Introduction
In the recurrent giant cell tumor of distal end of radius, multinucleated giants and stromal cells multiply within subchondral region of bone. This usually benign but locally aggressive neoplasm commonly first occurs in young adults and typically arises adjacent to the epiphysial-metaphyseal junctions of long bones such as the radius. 1
Despite its benign nature, the tumor's propensity for local recurrence necessitates vigilant management and follow-up. Histologically, it is marked by a dense collection of osteoclast-like giant cells amidst a background of mononuclear spindle-shaped stromal cells, with areas of hemorrhage and cystic change. 2 Radiographically, giant cell tumors exhibit lytic lesions with eccentric, well-defined margins, frequently extending to the subarticular surface.
Usually, the management of recurrent lesions involves a combination of curettage and additional treatments such as bone grafting, cryotherapy or local adjuvants in an effort to minimize re-occurrence. 3 The surgical intervention is meant to ensure complete excision while keeping intact as much surrounding normal tissues as possible so that functional loss or instability of joint may be avoided.
Whenever necessary adjuvant therapies, including PMMA cement or biologic agents can be used to enhance local control. 4 The significance of planning for comprehensive treatment and prolonged follow-up cannot be underestimated especially when it comes to managing cases with high recurrence rates prompted by insufficient initial resection and tumor size thereby safeguarding limb function.
Case Report
Here we present a case of 32-year-old female patient presented with painful lump over right wrist joint since 2 months. Previously patient was surgically treated with intralesional curettage and illiac crest bone graft and bone cement for GCT of distal end of Radius 2 years back.
Figure 7
Xray showingwide resection of distal third radius and ulna with radial strut graft and wrist arthrodesis with plates and screws
Figure 8
Xray showing wide resection of distal third radius and ulna with radial strut graft and wrist arthrodesis with plates and screws
Figure 9
Range of motion at metacarpophalangeal joint and grip strength at 1 year follow up was excellent with satisfactory outcome
Xray (Figure 1, Figure 2) and Magnetic resonance imaging (MRI) showed a well-defined u expansile lytic soft tissue lesion which is homogenously enhanced involving medullary cavity with cortical erosion and extending into soft tissue plane (Figure 3).
We performed wide resection of distal third radius and ulna using dorsal approach with radial strut graft and wrist arthrodesis (Figure 4, Figure 5). Postoperatively, the limb was immobilised in an above-elbow slab for 3 months. Patient were followed up 6 weekly until 6 months and then 3-monthly until one year. Radiographs of the wrist and chest were assessed for recurrence and metastasis (Figure 7, Figure 8). Functional outcome was evaluated using the modified Musculoskeletal Tumor Society scoring system. Grip strength was assessed using a dynamometer, and range of motion of the metacarpophalangeal joint was assessed using a goniometer. (Figure 9)
Discussion
There is a lot of diverse management approaches to these recurrent cases. Intralesional curettage should be the first option for any such lesions, with application of adjuvants including bone grafting or polymethylmethacrylate (PMMA) cement which fills up the defect and reinforces it thereby reducing recurrence rates. A research by Klenke et al. (2011).5 supported this by showing that curettage plus PMMA cement suppresses recurrence more effectively than curettage alone. According to a review by Wada et al., cryotherapy is another new technique that has proved effective in reducing local recurrences by inducing apoptosis by freezing.6, 7
Aydin et al. (2013) have concluded that high energy radiation therapy can be considered in resistant patients who are not amenable to surgical interventions though its use is often limited because of long-term complications and risk for secondary malignancies. Moreover, wider resections combined with reconstructive techniques like allografts or autografts have been recommended for more widespread or recurrent cases, based on a research paper by Puri et al. 8
Moreover, the use of denosumab, a monoclonal antibody that has been developed to target RANKL and other novel modalities including the use of chimeric antigen receptor T-cell therapy have also been used as effective in managing recurrent GCTs (Nakashima et al., 2019). Every one of these treatments has different advantages and disadvantages ranging from surgical measures to innovative pharmaceutical interventions. In many cases, however, selection of the modality depends on such factors as patient’s overall health history, tumor characteristics and previous therapeutic outcomes.7
Conclusion
In conclusion, wrist arthrodesis stands out as a good modality to treat giant cell tumors (GCTs) that recurr at the distal end of the radius. It's useful when other treatments fails, this surgery doesn't just control the tumor; it also makes the wrist more stable, which has good functional outcome.
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