Metadiaphyseal presentation of giant cell tumor in adolescent femur: A case report

S Kavin1, S Chockalingam2, P Ramasamy3, V. Senthilvelmurugan4, Aparana Devi5

1Senior Registrar – Department of Orthopaedic surgery, Kauvery Hospitals, Trichy

2Senior Consultant– Department of Orthopaedic surgery, Kauvery Hospitals, Trichy

3HOD & Senior Consultant – Department of Orthopaedic surgery, Kauvery Hospitals, Trichy

4Senior Consultant Radiologist, Kauvery Hospitals, Trichy

5Consultant Pathologist, Kauvery Hospitals, Trichy

Introduction

Giant Cell Tumor (GCT) of bone is typically seen in long tubular bones in skeletally mature individuals at the epiphyseal. location. The peak incidence is in the 3rd to 4th decade of life. Occurrence in children and adolescents is rare, especially prior to physical closure. We report a case of distal femoral Giant Cell Tumor (GCT) at metaphseo diaphysis site in a 13-year-old boy in the femur with an open physis. We managed this lesion successfully with curettage and bone grafting.

Case Presentation

A 13-year-old boy presented to our outpatient department with pain and swelling in the right thigh for 2 months. There was no history of trauma or fever.

On examination, there was tenderness over the distal third of the thigh, knee range of motion was preserved, and neurovascular status was normal. Radiographs revealed a lytic lesion in the meta-diaphyseal region of the distal femur, measuring approximately 12 × 5 × 3 cm (Figure 1). ACT-guided biopsy showed multinucleate giant cells confirming the diagnosis of giant cell tumor. (Figure 2)

The patient was taken up for surgery. A thorough intraregional curettage was performed, (Figure 3) The defect was reconstructed using autologous iliac crest bone graft along with hydroxyapatite bone graft substitute. (Figure 4) No adjuvant radiotherapy or chemotherapy was given. The post-operative radiographs Figure 5 showed complete filling of the defect. The postoperative period was uneventful. Patient was managed non weight bearing for six seeks and partial weight bearing up to three months after surgery. The patient was followed up at 3, 6, and 9 months, with clinical and radiological evaluation. The follow up radiographs showed gradual integration of the bone graft with replacement of bone substitutes with native bone. At one year of follow up, the bone appearance returned to normal with no sign of recruurnece. (Figures 6, 7 and 8 after 6 Weeks ,3 months. 9 months after surgery).

Figure 1: Lytic lesion

Figure 2: Multinucleate giant cells

Figure 3: Intraregional curettage

Figure 4: Hydroxyapatite bone graft

Figure 5: Hydroxyapatite bone graft

Figure 6: 6 Weeks Post op X-ray

Figure 7: 3 months’ post op X-ray

Figure 9: 9 months’ post op X-ray

Discussion

Primary bone tumors in children are commonly benign lesions with osteochondroma, simple bone cysts, aneurysmal bone cysts. osteoid osteoma, fibrous dysplasia, non-ossifying fibroma. should be considered for differential diagnosis. (Esra Akyüz Özkan ). Giant cell tumors are not commonly considered for differential diagnosis in children with an open physis/

A comprehensive review of paediatric bone lesions by Sebastian Breden in 2024 reported 420 children with primary bone lesions with the majority being benign bone lesions. (80%). They reported only 6 GCTs in children with only 2 in the femur among 335 benign bone lesions (0.6%)

GCTs are more common in Epimetaphyseal region of bone in adults. Puri et al showed similar incidence in children with the open physis not acting as a barrier to the tutor. Recently M Wülling  et al reported metaphaseal only location of GCT in children under the age of 18. Though they reported 18 patients, only five were with open physis. Our patient presented with an even rare Metadiaphyseal location of GCT which has hitherto not been reported.

Management typically involves curettage with bone grafting or bone substitutes, sometimes with adjuvants. Wide resection is reserved for aggressive or recurrent cases. Our patient underwent, curettage with bone grafting with bone substitutes as the lesion was large.

Recurrence rate has been reported by both Puri eat al and M Wülling, 20 and 80% respectively. Our patient had excellent functional and radiological outcomes without recurrence at 1 year.

This case highlights the importance of considering GCT even in patients with an open physis. The case report also highlights the unusual metaphaseo diaphyseal location of GCT within the long bone of femur.

Conclusion

GCT of the distal femur in children is rare. Thorough curettage with bone grafting can provide satisfactory results with good healing and low recurrence in properly selected cases. Upto our knowledge this is first reported case of Metadiaphyseal GCT in Adolescent femur.

References

  • Xu LH, Zhang Q, Hao L, Ding Y, Niu XH. Diagnosis and treatment of giant cell tumor of bone in skeletal immature patients. Zhonghua wai ke za zhi [Chinese Journal of Surgery]. 2013 Sep 1;51(9):827-30.
  • Puri A, Agarwal MG, Shah M, Jambhekar NA, Anchan C, Behle S. Giant cell tumor of bone in children and adolescents. Journal of Pediatric Orthopaedics. 2007 Sep 1;27(6):635-9.
  • Kim WJ, Kim S, Choi DW, Lim GH, Jung ST. Characteristics of giant cell tumor of the bone in pediatric patients: our 18-year, single-center experience. Children. 2021 Dec 8;8(12):1157.
  • Mani KK, Raju GC. Giant cell tumor of distal tibia in an immature skeleton: A case report. Journal of Orthopaedic Reports. 2022 Jun 1;1(2):100011.
  • Hosseinzadeh S, Tiwari V, De Jesus O. Giant cell tumor (osteoclastoma). InStatPearls [Internet] 2024 Jan 31. StatPearls Publishing.

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