|Year : 2017 | Volume
| Issue : 2 | Page : 37-39
Primary patellar giant cell tumor: A report of two cases
Jitendra Mishra, Bikram Keshari Kar, Nirmal Chandra Mohapatra, Anshuman Sahoo
Department of Orthopedics, SCB Medical College, Cuttack, Odisha, India
|Date of Web Publication||19-Jan-2018|
Dr. Nirmal Chandra Mohapatra
Department of Orthopedics, SCB Medical College, Cuttack - 753 007, Odisha
Source of Support: None, Conflict of Interest: None
Giant cell tumor (GCT) commonly arises from epiphysis of the long bones, and the most common sites for primary are distal femur, proximal tibia, proximal humerus, and distal radius. Patella is a very rare site for the development of primary GCT. We report two cases with primary GCT of the patella. Both the patients presented with a long history of intermittent right anterior knee pain and knee swelling and were treated by radical excision. In one case, temporary immobilization done by knee arthrodesis with cross K-wires followed by mobilization using hinged knee brace.
Keywords: Giant cell tumor, patella, radical excision
|How to cite this article:|
Mishra J, Kar BK, Mohapatra NC, Sahoo A. Primary patellar giant cell tumor: A report of two cases. Oncol J India 2017;1:37-9
| Introduction|| |
Giant cell tumor (GCT) is a benign, but locally aggressive osteoclastic bone tumor usually involving epiphysis of the long bones and comprises of multinucleated osteoclast-like giant cells in the background of mononuclear stromal cells. It comprises of 4%–9.5% of all primary bone tumors and about 18%–23% of benign bone lesion. Distal femur, proximal tibia, and distal radius are the common sites of presentation for the GCT. Primary GCT of the patella is uncommon and may present with anterior knee pain and/or swelling. Surgery is the mainstay of treatment for the GCT. We reported two cases of GCT of the patella in young age group and surgery was done to get a good functional outcome.
| Case Reports|| |
A 40-year-old female presented with a 1-year history of occasional left anterior knee pain with gradually progressing anterior knee swelling. Two weeks before visiting the hospital, the patient had been experienced with an increasing anterior knee pain following a sudden jerk. The physical examination revealed a large swelling and slight tenderness in the anterior aspect of the left knee [Figure 1]a. However, we did not observe any skin adhesion, local heat, redness, joint effusion, or limitation of the knee joint range of motion. The laboratory data were within normal limits, except for a marginal elevation of alkaline phosphatase levels. The patient's past medical history was unremarkable. X-ray of the left knee revealed a well-defined, osteolytic lesion involving almost whole of the patella with near total erosion of the bone, cortical breach, and involvement of local soft tissue [Figure 1]b. There was no periosteal reaction. On magnetic resonance imaging (MRI), the lesion exhibited slightly higher signal intensity compared to skeletal muscle on T1-weighted sequences. There was obvious soft-tissue involvement around the patella, but there was no intra-articular extension. Needle biopsy from the lesion on microscopic examination revealed features of GCT. Further investigations revealed no distant metastasis.
|Figure 1: (a) A swelling over the left patellar region on clinical photograph, (b) an osteolytic lesion involving patella with cortical breech on X-ray of the left knee, (c) excision of the whole patella along with adjacent tendon, and (d) stabilization of the joint by two cross K-wire on postoperative X-ray of the left knee|
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Surgery had been planned; whole of patella along with patella tendon and quadriceps excised [Figure 1]c. As the knee joint became unstable due to loss of involved ligaments and muscle mass, a cross K-wire fixation of the knee joint was done as a temporary measure [Figure 1]d. The postoperative course was uneventful. The cross K-wires removed after 1 month of surgery, and the patient returned to normal activities with a hinged knee brace as a support. At 16-month follow-up, the patient was asymptomatic, and there was no evidence of local recurrence or distant metastasis.
A 35-year-old male presented with a slow and progressive enlargement of the left knee for the last 8 months. The disease had progressively worsened over the last 6 months. He had no history of any trauma, fever, and evening rise of temperature. On local examination, there is a large mass over the right knee associated with mild tenderness on palpation and without any restricted range of movement of the knee. Patellar tap was negative, and there is no local rise of temperature. X-ray of the left knee revealed an osteolytic lesion involving almost whole of the patella without any adjacent bone and joint involvement [Figure 2]a and [Figure 2]b. MRI revealed an expansile hyperintense lesion involving the left patella with the involvement of quadriceps and patellar tendon [Figure 2]c and [Figure 2]d. Biopsy from the lesion suggested features of GCT. Further workup showed the absence of any distant metastasis. Excision of whole patella was done, and the gross specimen [Figure 3]a on microscopic examination showed the presence of rounded or spindle-shaped mononuclear cells admixed with numerous osteoclastic giant cells [Figure 3]b. Mitotic figures were present among the mononuclear cells, but there were no atypical mitoses identified. Postoperative scar was healthy, and X-ray of the left knee after surgery showed no residual [Figure 3]c and [Figure 3]d. The patient returned to normal activity after 2 months. At 12-month follow-up, there was no evidence of any local recurrence and metastasis.
|Figure 2: (a) X-ray of the left knee lateral (a) and skyline (b) view showing expansile osteolytic lesion over the left patella, and magnetic resonance imaging of the left knee sagittal view (c and d) showing altered signal intensity in the patella with involvement of adjacent quadriceps and patellar tendon|
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|Figure 3: (a) Postoperative gross specimen of the patella along with tumor showing the presence of hemorrhage with myxoid area at foci with occasional small cystic foci, (b) microscopic examination (H and E, ×100) showing the presence of multinucleated giant cells in the background of stromal cells, (c) postoperative clinical photograph with healthy scar mark, and (d) postoperative X-ray of the left knee|
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| Discussion|| |
Patellar bone tumor is rare among all the primary skeletal tumors and the majority of the cases are benign than malignant. The most frequent benign patellar tumors are GCT and chondroblastoma, followed by others such as aneurysmal bone cyst, osteoid osteoma, chondroma, simple bone cyst, osteochondroma, osteoblastoma, and osseous hemangioma., GCT stands for 33% of all the patellar tumors, whereas chondroblastoma is 16%. According to a survey of the Japanese Orthopaedic Association, out of 2126 number of registered cases of GCT, only 22 cases (1.47%) were found to be with primary from the patella.
The gradual onset of the anterior knee pain and swelling are the common presentations for the patellar tumors/GCT., Redness, local heat, swelling, effusion, tenderness, lump, crepitus, and the decrease in range of motion are the possible findings on physical examination. Increase in serum alkaline phosphatase as in one of our case and erythrocyte sedimentation rate may found in GCT with late presentation.
Chondroblastoma and hemangioma are main differential diagnoses for the patellar GCT. GCT most commonly occurs in aged 20–45 years with a female predominance. Chondroblastoma commonly occurs in the second decade of life with a male predominance.
In GCT, ill-defined margins and pathological fractures are commonly seen radiologically, and CT scan shows cortical expansion and destruction, while MRI shows the presence of intra-articular fluid, involvement of any ligaments, tendons, or surrounding soft tissue/joint. Chondroblastoma appears as a lytic lesion without any periosteal reaction but, in 19% of cases, there is the presence of calcification. The size of chondroblastoma is usually smaller in comparison to GCT. Hemangioma on radiograph shows no periosteal reaction or calcifications, but in MRI, it typically exhibits increased signal intensity on T1- and T2-weighted sequences, possibly due to fat contents of the lesion., Therefore, it is difficult to diagnose GCT on the basis of radiograph or imaging technique requiring the need of pathology proof before treatment, and a needle biopsy or incisional biopsy from the patellar lesion is recommended for the diagnosis. Few literatures reported the presence of cortical breech in GCT of patella supporting the present report.
At the early stage of presentation, GCTs can be treated with intralesional curettage or partial patellectomy with bone grafting and reconstruction of the extensor mechanism. However, most of the patellar GCTs present in late and requires excision of the whole patella followed by immobilization of the knee joint with two cross K-wires. Total patellectomy is the preferred treatment for aggressive lesions with cortical breakthrough. Previous literature reported a case of aggressive GCT of the patella treated with wide resection and reconstruction of the extensor mechanism using a patellar allograft. We too performed total patellectomy as cortical erosion was evident. This treatment was considered to be appropriate for our patient.
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.
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Conflicts of interest
There are no conflicts of interest.
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