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CORRESPONDENCE
Year : 2017  |  Volume : 13  |  Issue : 3  |  Page : 586-588

Giant cell tumour of distal ulna


1 Department of Orthopaedics and Trauma, Lilavati Shushrusha Hinduja Healthcare, Global Hospitals, Khar, Mumbai, Maharashtra, India
2 Department of Orthopaedics and Trauma, Lilavati Hospital, Shushrusha Hospital, Hinduja Healthcare, Global Hospitals, Mumbai, Maharashtra, India
3 Department of Orthopaedics and Trauma, Fellow in Trauma and Arthroplasty Under Dr. Shreedhar Archik, Mumbai, Maharashtra, India

Date of Web Publication31-Aug-2017

Correspondence Address:
Sanjay Kumar Tripathi
Department of Orthopaedics and Trauma, Lilavati Hospital and Research Centre, Bandra West, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.174190

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 > Abstract 


Giant cell tumor (GCT) of distal end epiphysis ulna is a rare presentation, and only few cases are reported in the scientific literature. We report a case of GCT of distal end epiphysis ulna treated at our Tertiary Care Hospital, Mumbai.

Keywords: En bloc excision of distal ulna, giant cell tumor of distal end epiphysis ulna, primary bone tumor


How to cite this article:
Archik S, Tripathi SK, Nanda SN, Choudhari A. Giant cell tumour of distal ulna. J Can Res Ther 2017;13:586-8

How to cite this URL:
Archik S, Tripathi SK, Nanda SN, Choudhari A. Giant cell tumour of distal ulna. J Can Res Ther [serial online] 2017 [cited 2020 May 27];13:586-8. Available from: http://www.cancerjournal.net/text.asp?2017/13/3/586/174190




 > Introduction Top


Most common site for giant cell tumor (GCT) is at the long bone meta-epiphysis, especially the distal radius and femur, proximal humerus, and tibia. Distal end epiphysis of the ulna is an uncommon site for primary bone tumors. GCT of bone is a rare, benign, locally invasive tumor, accounting for approximately 3–5% of all primary bone tumors.[1],[2] GCT at distal end epiphysis of the ulna is very rare, with a reported incidence from 0.45% to 3.2%.[3],[4],[5] It generally occurs in adults between the ages of 20 and 40 years. GCT of bone is very rarely seen in children or in adults older than 65 years of age. We here report a case of GCT of distal end epiphysis ulna treated by en bloc excision of the distal ulna. The goal of treatment is the adequate removal of the tumor to lower the risk of recurrence.


 > Case Report Top


A 24-year-old male patient came to hospital with painful progressive swelling of the right wrist since 1 month. There was no history of injury, pain, and fever.

On examination, the diffuse swelling was present over the wrist, more over distal aspect of ulna [Figure 1]. The skin over the swelling was normal with no evidence of dilated or engorged veins, stretch mark, or sinuses. On palpation, there was tenderness over the swelling, but temperature was not raised. The swelling was about 4 cm × 2 cm in dimension, arising from the distal end of ulna. It was soft to firm in consistency, not fixed to the overlying skin. Supination, pronation and ulnar deviation were painfully restricted. Radial pulse was palpable.
Figure 1: Diffuse swelling was present over wrist, more over distal aspect of ulna

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Routine blood investigations and serum biochemistry studies were within normal limits.

X-ray of right wrist anterior-posterior and lateral showed expansile, osteolytic, multiloculated lesion in the distal end of right ulna without any periosteal reaction [Figure 2]. It was showing characteristic soap bobble appearance suggestive of GCT of the distal ulna.
Figure 2: X-ray of right wrist anterior-posterior and lateral showed expansile, osteolytic, multiloculated lesion in the distal end of right ulna without any periosteal reaction

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No evidence of lung metastases was seen on the chest radiograph [Figure 3].
Figure 3: No evidence of lung metastases was seen on the chest radiograph

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Fine-needle aspiration cytology was done which further lead to a diagnosis of GCT of distal end epiphysis of ulna.

The patient was managed with an operative procedure involving en bloc excision of distal end ulna [Figure 4] under general anesthesia. The intraoperative specimen was sent for a biopsy, which further confirmed the diagnosis of GCT of distal end epiphysis of ulna.
Figure 4: Operative procedure involving en bloc excision of distal end ulna

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Postoperatively, patient was comfortable and previous severe and continuous pain was relieved except for surgical site pain which was reducing gradually. At the day of suture removal on the postoperative day 14, patients were absolutely pain-free. After 3 weeks of follow-up, physiotherapy was started, and the patient was gaining continuous increase mobility at wrist joint and at 6-week patient was fully recovered [Figure 5].
Figure 5: 6 Week post op clinical photograph showing recovery

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 > Discussion Top


Usually, the tumor is located at the long bone meta-epiphysis, especially the distal radius and femur, proximal humerus, and tibia. Distal end epiphysis of the ulna is an uncommon site for primary bone tumors. The incidence of GCT of bone is higher in Asian compared to the West populations.[6] In Malaysia, Ng et al. reported 34 (24%) out of 141 cases of primary bone tumors were GCT and 1 (2.9%) out of the 34 GCT cases involved the end of the distal ulna.[7] Therefore, there are no clear-cut guidelines about the preferred modality of treatment of GCT of distal end epiphysis of ulna. Depending on surgeon and preference and setup, primary goal of treatment is wide resection of the tumor to minimize recurrences with optional other procedures as intralesional curetage with adjuvants such as cryotherapy, phenol, burring, bone grafting, and polymethylmethacrylate cement or wide resection with or without stabilization or reconstruction of ulnar stump.

Simple curettage has high recurrence rate as compared to curettage with adjuvant therapy as per Campanacci et al.,[8] Sung et al.,[9] As per literature, adequate removal of the tumor is more important for decrease incidence of recurrence rate. It seems that recurrence rates correlate better with the inadequacy of tumor tissue removal rather than the type of specific adjuvant treatment used.[10] Kayias et al. found a high failure rate without stabilization of the ulna stump,[11] due to the dorsal translation of the stump at the resection site which tends to converge toward the radius. This inevitably leads to a limitation of forearm rotation, persistent pain due to instability and impingement on the radius. Cooney et al. reported good functional outcome after distal ulna resection without any stabilization and concluded that reconstruction is notroutinely indicated.[12]

GCT of the distal end epiphysis of ulna is an extremely rare entity; a literature review of reported cases with a resection of the distal ulna for primary bone tumors, is inconclusive as to (a) whether stabilization or reconstruction is required or not and (b) as to the optimal method of stabilization or reconstruction, if chosen.

Therefore, there are no clear-cut guidelines about the preferred modality of treatment. There is not enough evidence to recommend one ulnar stump stabilization procedure over the other. The authors also feel that the treatment should be individualized, taking into consideration the patient's age, the length of the ulnar resection and patient's expectation about postoperative function.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
McDonald DJ, Sim FH, McLeod RA, Dahlin DC. Giant-cell tumor of bone. J Bone Joint Surg Am 1986;68:235-42.  Back to cited text no. 1
    
2.
Sung HW, Kuo DP, Shu WP, Chai YB, Liu CC, Li SM. Giant-cell tumor of bone: Analysis of two hundred and eight cases in Chinese patients. J Bone Joint Surg 1982;57-A:167-73.  Back to cited text no. 2
    
3.
Blackley HR, Wunder JS, Davis AM, White LM, Kandel R, Bell RS. Treatment of giant-cell tumors of long bones with curettage and bone-grafting. J Bone Joint Surg 1997;78-A:811-20.  Back to cited text no. 3
    
4.
Goldenberg RR, Campbell CJ, Bonfiglio M. Giant-cell tumor of bone. An analysis of two hundred and eighteen cases. J Bone Joint Surg Am 1970;52:619-64.  Back to cited text no. 4
    
5.
Malawer MM, Henshaw RM, Shmookler BM. Principles of orthopaedic oncology. In: Dee R, Hurst LC, Gruber MA, Kottmeier SA, editors. Principles of Orthopaedic Practice. 2nd ed. New York: McGraw-Hill; 1997. p. 225-316.  Back to cited text no. 5
    
6.
Lim YW, Tan MH. Treatment of benign giant cell tumours of bone in Singapore. Ann Acad Med Singapore 2005;34:235-7.  Back to cited text no. 6
    
7.
Ng ES, Saw A, Sengupta S, Nazarina AR, Path M. Giant cell tumour of bone with late presentation: Review of treatment and outcome. J Orthop Surg (Hong Kong) 2002;10:120-8.  Back to cited text no. 7
    
8.
Campanacci M, Baldini N, Boriani S and Sudanese A. Giant-cell tumor of bone. The Journal of Bone and Joint Surgery American 1987; 69:106-11  Back to cited text no. 8
    
9.
Sung HW, Kuo DP, Shu WP, Chai YB, Liu CC, Li SM. Giant-cell tumor of bone: Analysis of two hundred and eight cases in Chinese patients. The Journal of Bone and Joint Surgery 1982;57-A:167-17.  Back to cited text no. 9
    
10.
Larsson SE, Lorentzon R, Boquist L. Giant-cell tumor of bone. A demographic, clinical, and histopathological study of all cases recorded in the Swedish Cancer Registry for the years 1958 through 1968. J Bone Joint Surg Am 1975;57:167-73.  Back to cited text no. 10
    
11.
Kayias EH, Drosos GI, Anagnostopoulou GA. Resection of the distal ulna for tumours and stabilisation of the stump. A case report and literature review. Acta Orthop Belg 2006;72:484-91.  Back to cited text no. 11
    
12.
Cooney WP, Damron TA, Sim FH, Linscheid RL. En bloc resection of tumors of the distal end of the ulna. J Bone Joint Surg Am 1997;79:406-12.  Back to cited text no. 12
    


    Figures

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



 

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