Introduction

Giant cell tumour (GCT), also known as Osteoclastoma, is a locally aggressive benign bone tumour, arising from epiphysis of long bones [1]. It commonly occurs in 20 to 40 year of age group and is more common in females [2]. Most common locations are distal femur, proximal tibia, distal radius and spine [3]. The proximal radius is an extremely rare site for giant cell tumours, in contrast to the distal radius. The prevalence of GCT proximal radius is reported to be 0.16%- 0.5% of all GCT cases [4].

We here thus present a rare such case of this tumour i.e. GCT in proximal radius in a twenty one year old female who was successfully managed by wide marginal resection of proximal radius.

Case report

A 21-year old female with right hand dominance presented to orthopaedic department with complain of pain and swelling over non-dominant left elbow and upper forearm since 1 month. Constitutional symptoms were absent. She had taken no treatment, except some analgesics and had never consulted a doctor.

Pain was insidious in onset, gradually progressive, localized to left lateral elbow and forearm, dull aching in character which was aggravated with supination-pronation and relieved temporarily by taking rest and oral analgesics. The pain was associated with mild to moderate swelling over the forearm and elbow which was more on the lateral aspect. Family history and past history were unremarkable. There was no other swelling in any other body parts.

On examination, there was localised moderate tenderness at radial head. On palpation, swelling was mild localized and was hard in consistency and immobile, whereas due to the swelling the deeper radial head could not be palpated. Bleeding or ulceration was absent. Range of motion (ROM) in the left elbow joint was 0° -140° of flexion, 40° of pronation, and 45° of supination (Figure 1). Distal neurovascular status was normal. All laboratory investigations were within normal limit.

Plain radiograph of affected elbow and forearm showed a relatively well-defined expansile lytic lesion in epiphysio-metaphyseal region of proximal radius with geographical bone destruction and loss of contours of radial head and neck (Figure 2).

Magnetic resonance imaging (MRI) T1 axial and sagittal image showed relatively well defined hyper-intense osteolytic destructive lesion involving proximal radius with cortical breach at anterolateral and postero-medial aspect (figure 3).

The radiological and MRI features showed the typical features of giant cell tumor, but to confirm the diagnosis needle biopsy was taken which showed stromal cells, numerous osteoclastic giant cells and scattered lymphocytes, which confirmed the diagnosis of Giant cell tumor of proximal radius.

Figure 4: Intra-operative photograph (a & b) showing the lesion involving the neck and proximal shaft of radius. Note the cartilage of radial head visible (black arrow).

Post-operatively, patient’s limb was kept in above elbow slab, which was removed after suture removal. She did not have any wound problems post-operatively. At final follow of 12 months, she had nearly full range of flexion/extension at elbow and supination/pronation with no clinical or radiological symptoms and signs of recurrence of tumour (figure 5).

Figure 5: Post-operative radiograph AP (a) and lateral (b) view and clinical photo (c & d) at 1 year post surgery. There were no signs of recurrence and complete range of pronation and supination.

Discussion

Giant cell tumour is a bone tumor that is most common in third to fourth decade of life, though rarely seen in younger age group also. It is benign but locally aggressive tumour involving epiphyseal region of skeletally mature long bones [1,2].

Patients may present with pain, swelling or pathological fracture. Radiologically, it presents as eccentric, expansile, lytic lesion in the epiphyses of long bones [1,2]. Distal femur, proximal tibia and distal radius are the usual sites involved [3,4].

Dahuja A et al performed resection and reconstruction with fibula autograft [15], Nayar SK et al performed resection and reconstruction with osteoarticular allograft [16]. Song WS et al performed reconstruction with polyethylene insert; pins, screws and bone cement [13], whereas Sakayama K et al used floating radial head prosthesis [10].

Resection and reconstruction with radial head prosthesis is a good option, when the tumor is small. Further loosening of the prosthesis is one of the most serious complications, but the major limitation with the use of radial head prosthesis (RHP) is that only short to midterm results are known and long term results of RHP are not known and the cost of RHP is a big issue especially in developing countries [19,20].

Osteoarticular allografts have been used for reconstruction after resection of giant cell tumor, which is cost effective, restores the bone stock and promotes biological bone union. But the drawbacks are that it is technically demanding surgery, long healing time, risk of fracture, risk of disease transmission, and surgical site infection [21-24]. Considering the benign nature of tumor, amputation per se has little place in the treatment of giant cell tumours.

In our case, the patient presented to us late, by that time, the disease had advanced to the extent where, curettage and bone grafting was not an advisable option, because of fear of recurrence [25,26]. Hence we planned the patient for extensive marginal resection. Resection alone, in our case appeared to be completely effective in eradicating the disease and providing excellent functional outcome. In our patient on last follow-up, she had nearly full range of flexion/extension at elbow, and supination/pronation after extensive supervised physiotherapy.

Conclusion

GCT of proximal radius is very rare tumor, for which, wide margin resection of tumour is a good, cost effective treatment with no recurrence, minimal complications, and disability.

References