SUDANESE JOURNAL OF PAEDIATRICS

2020; Vol 20, Issue No. 2

IMAGE

Carpal giant cell tumor

Venkata Subbaih Arunachalam (1), Sonal Saran (1)

(1) Department of Radiology, All India Institute of Medical Science (AIIMS) Rishikesh, Uttarakhand, India

Correspondence to:

Sonal Saran

Department of Radiology, All India Institute of Medical Science (AIIMS) Rishikesh, Uttarakhand, India

Email: sonalsaranmalik [at] gmail.com

Received: 03 April 2020 | Accepted: 26 April 2020

How to cite this article:

Arunachalam VS, Saran S. Carpal giant cell tumor. Sudan J Paediatr. 2020;20(2):189–191.

https://doi.org//10.24911/SJP.106-1585826722

---

A 18-year-old female presented with pain of insidious onset associated with swelling over the right wrist joint for 6 months. Swelling and pain gradually increased over the duration of 6 months. She came to the Orthopedician’s out-patient clinic when her symptoms affected her day-to-day activities. There was no history of trauma or pain in other joints. Radiograph of the right wrist postero-anterior and lateral view showed an expansile lytic lesion in the capitate and hamate bone with thinned out cortex. Computed tomography (CT) of the wrist showed an expansile lytic lesion in the capitate and hamate bone with cortical thinning and multifocal breach (Figure 1a and b). The matrix showed soft tissue attenuation with fine calcified septations. Adjacent carpo-metacarpal joint and inter-carpal joints were normal. Contrast enhanced Magnetic resonance imaging (MRI) of the right wrist was performed which revealed a well-defined lobulated soft tissue signal intensity lesion involving the capitate and hamate (Figure 1c and d). No fluid-fluid levels were seen. On post-contrast study, there was homogeneous enhancement. The lesion was closely abutting the carpal tunnel. The median nerve was displaced laterally but no obvious infiltration of nerve and adjacent tendons was seen. Differential diagnosis at the end of imaging investigation included giant cell tumor (GCT), aneurysmal bone cyst (ABC) and enchondroma. Incisional biopsy of the lesion was performed which revealed numerous multinucleated giant cells dispersed amidst sheets of mononuclear cells with surrounding areas of haemorrhage (Figure 2). Intralesional excision of the lytic lesion and obliteration of defect by autologous iliac crest bone graft was done (Figure 3). At 6 month follow up, the patient was symptom free with near normal range of movements and with no evidence of recurrence.

---

DISCUSSION

Giant cell tumour is a common neoplasm of long bones in skeletally mature patients. Common sites of occurrence include distal femur, proximal tibia and distal radius in decreasing order of frequency [1]. Only a handful of cases have been reported in small bones with only 0.2% of giant cell tumors being localised to the carpal bones. Capitate and hamate account for more than 60% of carpal giant cell tumours [2]. Averill et al reviewed 28 giant cell tumours of hand, 26 were in the tubular bones and only two involved the carpal bones [3]. Radiologically, it is difficult to differentiated carpal GCT from other osteolytic lesions of that area, including aneurysmal bone cyst, enchondroma and brown tumour of hyperparathyroidism. Brown tumour of hyperparathyroidism can be excluded in the absence of other changes of hyperparathyroidism. Enchondromas are most common tumors of hand frequently localised in phalanges and metacarpals. Enchondromas commonly show ring and arc pattern of calcification. Fluid-fluid level is an important imaging feature of ABC which is not seen in our case [4].

Figure 1. (a,b) Computed tomography of the wrist showing a well-defined lobulated expansile osteolytic lesion (arrows) with sharp margins arising from the capitate and hamate with soft tissue attenuation, periosteal thinning and multiple areas of cortical breach; (c) Coronal T1W sequence of MRI showing hypointense lobulated soft tissue mass involving capitate and hamate (arrow) which shows homogenous intense contrast enhancement on Post GD T1W sequence (d).

Figure 2. Histopathalogical photomicrograph showing multinucleated giant cells dispersed amidst sheets of mononuclear cells with surrounding areas of haemorrhage.

Figure 3. Post-operative radiograph of wrist showing autologous iliac crest bone graft in-situ (arrow).

Biscaglia et al. [5] reviewed giant cell tumors of the bones of the hand and foot at the Rizzoli Orthopaedic Institute over a period of 50 years (1947–1997) and found that GCT of hand is more frequently seen in younger females (as in our case), with nonspecific radiographic features and more aggressive nature than GCTs of large bones. So far, there is no standardised treatment protocol for these lesions. Proper curettage with bone grafting can give good functional results with minimal complications. Although, longer follow up will be required to comment on the recurrence rates.

---

DECLARATION OF CONFLICTING INTEREST

The authors declare that they have no conflict of interest.

---

FUNDING

None.

---

ETHICAL APPROVAL

Ethics clearance and approval of the study were granted by the ethics committee of our institute. Signed informed consent for participation and publication of medical details was also obtained from the parents of the patient. Confidentiality was ensured at all stages.

---

REFERENCES

1. Sobti A, Agrawal P, Agarwala S, Agarwal M. Giant cell tumor of bone—an overview. Arch Bone Jt Surg. 2016;4(1):2–9. PMID: 26894211; PMCID: PMC4733230.
2. Plate AM, Lee SJ, Steiner G, Posner MA. Tumor-like lesions and benign tumors of the hand and wrist. J Am Acad Orthop Surg. 2003;11(2):129–41.
3. Averill RM, Smith RJ, Campbell CJ. Giant-cell tumors of the bones of the hand. J Hand Surg. 1980;5A:39.
4. Levine MD, De Smet AA, Neff J. Role of radiologic imaging in management planning of giant cell tumor of the bone. Skelet Radiol. 1984;12:79–89.
5. Biscaglia R, Bacchini P, Bertoni F. Giant cell tumor of the bones of the hand and foot. Cancer. 2000;88(9):2022–32.