|Year : 2020 | Volume
| Issue : 1 | Page : 34-36
Giant-cell tumor of the metacarpal in a young female: A rare case report
Seema Singhal1, Chander Shekhar2
1 Department of Pathology, Indraprastha Apollo Hospital, Delhi, India
2 Department of Orthopedics, Indraprastha Apollo Hospital, Delhi, India
|Date of Submission||21-Nov-2019|
|Date of Acceptance||30-Dec-2019|
|Date of Web Publication||17-Mar-2020|
Department of Pathology, Indraprastha Apollo Hospital, Delhi
Source of Support: None, Conflict of Interest: None
Giant-cell tumors (GCTs) or osteoclastomas of the bone are locally aggressive tumors with tendency for local recurrence. The tumors show predilection for women with majority of patients in the third or fourth decades of life. Usually, GCT involves the ends of long bones. The most common sites involved are the distal femur, proximal tibia, distal radius, and the sacrum. Unusual locations such as scapula, skull, and small bones of the hand and feet are involved in approximately 2% of cases. Involvement of metacarpal has been reported in few cases so far. We report a case of GCT in the first metacarpal in a 16-year-old girl. We discuss the clinical, pathological, and radiological features. Awareness of this location is important, and GCT should be included in the differential diagnosis of expansile lesions of the small bones of the hand.
Keywords: Giant cell tumor, GCT, metacarpal
|How to cite this article:|
Singhal S, Shekhar C. Giant-cell tumor of the metacarpal in a young female: A rare case report. Apollo Med 2020;17:34-6
| Introduction|| |
We report a case of GCT in first metacarpal in a 16 year old girl. We discuss the clinical, pathological and radiological features. Awareness of this location is important.
| Case Report|| |
A 16-year-old girl presented with a swelling over her left hand with restricted movements of the left thumb for the past 6 months. There was no history of trauma. Local examination revealed a firm swelling on the thenar aspect, which was nontender [Figure 1]. The movements of the left thumb were grossly restricted. The rest of her general physical examination was unremarkable. Hematological investigations were within normal range.
The radiograph of the hand [Figure 2] revealed an expansile lytic lesion with “soap bubble appearance” involving the first metacarpal. The whole extent of the metacarpal was involved with subarticular extension of the lesion. No abnormal intralesional calcification was seen. The cortex was thinned out, but no obvious cortical breech or soft tissue mass was seen.
|Figure 2: X-ray hand (anteroposterior and oblique views) shows grossly expansile “soap bubble” lesion involving the first metacarpal. No cortical breech of soft tissue extension was seen|
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The differential diagnosis of aneurysmal bone cyst (ABC), enchondroma, brown tumor, histiocytosis, and giant-cell tumor (GCT) was considered and biopsy was advised.
The tissue sections [Figure 3] showed the presence of proliferation of two cell populations. The mononuclear cells were round to oval, whereas the multinucleated giant cells were numerous, uniformly scattered throughout the lesion. The nuclei of the giant cells resembled those of the mononuclear cells. There was no cytological atypia and mitosis. No osteoid formation was noted.
|Figure 3: (a) A well-vascularized, highly cellular tissue consisting of stromal mononuclear cells and multinucleated giant cells present in close association with each other (H and E, ×100). (b) Multinucleated giant cells uniformly present throughout the lesion (H and E, ×200)|
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On correlation of the histopathological and with radiological features, a diagnosis of GCT of the first metacarpal was given.
The patient underwent en bloc resection with auto bone graft and had an uneventful recovery. She was called for a follow-up visit to detect any local recurrence, but she did not come back, possibly because she remained symptom free.
| Discussion|| |
Lumps and bumps at the hands are commonly seen. Mostly, such growths are benign tumors; however, it is always imperative to avoid the misdiagnosis of a malignant tumor., A complete history and physical examination with special attention to the affected limb, supplemented by radiological studies and biopsies, are fundamental to obtain the correct diagnosis and the proper treatment.
GCTs of bones of the hand are rare, accounting for only 2% of cases, and here too phalangeal location of the tumor is more common than metacarpals.
GCT of the small bones appears as expansile lytic lesions and lacks any diagnostic radiographic feature. The differential diagnosis includes simple bone cyst, ABC, brown tumor, enchondromas, fibrous dysplasias, and rarely giant-cell reparative granuloma (GCRG) and metastasis.
Simple bone cyst and ABC have liquid contents, whereas GCT is solid which can be made out on magnetic resonance imaging scan.
Enchondromas are common in hand and have mild-to-moderate degree of expansion and may reveal chondroid calcification. Fibrous dysplasias and brown tumors can cause gross expansion, but are not so common in hand.
GCT of the hand is most frequently found in patients aged 20–40 years. Distal radius is affected most commonly. Few cases report GCT in small bones of the hand.,,
In addition, GCTs of the small bones have higher tendency of multicentricity, thus warranting a bone scan in each case. Furthermore, the tendency for recurrence is higher.
Our case was different from those reported because of young age of 16 years of presentation with involvement of the first metacarpal and presence of subarticular extension on radiography. This was a rare presentation of GCT at a rare site.
A Tru-cut needle biopsy was performed which clearly showed a GCT.
Microscopically, true GCT shows proliferation of two cell populations. The mononuclear cells are round to oval and usually distributed throughout the lesion. The nuclei of giant cells resemble those of the mononuclear cells and there is uniform distribution of giant cells. There should be no cytological atypia and mitosis.
Pathologically, the differential diagnosis of GCT includes many conditions that contain large number of giant cells such as enchondromas, ABC, unicameral bone cyst, and also few reactive conditions such as brown tumor of hyperparathyroidism and GCRG.
Enchondromas are microscopically quite hypercellular. Binucleated cells are frequent and there may be even myxoid change.
ABC shows cysts of various sizes separated by septa. Benign giant cells are usually present in ABC, but they form small clusters. However, rarely, appearance of GCT may form due to abundance of giant cells, but in these cases, the background shows fibrosis, and the cells are spindle shaped rather than oval as in GCT.
Unicameral bone cysts show thin fibrous lining the cysts. Few macrophages, giant cells, and leukocytes are seen.
In chondroblastoma, chondroid differentiation or mineralization must be seen microscopically, for the diagnosis.
Hyperparathyroidism produces brown cell tumors. Histologically, tissue sections show uneven clusters of hemosiderin-laden macrophages and reabsorption of bone trabeculae; trabeculation of unmineralized new bone; and a mixed population of osteoblasts, mononuclear cells, and multilocular giant cells.
GCRG consists of mononuclear, spindle-shaped, stromal cells along with multinucleated giant cells. In GCRG, the giant cells tend to cluster, whereas in GCT, there is uniform distribution of giant cells.
On radiological and pathological features, the diagnosis was not difficult in this case as the classical features were seen, but it was an unusual diagnosis at a rare site.
The treatment is usually surgical. The options include arthroplasty or arthrodesis for reconstruction of larger defects. In the past, intralesional curettage was associated with a significant rate of recurrence. Currently, the use of adjuvant (e.g., cryosurgery and bone cement packing) has decreased the rate of recurrence following intralesional curettage. With the use of these adjuvants, the rate of recurrence has decreased to below 10%. However, others still believe that the rate of local recurrence remains despite the use of bone grafting. Others have performed arthrodesis of the wrist following GCT resection, using a vascularized fibular flap for large lesions.
En bloc resection and bone grafting was done in this case due to limitation of resources.
| Conclusion|| |
Although GCTs of hand bones are rare, the awareness of its existence is essential as the lesion is most aggressive than other differentials and requires an early treatment. Thus, GCT should be included in the differential diagnosis of expansile lytic lesion of the small bones of the hand.
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Conflicts of interest
There are no conflicts of interest.
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