Giant-cell tumor of bone is a benign, locally invasive tumor that has been associated with a rate of local recurrence of 27 percent (forty-one of 151) after intralesional excision and 8 percent (ten of 122) after marginal excision1. The high rate of local recurrence and the occasional development of pulmonary metastasis are manifestations of the locally invasive nature of the tumor4-6,8,9,11,12.
A peripheral rim of ossification has been described as an almost pathognomonic sign of a soft-tissue recurrence2,3,11. However, a soft-tissue recurrence can be difficult to detect, especially when the recurrent lesion is asymptomatic and is not associated with the characteristic ossification.
We report on four patients who had an isolated soft-tissue recurrence of a giant-cell tumor of bone. Although a radiodense peripheral rim of ossification is thought to be pathognomonic of a soft-tissue recurrence of giant-cell tumor, this finding was not apparent on the plain radiographs of any of these patients. In each case, a soft-tissue mass was palpable on physical examination and magnetic resonance imaging scans revealed a soft-tissue mass with a heterogeneous signal pattern. The purpose of this report is to emphasize that a soft-tissue recurrence may not be recognized if a thorough physical examination is not performed and magnetic resonance imaging studies are not carried out.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Orthopaedic Oncology Unit, Orthopaedic Surgical Service (F. Y.-I. L., E. J. H., and H. J. M.), Department of Radiology (M. M. and S. K.), and Department of Pathology (S. B. K.), Massachusetts General Hospital, Boston, Massachusetts 02114. E-mail address for Dr. Mankin: hmankin@partners.org.
CASE 1. A forty-two-year-old woman was seen by us because of a rapidly enlarging soft-tissue mass in the posteromedial aspect of the proximal part of the right calf. Twenty-six months previously, the patient had been managed with curettage and bone-grafting because of a giant-cell tumor of the proximal aspect of the right tibia. Six months after the initial treatment, the patient had a recurrence of the giant-cell tumor and was managed with curettage and packing with polymethylmethacrylate cement. Ten months later (sixteen months after the diagnosis), the patient had another recurrence and was managed with wide resection followed by reconstruction of the proximal aspect of the tibia with an osteoarticular allograft. In addition, the patient had a wedge resection of the lower lobe of the right lung because of pulmonary metastasis. The patient was followed at another institution postoperatively for ten months, at which time she was evaluated at our institution. Physical examination revealed a nontender soft-tissue mass, nine by seven centimeters in size, that was palpable in the posteromedial aspect of the proximal part of the calf. Plain radiographs showed no evidence of a soft-tissue mass or peripheral circumferential ossification (Fig. 1-A). The allograft was intact. Magnetic resonance imaging studies revealed a heterogeneous soft-tissue mass in the muscle planes of the posteromedial aspect of the proximal part of the calf. The lesion was dark on T1-weighted images (Fig. 1-B) and bright on T2-weighted images (Fig. 1-C). The lesion showed substantial gadolinium enhancement in all areas but its central region, which appeared necrotic. The patient was managed with wide resection of the well circumscribed soft-tissue mass, which measured 7.5 by 5.5 by 4.5 centimeters and was located deep within the posterior compartment (Fig. 1-D). Histological analysis demonstrated a recurrent giant-cell tumor with vascular invasion by tumor cells (Fig. 1-E).
CASE 2. A thirty-six-year-old woman was managed with en bloc resection of a giant-cell tumor involving the proximal part of the right fibula three years before she was seen by us. Eight months after the resection, the patient began to have pain that radiated down the lateral aspect of the right leg. The patient was obese, which made palpation difficult. Plain radiographs revealed a soft-tissue mass without peripheral ossification. Magnetic resonance imaging scans showed a lesion within the fibular head and an associated soft-tissue mass. The patient was managed with complete resection of the proximal aspect of the fibula, which constituted a wide resection of the recurrent tumor. The patient did well for two years, at which time she was first seen by us. A nontender soft-tissue mass, six by five centimeters in size, was palpable at the site of the previous operation. The patient was asymptomatic. Plain radiographs demonstrated a soft-tissue density in the operative bed. A needle biopsy was performed under the guidance of computed tomography, and the findings of histological studies were consistent with a recurrent giant-cell tumor. Radiographs of the chest revealed normal findings. The patient was managed with wide resection of the recurrent tumor.
CASE 3. A fifty-five-year-old man was managed with resection of a giant-cell tumor involving the distal part of the ulna fifteen months before he was seen by us. A round, mobile, nontender, subcutaneous mass was palpated at the operative site five months after the resection. Plain radiographs were unremarkable. The patient was managed with resection of the mass, which was found to be a recurrent giant-cell tumor. When the patient was first seen by us approximately ten months later, two masses were palpable in the soft tissues at the operative site. Plain radiographs showed a single soft-tissue mass with no peripheral calcification, and magnetic resonance imaging scans revealed two separate soft-tissue masses. The first mass, which was located superficial to the extensor carpi ulnaris tendon, was a round, 1.2-centimeter-diameter lesion that demonstrated heterogeneous signal intensity on T2-weighted images as well as mild gadolinium enhancement. The other mass, which was two centimeters in diameter, was located adjacent to the ulnar aspect of the distal part of the radius. The patient was managed with en bloc resection of both soft-tissue masses, which proved to be recurrent giant-cell tumors.
CASE 4. A twenty-seven-year-old woman was seen by us because of recurrence of a giant-cell tumor of the distal aspect of the femur. Twenty months previously, the patient had been managed with curettage of the primary lesion and packing with polymethylmethacrylate cement. The intraosseous tumor had recurred during a pregnancy twelve months after the initial operation. When first seen by us, the patient had a nontender soft-tissue mass, two by two centimeters in size, that was palpable deep to the subcutaneous region adjacent to the previous wound. Plain radiographs revealed no ossification around the soft-tissue mass. Magnetic resonance imaging scans revealed a round, heterogeneous mass, 2.5 centimeters in diameter, in the vastus lateralis muscle. The lesion was dark on T1-weighted images (Fig. 2-A) and bright on T2-weighted images (Fig. 2-B) and demonstrated gadolinium enhancement. The radiographic findings were thought to be most consistent with a benign vascular lesion such as a lymphangioma or a hemangioma. A biopsy was performed under the guidance of computed tomography, and the findings of histological analysis were consistent with a recurrent giant-cell tumor (Fig. 2-C). The patient was managed with curettage of the recurrent intraosseous lesion and en bloc resection of the soft-tissue mass.