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LETTERS TO EDITOR
Year : 2019  |  Volume : 67  |  Issue : 1  |  Page : 303-305

Giant cell tumor of the spine with pulmonary metastasis


Department of Radiodiagnosis, SMS Medical College and Hospital, Jaipur, Rajasthan, India

Date of Web Publication7-Mar-2019

Correspondence Address:
Dr. Somshankar Pandey
Department of Radiodiagnosis, Room No. 16, SMS Medical College and Hospital, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.253582

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How to cite this article:
Pandey S, Jaipal U. Giant cell tumor of the spine with pulmonary metastasis. Neurol India 2019;67:303-5

How to cite this URL:
Pandey S, Jaipal U. Giant cell tumor of the spine with pulmonary metastasis. Neurol India [serial online] 2019 [cited 2019 Mar 20];67:303-5. Available from: http://www.neurologyindia.com/text.asp?2019/67/1/303/253582




Sir,

A 20-year-male patient presented with weakness in both the lower limbs since 6 months which progressed gradually. General physical examination was normal. No tenderness or deformity was noted in the spine. Neurological examination showed a reduced power in both the lower limbs, that is, 2/5. Sensory level was localized at T4 vertebral level. With clinical suspicion of Pott's spine, magnetic resonance imaging (MRI) spine was done which showed a heterogeneous soft tissue mass with hemorrhagic foci on T1-weighted MRI [Figure 1]. T2-weighted MRI showed a multiloculated hyperintense lesion with fluid–fluid level suggestive of secondary aneurysmal bone cyst formation and complete collapse of T1 vertebral body [Figure 2] and [Figure 3]. For further characterization, a contrast-enhanced computed tomography of the chest with the spine was advised which showed a soft tissue density mass lesion with cystic changes and complete collapse of T1 vertebral body and also lytic destruction of the T2 vertebral body; however, matrix mineralization was absent [Figure 4]. Bilateral pulmonary parenchyma showed well-defined multiple homogeneous nodules without osteoid matrix, which was suggestive of metastasis [Figure 5]. Therefore, the diagnosis of a giant cell tumor (GCT) with secondary presence of an aneurysmal bone cyst was suggested. Due to the young age and the site of involvement, that is, the vertebra, and metastatic appearance in the lung seen on computed tomography, the differential diagnosis was limited. Telengiectatic osteosarcoma was kept as a close differential diagnosis. Histopathology evaluation was advised for further confirmation which showed relative monomorphic neoplastic cells along with giant cells; no evidence of atypical features like anaplasia or abnormal mitosis was noted [Figure 6]. Absence of sarcomatous component excluded the giant cell variant of an osteosarcoma. Brown tumor of hyperparathyroidism also shows a similar histomorphology as present in our case; however, spine is a rare site for Brown's tumor. Therefore, in accordance with the imaging features and histological findings, the final diagnosis of a benign GCT of the spine was kept.
Figure 1: Axial T1-weighted MRI showing a heterogeneously hypointense mass lesion (thick arrow) with hyperintense signal intensities suggestive of hemorrhagic foci (thin arrow)

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Figure 2: T2-weighted MRI axial image at the T2 vertebral level showing a heterogeneously hyperintense signal lesion with fluid–fluid levels suggestive of secondary aneurysmal bone cyst formation (thick arrow); signal intensity change is also noted in the vertebral body (thick arrow)

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Figure 3: T2-weighted sagittal MRI image showing complete collapse of T1 vertebral body as evident by the intimate relationship of two contiguous intervertebral discs (thin arrow); signal intensity changes are also noted in the posterior elements of T1 vertebra (thick arrow)

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Figure 4: Contrast-enhanced computed tomography chest, axial view, soft tissue window showing a heterogeneous, soft tissue density, enhancing mass lesion with necrotic areas noted in the posterior mediastinum (thin arrow). Destruction of T2 vertebral body is also noted (thick arrow)

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Figure 5: Computed tomography chest lung window, coronal view, showing multiple well-defined homogeneous nodules of variable size noted throughout bilateral lung parenchyma suggestive of lung metastasis (arrow)

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Figure 6: Microscopic view of the resected specimen, stained with hematoxylin and eosin, seen under ×40 magnification, showing multiple multinucleated giant cells (red arrow) in the background of mononuclear stromal cells (green arrow) with absence of sarcomatous component, abnormal mitosis, or anaplastic cells

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Yang et al.,[1] reported that local recurrence and a high Campanacci stage were important predictors of pulmonary metastasis related to the benign GCT of bone. Chan et al.,[2] followed up 167 cases of benign GCT of the bone for at least 2 years and concluded that younger patients, patients presenting with Enneking–Campanacci stage 3 disease, local recurrence, and axial location of the disease showed an increased risk of pulmonary metastasis of GCT of bone.

Multinucleated giant cells can arise in bone in some conditions, including chondroblastoma, fibrous dysplasia, eosinophilic granuloma, chondromyxoid fibroma, giant-cell-rich osteosarcoma, malignant fibrous histiocytoma and giant cell reparative granuloma.[3] Management of lung metastasis of GCT of the bone requires a prolonged follow-up, and there is no need for a aggressive radiation therapy or chemotherapy in these patients because their overall prognosis and outcomes are favorable.[4] Diagnosis of an aggressive GCT must be considered in case of collapse of the vertebral body with pulmonary metastasis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yang Y, Huang Z, Niu X, Xu H, Li Y, Liu W, et al. Clinical characteristics and risk factors analysis of lung metastasis of benign giant cell tumor of bone. J Bone Oncol 2017;7:23-8.  Back to cited text no. 1
    
2.
Chan CM, Adler Z, Reith JD, Gibbs CP Jr. Risk factors for pulmonary metastases from giant cell tumor of bone. J Bone Joint Surg Am 2015;97:420-8.  Back to cited text no. 2
    
3.
Lee MJ, Sallomi DF, Munk PL, Janzen DL, Connell DG, O'Connell JX, et al. Pictorial review: Giant cell tumours of bone. Clin Radiol 1998;53:481-9.  Back to cited text no. 3
    
4.
Viswanathan S, Jambhekar NA. Metastatic giant cell tumor of bone: Are there associated factors and best treatment modalities? Clin Orthop Relat Res 2010;468:827-33.  Back to cited text no. 4
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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