A fifty-nine-year-old man was first seen at another institution in March 1986. He reported that he had had pain in the right wrist for five months. Radiographic evaluation revealed a large, well delineated, lucent tumor of the distal part of the radius that was consistent with a diagnosis of benign giant-cell tumor. The patient was taken to the operating room, where excision of the tumor by curettage followed by iliac bone-grafting was performed.
In December 1986, a local recurrence developed and the patient was referred to our institution. Wide en bloc resection of the right radius was performed, and an arthrodesis of the wrist was done with an intercalary fibular graft.
In May 1992, the patient sustained a comminuted fracture of the fibular graft that caused malalignment of the wrist and was complicated by non-union. The fracture was treated with open reduction and internal fixation as well as bone-grafting. Histopathological evaluation of multiple biopsy specimens revealed no evidence of local recurrence of the tumor.
At that time, a radiograph of the chest demonstrated a large mediastinal mass. A computed tomography scan of the chest (Fig. 1-A) revealed a mass that measured 8.5 by 5.5 by 10.0 centimeters in the cephalad part of the anterior mediastinum. The mass extended from the left innominate vein down to the left ventricle and compressed the superior vena cava. There was no evidence on the computed tomography scan of any pulmonary metastases, and the mediastinal mass appeared to be separate from the adjacent right lung.
In June 1992, bronchoscopy and an anterior mediastinotomy on the right was performed. A biopsy of the mass was done, and it confirmed the diagnosis of metastatic benign giant-cell tumor of bone in the lymph nodes, which was histologically identical (Figs. 2-A, 2-B, and Fig. 2-C) to the primary tumor.
Because of the large size of the metastatic mediastinal tumor and the proximity to vital mediastinal structures, it was decided to attempt to reduce the size of the tumor with high doses of corticosteroids. The patient was started on a titrated initial dose of twenty milligrams of prednisone together with prophylactic administration of Tagamet (cimetidine) and Bactrim (trimethoprim and sulfamethoxazole). A computed tomography scan (Fig. 1-B) made five months later showed a reduction in the size of the mass of approximately 66 per cent.
The dosage of prednisone was tapered to five milligrams per day for a two-week period, and a median sternotomy with resection of the mediastinal mass was performed in November 1992. This was accomplished by dissection of the tumor off the pericardium and superior vena cava, and it included en bloc resection of a small wedge of the right upper lobe adherent to the tumor. Although the tumor was adherent to the visceral pleura of the lung, there was no evidence of any primary or secondary involvement of the lung. The patient had an uneventful postoperative recovery, and use of the prednisone was tapered off during the next two weeks. The findings of the pathological examination of the resected specimen were again consistent with a histologically benign giant-cell tumor and were similar to those of the biopsy of the mediastinal mass before the use of prednisone. At the most recent follow-up visit, in July 1994 (nineteen months after the operative resection), the patient had no evidence of disease.