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Sudan J Paed. 2020; 20(2): 189-191 SUDANESE JOURNAL OF PAEDIATRICS 2020; Vol 20, Issue No. 2 IMAGE Carpal giant cell tumorVenkata 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 © 2020 SUDANESE JOURNAL OF PAEDIATRICS 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. DISCUSSIONGiant 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 INTERESTThe authors declare that they have no conflict of interest. FUNDINGNone. ETHICAL APPROVALEthics 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
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Pubmed Style Arunachalam VS, Saran S. Carpal giant cell tumor. Sudan J Paed. 2020; 20(2): 189-191. doi:10.24911/SJP.106-1585826722 Web Style Arunachalam VS, Saran S. Carpal giant cell tumor. http://www.sudanjp.com/?mno=96527 [Access: January 22, 2021]. doi:10.24911/SJP.106-1585826722 AMA (American Medical Association) Style Arunachalam VS, Saran S. Carpal giant cell tumor. Sudan J Paed. 2020; 20(2): 189-191. doi:10.24911/SJP.106-1585826722 Vancouver/ICMJE Style Arunachalam VS, Saran S. Carpal giant cell tumor. Sudan J Paed. (2020), [cited January 22, 2021]; 20(2): 189-191. doi:10.24911/SJP.106-1585826722 Harvard Style Arunachalam, V. S. & Saran, . S. (2020) Carpal giant cell tumor. Sudan J Paed, 20 (2), 189-191. doi:10.24911/SJP.106-1585826722 Turabian Style Arunachalam, Venkata Subbaih, and Sonal Saran. 2020. Carpal giant cell tumor. Sudanese Journal of Paediatrics, 20 (2), 189-191. doi:10.24911/SJP.106-1585826722 Chicago Style Arunachalam, Venkata Subbaih, and Sonal Saran. "Carpal giant cell tumor." Sudanese Journal of Paediatrics 20 (2020), 189-191. doi:10.24911/SJP.106-1585826722 MLA (The Modern Language Association) Style Arunachalam, Venkata Subbaih, and Sonal Saran. "Carpal giant cell tumor." Sudanese Journal of Paediatrics 20.2 (2020), 189-191. Print. doi:10.24911/SJP.106-1585826722 APA (American Psychological Association) Style Arunachalam, V. S. & Saran, . S. (2020) Carpal giant cell tumor. Sudanese Journal of Paediatrics, 20 (2), 189-191. doi:10.24911/SJP.106-1585826722 |