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Recurrent metacarpal giant cell tumour treated by en bloc resection and metatarsal transfer
RECURRENT METACARPAL BY EN BLOC RESECTION
GIANT CELL TUMOUR TREATED AND METATARSAL TRANSFER
J. PARDO-MONTANER, A. PINA-MEDINA and M. BARCELO-ALCAI~IZ
From the Service of Traumatology and Orthopaedic Surgery, La Fd Hospital, Valencia, Spain Recurrent giant-cell tumours of bone have a higher risk of malignancy than primary giant-cell tumours of bone, and giant-cell tumours of bone in the hand are~more likely to recur than those that arise elsewhere. Therefore, en bloc resection and reconstruction, or amputation, have been the accepted treatments for recurrent giant-cell tumours of bone in the hand. We describe two cases of successful transplantion of a metatarsal to a metacarpal, which was the site of a recurrent giant-ceil tumour. The patients had satisfactory results 3 years later without problems in the foot. En bloc resection of the tumour and reconstruction with an autograft should be considered in the treatment of recurrent giant cell tumour of the hand.
Journal of Hand Surgery (British and European Volume, 1998) 23B." 2." 275-278 Giant cell tumour of bone accounts for 5% of all primary bone tumours (Dahlin and Unni, 1996; Goldenberg et al, 1970; Jaffe, 1953; Jaffe et al, 1940; McGrath, 1972). Giant cell tumours in the hand are rare. Minguella (1982) found that only 3% of all giant cell tumours of bone affected the hand. Averill et al (1980) reviewed 20 reported series of 1,228 giant cell tumours of bones. They found that 2% occurred in hand bones, almost 1% in metacarpals and 1% in phalanges. Recurrent giant-cell tumours of bone have a higher risk of malignancy than primary giant-cell tumours of bone (Goldenberg et al, 1970; Hutter et al, 1962), and giant-cell tumours of bone in the hand are more likely to recur than those that arise elsewhere (Averill et al, 1980; Patel et al, 1987). Therefore, en bloc resection and reconstruction, or amputation, have been the accepted treatments for recurrent phalangeal giant-cell tumours of bone in the hand (Averill et al, 1980; Eckardt and Grogan, 1986; Patel et al, 1987). We describe two cases of successful transplantion of a metarsal to replace a metacarpal which was the location of a recurrent giant-cell tumour.
The open biopsy confirmed the diagnosis of giant-cell tumour. Six weeks after the operation X-ray showed a disappearance of bony trabeculation and recurrence. This was treated with curettage and packing with polymethylmethacrylate cement. Four years later it had again recurred. It seemed obvious that a third curettage would not be feasible because of the thinning of the cortex. Therefore, it was decided to do an en bloc resection of the tumour and reconstruction by an osteoarticular autograft of the metatarsal from the left foot. A dorsal incision was again used to expose the metacarpal, from the metacarpophalangeal joint to the proximal metacarpal, and it was released from its attachments to the proximal phalanx. The metacarpal was excised en bloc, except in its proximal third. The fourth metatarsal was taken from the left foot and used to replace the excised metacarpal. It was fixed with a K-wire and staple to avoid rotation (Fig lb). Repeated X-ray examinations in the following months showed some narrowing of the metacarpophalangeal joint, and slight change in the structure of the head of the autograft. However, no change in the density of the transplanted metatarsal was observed (Fig lc). After 3 years there was no loss of joint mobility and no pain. There was no evidence of recurrence of the tumour. Chest X-ray showed no lung metastases.
CASE REPORTS Case 1
Case 2
A 22-year-old man was first seen by us in January 1990 after he had swelling and pain in the area of the left hand ring finger that had occurred suddenly without any history of injury. Examination showed that the patient was in good general physical condition. There was a fusiform non-tender swelling of the distal metacarpal of the left ring finger ray. Mobility of the joints of the finger was restricted. X-rays revealed a lytic expansile lesion in the distal end of the metacarpal (Fig la). There was cortical thinning and expansion and the suggestion of loculation. A bone scan showed a solitary region of increased uptake at that site. Laboratory evaluation revealed normal findings. In February 1990, the lesion was curetted and a bone graft from the right iliac crest was inserted into the cavity.
A 21-year-old man was first seen by us in March 1993 because of swelling and pain in the area of the ring finger of the left hand that had occurred suddenly without history of injury. Examination showed that he was in good general physical condition. There was a fusiform non-tender swelling of the distal metacarpal of the left ring finger. Mobility of the joints of the finger was not restricted. Radiographs revealed a lytic expansile lesion in the distal end of the ring finger metacarpal. There was cortical thinning and expansion and the suggestion of loculation (Fig 2a). A bone scanshowed a solitary region of increased uptake at that site. Laboratory evaluation revealed normal findings. 275
276
THE JOURNAL OF HAND SURGERY VOL. 23B No. 2 APRIL 1997
Fig 1 (a) Case 1. Preoperative X-ray of the hand showing the expansile lytic tumour of the ring finger metacarpal. (b) Postoperative X-ray showing replacement with a metatarsal autograft. (c) X-ray 3 years later showing some narrowing of the metacarpophalangeal joint.
in soft tissues; this finding was consistent with recurrent giant-cell tumour (Fig 2b). A bone scan indicated a single focus of increased uptake in the ring finger metacarpal (Fig 2c). In November 1993, the lesion was treated by en bloc resection of the tumour including the involved soft tissues and reconstruction with an osteoarticular autograft using the same technique as in the previous case (Fig 2d). X-rays studies showed good osteointegration of the autograft bone and there was no evidence of local recurrence (Fig 2e). Narrowing of the space joint was again observed with slight loss of the trabeculation in the head of the bone graft. After 3 years there was no loss of mobility and no pain. There was no evidence of recurrence of the tumour. Chest X-ray showed no lung metastases. DISCUSSION In March 1993, the lesion was curetted and a bone graft from the ipsilateral olecranon was inserted into the cavity. The open biopsy confirmed the diagnosis of giant-cell tumour. During the next few months, radiographic studies showed recurrence of the tumour. Magnetic resonance imaging demonstrated an increased T2 signal in the distal part of the metacarpal and tumour
Giant cell tumour in the hand has been considered to be aggressive, with an earlier and higher rate of recurrence than in other skeletal sites (Patel et al, 1987). It seems that giant cell tumour of the bones in the hand is not only aggressive and associated with a higher incidence of recurrence but it also has a predilection for pulmonary metastasis. Metastasis to bone is extremely rare (Patel et al, 1987; Sanjay et al, 1996). Local recurrence is a well
RECURRENT METACARPALGIANT CELL TUMOUR
277
Fig 2 (a) Case 2. Preoperative X-ray of the hand showing the expansile lytic tumour of the ring finger metacarpal. (b) Magnetic resonance imaging demonstrating an increased signal in the distal part of the metacarpal and extension of the turnout into soft tissues. (c) A bone scan showing increased uptake in the ring finger metacarpal. (d) Postoperative X-ray showing replacement with a metatarsal autograft. (e) Anteroposterior radiograph of the left ring finger 3 years after transplantation of the metatarsal.
278
documented problem. It has been as frequent as 50% after simple curettage (Jacobs and Clemency, 1985; Johnson and Dahlin, 1959) and 7% after excision with curettage (Sung et al, 1982). It has been reported to be 0% after wide or radical resection (Campanacci et al, 1987). More than 95% of recurrences of giant cell tumour of bone occur within 2 years of surgery (Goldenberg et al, 1970) and in the hand, tumours recur within a year (Averill et al, 1980; Scully et al, 1994). Curettage alone or curettage with bone grafting is usually not effective in treating giant cell tumours of the hand (Sanjay et al, 1996). In general, the best results have been obtained by en bloc excision of the giant cell tumours (Averill et al, 1980; Goldenberg et al, 1970; McDonald et al, 1986; McGrath, 1972; Sung et al, 1982). Reconstruction with an autograft should be done where necessary to obtain a functional and cosmetically acceptable hand. We describe a technique of transfering a part or all of a metatarsal bone as an articular graft to substitute for metacarpal bone loss. The advantage of a transplantation procedure in the treatment of giant-cell tumours of the bones in the hand is that the length of the finger and the function of the hand are retained (Torpey et al, 1994). The osteointegration of the autograft is good, without problems at the donor site. It is our impression, however, that anatomical congruency, reconstruction of ligaments, and the technique of internal fixation are all important factors. En bloc resection of the tumour and reconstruction with autograft should be considered in the treatment of recurrent giant cell tumour of the hand (Sanjay et al 1996). References Averill R M, Smith R J, Campbell C J (1980). Giant cell tumors of the bones of the hand. Journal of H a n d Surgery, 5A: 3 9 4 9 .
THE J O U R N A L OF H A N D SURGERY VOL. 23B No. 2 A P R I L 1992 Campanacci M, Baldini N, Boriani S, Sudanese A (1987). Giant-cell tumor o bone. Journal of Bone and Joint Surgery, 69A: 106 114. Dahlin D C, Unni K K. Bone tumors: General aspects and data on 11,087 cases' 5th edn. Philadelphia, Lippincott-Raven, 1996: 285. Eckardt J J, Grogan T J (1986). Giant cell tumor of bone. Clinical Orthopaedic: and Related Research, 204:45 58. Goldenberg R R, Campbell C J, Bonfiglio M (1970). Giant cell tumour of bone: at analysis of 218 cases. Journal of Bone and Joint Surgery, 52A: 61%663. Hurter R V P, Worcester J N, Francis K C, Foote F W, Stewart F W (1962) Benign and malignant giant cell tumors of bone. A clinicopathologica analysis of the natural history of the disease. Cancer, 15:653 690. Jacobs P A, Clemency R E (1985). The closed cryosurgical treatment of giant cel tumor. Clinical Orthopaedics and Related Research, 192:149 158. Jaffe H L (1953). Giant cell tumour (osteoclastoma of bone): its pathologi~ delimitation and the inherent clinical implication. Annals of the Roya College of Surgeons, i3: 343-353. Jaffe H L, Lichtenstein L, Portis R B (1940). Giant cell tumour of bone: it'. pathologic appearance, grading, supposed variants and treatment Archives of Pathology, 30:993-1031. Johnson E W, Dahlin D C (1959). Treatment of giant-cell tumor of bone. Journa of Bone and Joint Surgery, 41A: 895 904. McDonald D J, Sim F H, Mcleod R A, Dahlin D C (1986). Giant cell tumor o bone. Journal of Bone and Joint Surgery, 68A: 236-242. McGrath P J (1972). Giant cell tumor of bone. An analysis of 52 cases. Journal o Bone and Joint Surgery, 54B: 216-227. Minguella J (1982). Giant cell tumor of the metacarpal in a child of unusual ag~ and site. The Hand, 14: 9 3 4 6 . Patel M R, Desai S S, Gordon S L, Nimberg G A, Sclafani S J, Vigorita V J Mirra J H, Sung H W (1987). Management of skeletal giant cell tumor~ of the phalanges of the hand. Journal of H a n d Surgery, 12A: 70-77. Sanjay B K S, Raj G A, Younge D A (1996). Giant cell tumours of the hand Journal of Hand Surgery, 21B: 683-687. Scully S P, Mott M P, Temple H T, O'Keefe R J, O'Donnell R J, Mankin H . (1994). Late recurrence of giant cell tumor of bone: a report of fou: cases. Journal of Bone and Joint Surgery, 76A: 1231-1233. Sung H W, Kuo D P, Shu W P, Chai Y B, Liu C C, Li S M (1982). Giant cel tumor of bone: analysis of two hundred and eight cases in Chines~ patients. Journal of Bone and Joint Surgery, 64A: 755~61. Torpey B, Faierman E, Lehmann O (1994). Phalangeal transfer for recurren giant cell tumor of the phalanx of a finger in a nine year-old child. A cas~ report with forty one year follow-up. Journal of Bone and Joint Surgery 76A: 1864-1869.
Received: 28 April 1997 Accepted after revision: 6 August 1997 A. Pina-Medina MD, c/Guardia Civil 22 5, pta 6, 46020-Valancia,Spain. © 1998The British Society for Surgery of the Hand
GIANT CELL TUMOUR TREATED AND METATARSAL TRANSFER
J. PARDO-MONTANER, A. PINA-MEDINA and M. BARCELO-ALCAI~IZ
From the Service of Traumatology and Orthopaedic Surgery, La Fd Hospital, Valencia, Spain Recurrent giant-cell tumours of bone have a higher risk of malignancy than primary giant-cell tumours of bone, and giant-cell tumours of bone in the hand are~more likely to recur than those that arise elsewhere. Therefore, en bloc resection and reconstruction, or amputation, have been the accepted treatments for recurrent giant-cell tumours of bone in the hand. We describe two cases of successful transplantion of a metatarsal to a metacarpal, which was the site of a recurrent giant-ceil tumour. The patients had satisfactory results 3 years later without problems in the foot. En bloc resection of the tumour and reconstruction with an autograft should be considered in the treatment of recurrent giant cell tumour of the hand.
Journal of Hand Surgery (British and European Volume, 1998) 23B." 2." 275-278 Giant cell tumour of bone accounts for 5% of all primary bone tumours (Dahlin and Unni, 1996; Goldenberg et al, 1970; Jaffe, 1953; Jaffe et al, 1940; McGrath, 1972). Giant cell tumours in the hand are rare. Minguella (1982) found that only 3% of all giant cell tumours of bone affected the hand. Averill et al (1980) reviewed 20 reported series of 1,228 giant cell tumours of bones. They found that 2% occurred in hand bones, almost 1% in metacarpals and 1% in phalanges. Recurrent giant-cell tumours of bone have a higher risk of malignancy than primary giant-cell tumours of bone (Goldenberg et al, 1970; Hutter et al, 1962), and giant-cell tumours of bone in the hand are more likely to recur than those that arise elsewhere (Averill et al, 1980; Patel et al, 1987). Therefore, en bloc resection and reconstruction, or amputation, have been the accepted treatments for recurrent phalangeal giant-cell tumours of bone in the hand (Averill et al, 1980; Eckardt and Grogan, 1986; Patel et al, 1987). We describe two cases of successful transplantion of a metarsal to replace a metacarpal which was the location of a recurrent giant-cell tumour.
The open biopsy confirmed the diagnosis of giant-cell tumour. Six weeks after the operation X-ray showed a disappearance of bony trabeculation and recurrence. This was treated with curettage and packing with polymethylmethacrylate cement. Four years later it had again recurred. It seemed obvious that a third curettage would not be feasible because of the thinning of the cortex. Therefore, it was decided to do an en bloc resection of the tumour and reconstruction by an osteoarticular autograft of the metatarsal from the left foot. A dorsal incision was again used to expose the metacarpal, from the metacarpophalangeal joint to the proximal metacarpal, and it was released from its attachments to the proximal phalanx. The metacarpal was excised en bloc, except in its proximal third. The fourth metatarsal was taken from the left foot and used to replace the excised metacarpal. It was fixed with a K-wire and staple to avoid rotation (Fig lb). Repeated X-ray examinations in the following months showed some narrowing of the metacarpophalangeal joint, and slight change in the structure of the head of the autograft. However, no change in the density of the transplanted metatarsal was observed (Fig lc). After 3 years there was no loss of joint mobility and no pain. There was no evidence of recurrence of the tumour. Chest X-ray showed no lung metastases.
CASE REPORTS Case 1
Case 2
A 22-year-old man was first seen by us in January 1990 after he had swelling and pain in the area of the left hand ring finger that had occurred suddenly without any history of injury. Examination showed that the patient was in good general physical condition. There was a fusiform non-tender swelling of the distal metacarpal of the left ring finger ray. Mobility of the joints of the finger was restricted. X-rays revealed a lytic expansile lesion in the distal end of the metacarpal (Fig la). There was cortical thinning and expansion and the suggestion of loculation. A bone scan showed a solitary region of increased uptake at that site. Laboratory evaluation revealed normal findings. In February 1990, the lesion was curetted and a bone graft from the right iliac crest was inserted into the cavity.
A 21-year-old man was first seen by us in March 1993 because of swelling and pain in the area of the ring finger of the left hand that had occurred suddenly without history of injury. Examination showed that he was in good general physical condition. There was a fusiform non-tender swelling of the distal metacarpal of the left ring finger. Mobility of the joints of the finger was not restricted. Radiographs revealed a lytic expansile lesion in the distal end of the ring finger metacarpal. There was cortical thinning and expansion and the suggestion of loculation (Fig 2a). A bone scanshowed a solitary region of increased uptake at that site. Laboratory evaluation revealed normal findings. 275
276
THE JOURNAL OF HAND SURGERY VOL. 23B No. 2 APRIL 1997
Fig 1 (a) Case 1. Preoperative X-ray of the hand showing the expansile lytic tumour of the ring finger metacarpal. (b) Postoperative X-ray showing replacement with a metatarsal autograft. (c) X-ray 3 years later showing some narrowing of the metacarpophalangeal joint.
in soft tissues; this finding was consistent with recurrent giant-cell tumour (Fig 2b). A bone scan indicated a single focus of increased uptake in the ring finger metacarpal (Fig 2c). In November 1993, the lesion was treated by en bloc resection of the tumour including the involved soft tissues and reconstruction with an osteoarticular autograft using the same technique as in the previous case (Fig 2d). X-rays studies showed good osteointegration of the autograft bone and there was no evidence of local recurrence (Fig 2e). Narrowing of the space joint was again observed with slight loss of the trabeculation in the head of the bone graft. After 3 years there was no loss of mobility and no pain. There was no evidence of recurrence of the tumour. Chest X-ray showed no lung metastases. DISCUSSION In March 1993, the lesion was curetted and a bone graft from the ipsilateral olecranon was inserted into the cavity. The open biopsy confirmed the diagnosis of giant-cell tumour. During the next few months, radiographic studies showed recurrence of the tumour. Magnetic resonance imaging demonstrated an increased T2 signal in the distal part of the metacarpal and tumour
Giant cell tumour in the hand has been considered to be aggressive, with an earlier and higher rate of recurrence than in other skeletal sites (Patel et al, 1987). It seems that giant cell tumour of the bones in the hand is not only aggressive and associated with a higher incidence of recurrence but it also has a predilection for pulmonary metastasis. Metastasis to bone is extremely rare (Patel et al, 1987; Sanjay et al, 1996). Local recurrence is a well
RECURRENT METACARPALGIANT CELL TUMOUR
277
Fig 2 (a) Case 2. Preoperative X-ray of the hand showing the expansile lytic tumour of the ring finger metacarpal. (b) Magnetic resonance imaging demonstrating an increased signal in the distal part of the metacarpal and extension of the turnout into soft tissues. (c) A bone scan showing increased uptake in the ring finger metacarpal. (d) Postoperative X-ray showing replacement with a metatarsal autograft. (e) Anteroposterior radiograph of the left ring finger 3 years after transplantation of the metatarsal.
278
documented problem. It has been as frequent as 50% after simple curettage (Jacobs and Clemency, 1985; Johnson and Dahlin, 1959) and 7% after excision with curettage (Sung et al, 1982). It has been reported to be 0% after wide or radical resection (Campanacci et al, 1987). More than 95% of recurrences of giant cell tumour of bone occur within 2 years of surgery (Goldenberg et al, 1970) and in the hand, tumours recur within a year (Averill et al, 1980; Scully et al, 1994). Curettage alone or curettage with bone grafting is usually not effective in treating giant cell tumours of the hand (Sanjay et al, 1996). In general, the best results have been obtained by en bloc excision of the giant cell tumours (Averill et al, 1980; Goldenberg et al, 1970; McDonald et al, 1986; McGrath, 1972; Sung et al, 1982). Reconstruction with an autograft should be done where necessary to obtain a functional and cosmetically acceptable hand. We describe a technique of transfering a part or all of a metatarsal bone as an articular graft to substitute for metacarpal bone loss. The advantage of a transplantation procedure in the treatment of giant-cell tumours of the bones in the hand is that the length of the finger and the function of the hand are retained (Torpey et al, 1994). The osteointegration of the autograft is good, without problems at the donor site. It is our impression, however, that anatomical congruency, reconstruction of ligaments, and the technique of internal fixation are all important factors. En bloc resection of the tumour and reconstruction with autograft should be considered in the treatment of recurrent giant cell tumour of the hand (Sanjay et al 1996). References Averill R M, Smith R J, Campbell C J (1980). Giant cell tumors of the bones of the hand. Journal of H a n d Surgery, 5A: 3 9 4 9 .
THE J O U R N A L OF H A N D SURGERY VOL. 23B No. 2 A P R I L 1992 Campanacci M, Baldini N, Boriani S, Sudanese A (1987). Giant-cell tumor o bone. Journal of Bone and Joint Surgery, 69A: 106 114. Dahlin D C, Unni K K. Bone tumors: General aspects and data on 11,087 cases' 5th edn. Philadelphia, Lippincott-Raven, 1996: 285. Eckardt J J, Grogan T J (1986). Giant cell tumor of bone. Clinical Orthopaedic: and Related Research, 204:45 58. Goldenberg R R, Campbell C J, Bonfiglio M (1970). Giant cell tumour of bone: at analysis of 218 cases. Journal of Bone and Joint Surgery, 52A: 61%663. Hurter R V P, Worcester J N, Francis K C, Foote F W, Stewart F W (1962) Benign and malignant giant cell tumors of bone. A clinicopathologica analysis of the natural history of the disease. Cancer, 15:653 690. Jacobs P A, Clemency R E (1985). The closed cryosurgical treatment of giant cel tumor. Clinical Orthopaedics and Related Research, 192:149 158. Jaffe H L (1953). Giant cell tumour (osteoclastoma of bone): its pathologi~ delimitation and the inherent clinical implication. Annals of the Roya College of Surgeons, i3: 343-353. Jaffe H L, Lichtenstein L, Portis R B (1940). Giant cell tumour of bone: it'. pathologic appearance, grading, supposed variants and treatment Archives of Pathology, 30:993-1031. Johnson E W, Dahlin D C (1959). Treatment of giant-cell tumor of bone. Journa of Bone and Joint Surgery, 41A: 895 904. McDonald D J, Sim F H, Mcleod R A, Dahlin D C (1986). Giant cell tumor o bone. Journal of Bone and Joint Surgery, 68A: 236-242. McGrath P J (1972). Giant cell tumor of bone. An analysis of 52 cases. Journal o Bone and Joint Surgery, 54B: 216-227. Minguella J (1982). Giant cell tumor of the metacarpal in a child of unusual ag~ and site. The Hand, 14: 9 3 4 6 . Patel M R, Desai S S, Gordon S L, Nimberg G A, Sclafani S J, Vigorita V J Mirra J H, Sung H W (1987). Management of skeletal giant cell tumor~ of the phalanges of the hand. Journal of H a n d Surgery, 12A: 70-77. Sanjay B K S, Raj G A, Younge D A (1996). Giant cell tumours of the hand Journal of Hand Surgery, 21B: 683-687. Scully S P, Mott M P, Temple H T, O'Keefe R J, O'Donnell R J, Mankin H . (1994). Late recurrence of giant cell tumor of bone: a report of fou: cases. Journal of Bone and Joint Surgery, 76A: 1231-1233. Sung H W, Kuo D P, Shu W P, Chai Y B, Liu C C, Li S M (1982). Giant cel tumor of bone: analysis of two hundred and eight cases in Chines~ patients. Journal of Bone and Joint Surgery, 64A: 755~61. Torpey B, Faierman E, Lehmann O (1994). Phalangeal transfer for recurren giant cell tumor of the phalanx of a finger in a nine year-old child. A cas~ report with forty one year follow-up. Journal of Bone and Joint Surgery 76A: 1864-1869.
Received: 28 April 1997 Accepted after revision: 6 August 1997 A. Pina-Medina MD, c/Guardia Civil 22 5, pta 6, 46020-Valancia,Spain. © 1998The British Society for Surgery of the Hand