Musculoskeletal Imaging

Giant cell tumour

a locally aggressive neoplasm composed of connective tissue, giant cells and stromal cells. Earliest manifestations include pain, local swelling, limitation of motion and pathologic fractures. The sites affected most frequently are the long tubular bones, bones about the knee, spine, and innominate bone. The epiphyses of the tubular bones will have been involved extensively by the time of diagnosis, although the tumour may originate in the metaphysis. Metaphyseal location is especially noted in children and adolescents. In other bones (sternum, clavicle, scapula, ribs) the tumour is present in subchondral regions. Giant cell tumours may also arise within a tendon sheath, especially in the fingers and wrist, or from joint capsules or ligaments.

On radiographs, the long and short tubular bones reveal eccentric osteolytic lesions extending to the subchondral bone (Fig.1). A delicate trabecular pattern results from subsequent cortical thinning and expansion. Violation of the cortical surface and spread into contiguous soft tissues is striking evidence of the aggressiveness of some giant cell tumours. Tumours involving the flat bones may also be osteolytic; vertebral collapse may occur if the spine is affected.

Other imaging techniques that are helpful in diagnosing giant cell tumours are bone scintigraphy, CT scanning, angiography and MR imaging. With MR imaging, intraosseous fluid levels may be seen. Recurrence is common, and the tumour may spread passively by vascular transport to a distant site, particularly the lungs, in a manner distinct from malignant metastasis. In some cases, however, malignant transformation may occur. Giant cell tumours may be associated with Pagets disease. In this disorder, the bones affected are always those that are also involved in Paget's disease (skull, facial bones).

Giant cell tumours of a tendon sheath represent a nodular lesion of a tendon sheath in the hand or foot, which may sometimes be confused with pigmented villonodular synovitis because of similar histologic features (Fig.2).

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Fig.2

Giant cell tumour of tendon sheath. a. Oblique radiograph of the foot demontrates a well-defined eccentric erosion at the base of the 5th metatarsal and the adjacent cuboid due to a giant cell tumour of the tendon sheath. b, c. Sagittal T1-weighted (b) and T2-weighted (c) MR images of the same foot demonstrate a low signal intensity soft tissue mass on both pulse sequences. (Courtesy of Roger Kerr, MD; Santa Monica, California)
Giant cell tumour, Fig.1 (a)
Giant cell tumour, Fig.1 (b)
Giant cell tumour, Fig.1 (c)
Giant cell tumour, Fig.1 (d)
Giant cell tumour, Fig.2 (a)
Giant cell tumour, Fig.2 (b)
Giant cell tumour, Fig.2 (c)