Rev. bras. ortop. vol.51 número6

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

Report

Giant

cell

tumor

of

the

femoral

neck:

case

report

夽

Paulo

Silva,

Rogério

Andrade

do

Amaral,

Leandro

Alves

de

Oliveira,

Frederico

Barra

de

Moraes

_,

_Eduardo

_Damasceno

_Chaibe

UniversidadeFederaldeGoiás(UFG),FaculdadedeMedicina,HospitaldasClínicas,Goiânia,GO,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received13October2015 Accepted8March2016 Availableonline4October2016

Keywords: Hip Bones

Femoralneckfractures Giantcelltumors

a

b

s

t

r

a

c

t

Theauthorspresentthecaseofapatientwithagiantcelltumoroftheleftfemoralneck, withadjacentprogressiveinvasionofbonetissue.Initialtreatmentwasdonewithlocal curettageandautologousbonegraftfromfibula,electrocauterizationandfillingwithmethyl methacrylate.Alocaltumoralrelapsewaspresentafteroneyear;thereforeanewsurgical procedurewasnecessary,withproximalfemoralwideresectionandunconventional endo-prosthesisfixation.Thearticlediscussestheclinicalaspectsandsurgicaltreatment.This reportaimedtodemonstratethenecessitytoperformwideresectionforgiantcelltumor ofthefemoralneck,prioritizingtotalresectionofthetumoranditslocalextension, preser-vinglimbintegrityanddemonstratingthecompletefailureofpreservingsurgeryincases offemoralneckinvolvement.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Tumor

de

células

gigantes

do

colo

do

fêmur:

relato

de

caso

Palavras-chave: Quadril Ossos

Fraturasdocolofemoral Tumoresdecélulasgigantes

r

e

s

u

m

o

Osautoresapresentamumcasodeumapacienteportadoradetumordecélulasgigantesdo colodofêmuresquerdocominvasãoprogressivadetecidoósseoadjacente.Foitratado ini-cialmentecomesvaziamentopormeiodecuretagemlocaleenxertiaautólogacomtabiques dafíbula,eletrofulgurac¸ãoepreenchimentocommetilmetacrilato.Apacienteevoluiucom recidivadalesãotumorallocalapósumano,foinecessáriaumanovaintervenc¸ão cirúr-gica,comressecc¸ãoemblocodaparteproximaldofêmurefixac¸ãodeendoprótesenão convencional.Sãodiscutidososaspectosclínicoseaabordagemterapêutica.Orelatotem porfunc¸ãodemonstraranecessidadedeabordarotumordecélulasgigantesdocolodo fêmur,emobediênciaaosprincípiosoncológicosderessecc¸ãoóssea,comprioridadepara

夽

StudyconductedattheHospitalGeraldeGoiânia,Servic¸odeCirurgiadoQuadril,Goiânia,GO,Brazil. ∗ _{Correspondingauthor.}

E-mail:[email protected](F.B.Moraes). http://dx.doi.org/10.1016/j.rboe.2016.09.006

demonstrac¸ãodatotalfalhadetentativaspreservadorasnocasodeacometimentodocolo femoral.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Giantcelltumor(GCT)isdefinedasanaggressivebenignbone tumorwithuncertainbiologicalbehavior,characterized histo-logicallybyrichlyvascularizedtissuewithovoidandfusiform cellsandnumerousosteoclasticgiantcells,evenlydistributed throughoutthetumortissue.1,2

GCTmainlyaffectsyoungadultsbetweentheagesof20–35 years,andthemostfrequentlocationsarethedistalfemurand proximaltibia.Itismorecommoninfemales,andconstitutes 8%ofprimarybonetumors.3

Themain purpose ofthis report isto demonstrate the importanceofresectionfollowingoncologicalprinciplesfor suchlesionswithinvolvementthefemoralneckandwhose treatmentismainlysurgical,withradicalreplacementofthe segment;incaseoffailureofothertechniques,suchas curet-tageand autologousorhomologous bonegrafts,prosthetic replacement (non-conventional endoprosthesis) is manda-tory.

Case

report

Femalepatient,aged33years,reportedpaininthelefthip andlower backforthelastsixmonthsand hadnohistory oftraumaorphysicaleffortandprogressiveworseningofthe pain.Atphysicalexamination,thepatientpresentedpainon palpationintheanterioraspectandduringmovementofthe lefthip,withnormalrangeofmotion.

Theinitialradiologicalstudy(pelvisradiograph)disclosed thepresenceofanextensiveosteolyticlesiononthefemoral neckandproximalthirdofthegreatertrochanter(Fig.1).

Magnetic resonance imaging (MRI) revealed an expan-sile, destructive, insufflated bone lesion the epiphysis-metaphysealregionoftheleftproximalfemur,withregular andwell-definedcontours,whichstartedonthefemoralneck andextendedtotheanterioraspectofthefemoralhead.The lesionpresentedahomogeneoussolid matrix,hypointense on T1, and with intermediate signal on T2, with intense uptakeafterintravenouscontrastadministration.Bone mar-rowedemawas observednearthe lesion,withoutsigns of expansiontotheadjacentsofttissue(Fig.2).

Inlightofthesefindings,thepossibilityofGCTwas con-sidered and a bone biopsy was proposed; the biopsy was performedimmediately,corroboratingtheprimarydiagnostic hypothesis.Theauthorsdecidedtoperformanintralesional resection, with local curettage and electrocauterization as anadjuvanttreatment, aswell asfilling ofthecavity with autologous bone graft from the fibula and bone cement (methylmethacrylate)(Fig.3).

Thepatienthadnosignificantclinicalabnormalities.Full weightbearingwasauthorizedafter120days.Oneyearafter surgery,acontrolMRIwasperformed;althoughthepatient iscompletelyasymptomatic,nodularlesionsofregular and well-defined borders were observed, withT1and T2 isoin-tensity,homogeneouslycapturingtheintravenouscontrastin theintertrochantericregion,inthelowerportionofthe sur-gical cavity.Bonemarrow edemawas observedadjacentto thelesionandtothebonegraft/cement,aswellasreactive periostitis,consistentwithtumorrecurrence(Fig.4).

Inlightofthesefindings,anewsurgicalinterventionwas proposed;ablockresectionoftheproximalthirdofthefemur wasperformed,replacedwithnon-conventionalmodular tita-niumendoprosthesisanduncementedacetabularprosthesis (Figs.5and6).

Discussion

ThetreatmentofGCTisessentiallysurgical.Thereisevidence contrarytocurettage,butthereisacorrelationwithsurgery and method, histologic type, tumorsize,location, and age ofthepatient–thesearefactorsthatdirectlyinfluencethe prognosis,aswellaslesionstaging.4

In1983,Ennekingproposedathree-stageradiographic clas-sification:stageI–_{tumorwithwell-definededgesandcortical}

integrity;stageII–_{expandedcortexwithwell-definededges;}

stageIII–_{non-definededgeswithsofttissueinvasion.Stage}I

istreatedwithcurettageandadjuvanttreatment (electrocau-terization,methylmethacrylate,liquidnitrogen,andphenol). StageII_{canalsobetreatedbythis method,butit presents}

worsefunctionaloutcomeswhentreatedsimilarlytostageIII

(wideresectionofthelesionandreplacement).4–6

Bonecementhasnobiologicalpropertiesandlong-term resultsare very difficulttoanticipate,especiallywhen this methodisused inthetreatmentofGCT.7,8 _Althoughsome authorshavedemonstratedexcellentresultswiththismethod based ontheclinical approach,no deleteriouseffects were directlyrelatedtotheuseofmethylmethacrylateandother adjuvanttreatmentsthathavebeenrecommendedtoreduce GCTrecurrencewereobserved.9

Treatmentsinvolvingsubstitution,suchasreconstruction ofthe proximalfemur withfemoralprostheses,the useof proximalendoprosthesisforlargereplacementsofproximal femoral neoplasms, modular titanium endoprosthesis, and conventional totalhiparthroplasty aretechniquesusedfor GCTofthehip.10–13

Fig.1–Hipradiographinanteroposterior(A)andLowensteinlateral(B)viewsshowingosteolyticlesionintheleftfemoral neck.

Fig.2–Magneticresonanceimagingofthepelvis,coronalinT2(A),andaxialplanewithcontrastinT2(B)showinglesion

intheleftfemoralneck.

Fig.3–Hipradiographinanteroposterior(A)andLowensteinlateral(B)viewsshowingpostoperativeGCTintheleftfemoral

Fig.4–MagneticresonanceimagingofthelefthipinsagittalplaneinT2,showingGCTrecurrenceoneyearafterthefirst surgery.

Fig.5–Intraoperativeimageswithendoprosthesis.

Fig.6–Lefthipradiographsinanteroposteriorview,showingthesectionwithsafetymargin(A),andtheendoprosthesis

removedandacementless prosthesisisusedinacetabular preparationtoensurethedurabilityandreliabilityofthe sys-tem.

Resectionoftheproximalthirdofthefemurisasuitable surgicaltreatmentforcasesoffemoralneckGCT.Asinthe presentcase,itisaviablesurgicalalternativetoresectionwith curettageandotherfillingmethods,whichhavebeenproven tobecomparativelyineffective.

Conclusion

Thefemoral neckis not the mostcommon region forthe presence of GCT. In the present case, the authors con-cludedthatthefemoralneckGCTshouldbewidelyresected, pursuant to all the criteria and principles of oncological surgery.Blockresectionoftheentirelesionwithasafety mar-ginfor the removalof the entire affected area, aswell as the underlyingtissue thatpresented contaminated macro-scopic features, followed by a non-conventional prosthetic replacement was opted. The authors emphasize the need forcompleteandsaferesectiontopreventrecurrenceofthe lesion.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

r

e

f

e

r

e

n

c

e

s

1. SchajowiczF.Tumoresylesionespseudotumoralesdehuesos yarticulaciones.BuenosAires:Panamericana;1982.

2. CamargoOP,CrociAT,OliveiraCRG,BaptistaAM,CaieroMT, GiannottiMA.Tumordecélulasgigantes–_{evoluc¸ãohistórica}

doseudiagnósticoetratamentojuntoaoInstitutode OrtopediaeTraumatologiadaFMUSP.ActaOrtopBras. 2001;9(4):46–52.

3.CatalanJ,FonteAC,LusaJRB,MeloES,JustinoJúniorRO,Min TT,etal.Tumordecélulasgigantesósseo:aspectosclínicose radiográficosde115casos.RadiolBras.2006;39(2):119–22. 4.FilhoRJG,KorukianM,IshiraraHI,MicenoFilhoNM,

FigueiredoMTB,SeixasMT.Éacuretagemummétodo eficientenotratamentodostumoresósseos?RevBrasOrtop. 1993;28(11/12):813–6.

5.CamargoOPO.Estadodaartenodiagnósticoetratamentodo tumordecélulasgigantes.RevBrasOrtop.2002;37(10):424–9. 6.OdaY,MiuraH,TsuneyoshiM,IwamotoY.Giantcelltumorof

bone:oncologicalandfunctionalresultsoflong-term follow-up.JpnJClinOncol.1998;28(5):323–8.

7.ShihHN,ChengCY,ChenYJ,HuangTJ,HsuRW.Treatentof thefemoralneckamdtrochantericbenignlesions.Clin OrthopRelatRes.1996;(328):220–6.

8.CamargoOP,CrociAT,OliveiraCRGMC,BaptistaAM,Caiero MT.Avaliac¸ãoradiográficaefuncionalde214lesõesósseas benignasagressivastratadascomcuretagem,cauterizac¸ãoe cimentac¸ão:24anosdeseguimento.Clinics.

2005;60(6):439–44,60.

9.ProsserGH,BalochKG,TillmanRM,CarterSR,GrimerRJ.Does curettagewithoutadjuvanttherapyprovidelowrecurrence ratesingiant-celltumorsofbone?ClinOrthopRelatRes. 2005;(435):211–8.

10.MenendezLR,AhlmannER,KermaniC,GothaH.

Endoprostheticreconstructionforneoplasmsoftheproximal femur.ClinOrthopRelatRes.2006;450:46–51.

11.CrociAT,CamargoOP,BaptistaAM,CaieroMT.Theuseofa modulartitaniumendoprosthesisinskeletalreconstructions afterbonetumorresections:methodpresentationand analysisof37cases.RevHospClinFacMedSãoPaulo. 2000;55(5):169–76.

12.DonatiD,GiacominiS,GozziE,MercuriM.Proximalfemur reconstructionbyanallograftprosthesiscomposite.Clin OrthopRelatRes.2002;(394):192–200.