle cells. This tissue is quite vascular.
FIG. 3. A
MicroscopicaIIy, multiple sections of the tissue reveaIed a striking picture. In some areas the marrow spaces were very large and hIled with adipose tissue which in places presented sIight focal fibrosis and round ceI1 infiItration. Some of the fat ceIIs appeared to have coaIesced to form Iarge vacuoIes. In some areas there was extensive fibrosis and round ceI1 i&Itration with evidence of new bone formation. Many of the bone IameIlae were lined by numerous osteoblasts. Those IameIIae bordering the cyst cavities showed no osteobIasts on that aspect of the Iamella bordering the cyst. Lining the cyst cavity couId be seen a reIativeIy Iarge amount of tumor tissue composed of hyperchromatic spindle ceIIs. polymorphic Scattered among these ceIIs were numerous muItinucIeated giant ceIIs greatIy resembling
newly formed bone Iamellae. In some areas the tumor ceIIs were surrounded by a homogeneous hyalin matrix resuIting in the impression of immature cartilage formation. Few mitotic figures were seen. (Fig. 3.) Diagnosis: Cystic giant ceI1 tumor of the pateha (benign). The postoperative course was uneventful. Six months after surgery the patient has no pain or discomfort. The range of motion is angle of greatest extension 180 degrees, angIe of greatest hexion 70 degrees, and fIexion range is continuing to improve. COMMENT I. The case presented compares favorabIy with the usual age of average patient
NEW SERIES VOL. LXII,
No.z
Levine-Tumor
with giant ceII tumor which is between twenty-nine and thirty years of age. 2. In every case trauma has been a predisposing factor. Some pathoIogists consider a benign giant ceI1 tumor as a granuIoma resuIting from an organization of a rather extensive hematoma in the bone marrow. This concept wouId bear out the cIinica1 anaIysis of trauma in aImost every case reported.
of PateIIa
American Journaf of Surgery
289
3. UnIike the majority IO:$ this case is of a maIe. 4. Excision of the pateHa is the treatment of choice and has the most successfuJ results. REFERENCES I. LINDE, S. ARTHUR. Giant ceII tumor of the patella.
Am. J. Surg., 28: ISO, 1935. 2. DILLEHIJNT, RICHARDB. and CHUINARD,E. GEORGE, Giant cell tumor of the patella. West. J. Surg., Obst. t’s+qynec., 46: 525, 1938.
EVERY severeIy wounded person is shocked, especially if there is accompanying soft tissue damage and hemorrhage such as occurs with compound fractures. Shock shouId be anticipated and prevented as much as possibIe. When the patient is severely shocked, the general treatment must have precedence over IocaI treatment. From “Fractures and Dislocations for Practitioners” by Edwin 0. GeckeIer (Williams & Wilkins Company).
REPORT
A.
Professor of Orthopedic
LEVINE,
LOS ANGELES,
T
of presentation case is made because of the giant ceII tumor HE
M.D.
Surgery, CoIlege of nledical Evangelists
the folIowing of the rarity in the patella.
CALIFORNIA
and Chuinard.2 Their addition made it the fifteenth reported case. It is interesting to note that in the cases
FIG. I. LateraI roentgenogram shows Iarge cystic defect in the patelIa. Note the near break through at the articular surface of the pateIIa.
In addition this case is interesting because of the earhness of the Iesion. Very few cases have so far been reported with as IittIe invoIvement of the pateHa. The most compIete review of the Iiterature was abIy presented by S. Arthur Linde.l At that time he added a case to thirteen aIready reported. The Iast case of giant ceI1 tumor of the pateIIa was reported by DiIIehunt * From the Orthopedic
Departments,
reviewed by Linde, that reported by DiIIehunt and Chuinard, as we11 as the case that is being presented by the author, trauma had been a predominate factor. CASE REPORT M. L., Jr. a white maIe, thirty-one years old, was seen at the offxe ApriI 6, 1942. His chief pain over the compIaints were, moderate
College of MedicaI Evangelists, 286
and Cedars of Lebanon HospitaI.
NEW
SERIESVOL. LXII,
No.
2
Levine-Tumor
medial aspect of the right knee and severe pain on pressure of the right “ knee cap. ” Duration was approximately one year, shortly following
of
PateIIa
American
Journal
of Surgery
287
as well as the capsular surfaces of the patella were in tact and no evidence of any disorder was noted, except for a “derby hat” feeling
FIG. 2. Gross specimen. Section showing the multiloculated cystic defect invoIving approximately two-thirds of the marrow.
a fall on his knee while playing bal1. The patient stated that even slight pressure on his knee always caused considerable discomfort. Physical examination was essentially negative except for the right lower extremity. Atrophy of the right thigh was one-half inch. The right knee was s/4 of an inch greater in circumference than that of the left. The right calf presented three-fourths of one inch atrophy. There was no limitation of motion except for the last ten degrees of passive hyperflexion which was also painful. No patellar asymmetry or enlargement could be noted with the naked eye. Anteroposterior and lateral view radiographs of the right knee were taken which revealed an irregular cystic lesion occupying approximately two-thirds of the patella. (Fig. I .) Excision of the patella was advised, however, the patient was not admitted to the Cedars of Lebanon Hospital until June 18, 1942. A sterile twenty-four hour preparation of the right upper extremity was done. This was followed by the operation of the right knee on June 19, 1942. Through a paramedian incision, the right knee joint was exposed. The articular
of the anterior surface. This was due to the extreme thinning of this surface by the tumor. With a scalpel the cortex was entered and the tumor was noted to occupy at least twothirds of the patella. The entire patella was excised. The capsular ligaments were approximated with chromic mattress and purse-string sutures. The repair was well tested with fortyfive degree passive knee ffexion. Further closure was completed and the right leg was placed in a plaster of paris cylinder cast extending from the groin to the ankle. The pathological report by Dr. Reuben Strauss stated that the specimen consisted of a patella, apparently from an adult. The articular surface presented nothing remarkable and the anterior aspect showed evidence of dissection. There was a small defect, 13 by 8 mm. on the anterior aspect which appeared to be an artefact. The edges of the defect were sharp. It communicated with a cystic defect involving the marrow. On section there was a multiloculated cystic defect involving approximately two-thirds of the marrow. These locules were lined by a smooth, grayish-white membrane which showed considerable reddish-brown dis-
288
American Journal of Surgery
coIoration. eIsewhere
Levine-Tumor
The cancehous bone of the marrow was normal in appearance and
consistency. (Fig. 2.)
of PateIIa
NOVEMBER. rgd,
osteoclasts. This tumor tissue was moderately In the area moderate amount of vascular. osteoid tissue could also be seen and some
microphotograph showing numerous giant ~11s resembling osteoclasts scattered among a relatively large amount of tumor tissue composed of spindle cells. This tissue is quite vascular.
FIG. 3. A
MicroscopicaIIy, multiple sections of the tissue reveaIed a striking picture. In some areas the marrow spaces were very large and hIled with adipose tissue which in places presented sIight focal fibrosis and round ceI1 infiItration. Some of the fat ceIIs appeared to have coaIesced to form Iarge vacuoIes. In some areas there was extensive fibrosis and round ceI1 i&Itration with evidence of new bone formation. Many of the bone IameIlae were lined by numerous osteoblasts. Those IameIIae bordering the cyst cavities showed no osteobIasts on that aspect of the Iamella bordering the cyst. Lining the cyst cavity couId be seen a reIativeIy Iarge amount of tumor tissue composed of hyperchromatic spindle ceIIs. polymorphic Scattered among these ceIIs were numerous muItinucIeated giant ceIIs greatIy resembling
newly formed bone Iamellae. In some areas the tumor ceIIs were surrounded by a homogeneous hyalin matrix resuIting in the impression of immature cartilage formation. Few mitotic figures were seen. (Fig. 3.) Diagnosis: Cystic giant ceI1 tumor of the pateha (benign). The postoperative course was uneventful. Six months after surgery the patient has no pain or discomfort. The range of motion is angle of greatest extension 180 degrees, angIe of greatest hexion 70 degrees, and fIexion range is continuing to improve. COMMENT I. The case presented compares favorabIy with the usual age of average patient
NEW SERIES VOL. LXII,
No.z
Levine-Tumor
with giant ceII tumor which is between twenty-nine and thirty years of age. 2. In every case trauma has been a predisposing factor. Some pathoIogists consider a benign giant ceI1 tumor as a granuIoma resuIting from an organization of a rather extensive hematoma in the bone marrow. This concept wouId bear out the cIinica1 anaIysis of trauma in aImost every case reported.
of PateIIa
American Journaf of Surgery
289
3. UnIike the majority IO:$ this case is of a maIe. 4. Excision of the pateHa is the treatment of choice and has the most successfuJ results. REFERENCES I. LINDE, S. ARTHUR. Giant ceII tumor of the patella.
Am. J. Surg., 28: ISO, 1935. 2. DILLEHIJNT, RICHARDB. and CHUINARD,E. GEORGE, Giant cell tumor of the patella. West. J. Surg., Obst. t’s+qynec., 46: 525, 1938.
EVERY severeIy wounded person is shocked, especially if there is accompanying soft tissue damage and hemorrhage such as occurs with compound fractures. Shock shouId be anticipated and prevented as much as possibIe. When the patient is severely shocked, the general treatment must have precedence over IocaI treatment. From “Fractures and Dislocations for Practitioners” by Edwin 0. GeckeIer (Williams & Wilkins Company).