2007'den Bugüne 92,260 Tavsiye, 28,210 Uzman ve 19,973 Bilimsel Makale
Site İçi Arama
Yeni Tavsiye Ekleyin!



The Coexıstence Of Gıant Cell Tumor, Paraartıcular
MAKALE #1883 © Yazan Prof.Dr.Fahri ERDOĞAN | Yayın Kasım 2008 | 6,208 Okuyucu
OLGU SUNUMU / CASE REPORT Vol. 13, No. 1, (49-56), 2002


THE COEXISTENCE OF GIANT CELL TUMOR, PARAARTICULAR
OSTEOCHONDROMA AND IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) IN ONE PATIENT: A CASE REPORT



Nurettin HEYBELİ
*, Müjdat ÖK**, Fahri ERDOĞAN*** Muharrem BABACAN

****


***
* Assist. Prof., Department of Orthopaedics and Traumatology School of Medicine Süleyman Demirel University Isparta Turkey.


**
** Orth., Surgeon. Department of Orthopaedics and Traumatology Cerrahpaşa School of Medicine Ýstanbul University Istanbul Turkey.


*
*** Assoc. Prof., Department of Orthopaedics and Traumatology Cerrahpasa School of Medicine Istanbul University Istanbul Turkey.

**** Prof., Department of Orthopaedics and Traumatology Cerrahpasa School of Medicine Istanbul University Istanbul Turkey.

SUMMARY


Giant-cell tumor (GCT) of bone is a primary bone neoplasm which is most commonly seen around the knee joint. Curettage and bone grafting is the
mainstay of treatment in GCT. However, local recurrence is a frequent complication. Osteochondroma is a common benign tumor, which arises
from a developmental defect in the growth plate. A para-articular osteochondroma is a rare lesion with only a few reported cases in the literature. This case is presented as, in the literature survey, we were not able to find any case where a GCT and para-articular osteochondroma occurred in the same patient. Furthermore, a superimposed Idiopathic Thrombocytopenic Purpura was detected and treated before her second "primary" operation.

Key Words:
Giant-cell Tumor, Para-articular Osteochondroma, Idiopathic Thrombocytopenic Purpura.



ÖZET


DEV HÜCRELİ TÜMÖR, PARAARTIKÜLER OSTEOKONEDROMA VE IDIOPATIK
TROMBSITOPENIK PURPURANIN (ITP) BIRLIKTE GÖRÜLMESI: OLGU SUNUMU
Dev hücreli kemik tümörü sıklıkla diz çevresinde görülen primer bir neoplasmdır. Dev hücreli tümörün tedavisinde küretaj ve kemik grefti uygulaması yapılmaktadır. Bununla birlikte, lokal nüksler sık görülmektedir. Osteokondrom ise büyüme kıkırdağındaki bir gelişme defekti sonucu ortaya çıkan ve sık görülen selim tümörlerdendir. Fakat, literatürde sadece az sayıda olgu sunusu olarak bildirilmis olan eklem çevresi osteokondromlarına nadiren rastlanmaktadır. Bu olgu, literatür incelememizde aynı hastada hem Dev Hücreli Tümör hem de osteokondrom lezyonlarına rastlamamız nedeniyle sunulmustur. Bunun yanında, hastanın ikinci "primer" tümörünün ameliyatından önce ıdiyopatik Trombositopenik Purpura tespit edilerek tedavisi
gerçeklestirilmistir.

Anahtar Kelimeler:
Dev Hücreli Tümör, Paraartiküler Osteokondrom, idiyopatik Trombositopenik



Purpura.


INTRODUCTION


The giant-cell tumor (GCT) of bone is a primary bone neoplasm. It was first described macroscopically by Cooper in 1818 and later by Lebert using microscopy in 1845. An important progress was made by Jaffe who in 1940 defined this tumor as a separate clinical and radiological entity

1. GCT is a monostotic condition probably originating from histio-fibroblastic


elements in the metaphyseoepiphyseal areas of long bones
2. It is constituted by round, ovoid or spindleshaped basic cells that tend to fuse into multinucleate giant cells. It occurs relatively frequently and the transformation to sarcoma is around 5%. There is a slight predilection for the female sex. It occurs rarely before puberty and after 50 years of age. The most common localization is around the knee joint; more than 25%of all cases occurring in the proximal tibia

3,4. Though curettage with bone grafting is the mainstay of treatment. A variety of adjuvant methods have been developed to reduce local recurrence rates which can be as high as 40%-60%. These include liquid nitrogen cryotherapy, phenol and alcohol chemical cautery and heat cauterization with saline or Polymethylmethacrylate (PMMA). Follow-up should include a quarterly history and physical examination as well as roentgenograms of the chest and involved extremities during the first two years Osteochondromas develop from an aberrant subperiosteal germ of foetal cartilage. Para-articular or juxta-articular chondromas arise from the capsule or the extracapsular connective tissue of a large joint


5. The concept of para-articular osteochondroma was first introduced in 1958 by Jaffe who used the terms para-articular chondroma and intracapsular chondroma to describe osteochondral metaplasia occurring in the joint capsule or soft tissues adjacent to a joint. Malignant transformation has not been reported though the histologic features may be suggestive of a malignant tumor including hypercellularity of the cartilaginous component and atypia of individual chondrocytes. Because marginal excision is adequate for these tumors it is important to distinguish them from synovial chondromatosis and chondrosarcoma



6.Idiopathic (Immunologic) Thrombocytopenic Purpura (ITP) is in most adults a chronic disorder with no apparent predisposing course. In childhood ITP, a viral antigen is thought to trigger the synthesis of antibodies that may react with virus coated platelets in contrast to adults where the antibodies are directed against a structural platelet antigen (glycoprotein IIb-IIIa or glycoprotein complex Ib-IX). Acute ITP is generally seen in the paediatric population constituting only about 10% of adult cases where antibodies produced against a viral antigen cross-react with platelets accelerating their clearance. Chronic ITP mostly affects women in their 20-40s. The female to male ratio is 3:1


7. CASE REPORT




A 31-year old female patient was first seen by us in January 1992 because of left knee pain of three months duration. The pain became worse with long distance walking. No significant personal or family history was elicited. A slight expansion of the proximal tibia was found on physical examination. There were no abnormal findings in the blood tests. An osteolytic lesion in the proximal metaphyseal region of the left tibia was seen on the plain radiographs (Fig. 1). Subsequently, the lesion was biopsied which revealed a GCT of bone (Fig. 2). A formal curettage and washout of the cavity with hot saline (60 °C) was performed as a definitive treatment. The resulting cavity was then filled with autogenous iliac bone graft and cement (Fig. 3). The postoperative course passed uneventfully and the patient was discharged with restricted weightbearing on the involved extremity. She came to monthly follow-up visits and was allowed full weight-bearing at three months postoperatively when graft incorporation was observed.
Two and-a-half years had passed since the operation when the patient presented with pain in her right hip radiating to the knee. The physical examination revealed severe restriction of the Range of Motion (ROM) of the right hip. A proliferative lesion showing non-homogenous calcifications in the subcapital region of the right femur was seen on anteroposteriror and lateral views (Fig. 4). The patient was hospitalized again for surgery. Incidentally, it was found that the preoperative blood count showed marked thrombocytopenia (48,000/mm³), so a haematological survey was started. The Prothrombin Time (PT) was normal and the activated Partial Thromboplastin Time (aPTT) was slightly delayed being 38 seconds (Normal: 26-34 sec.). Anti-nuclear antibodies were tested negative. The peripheral blood-smear revealed scarcely clustered thrombocytes and the bone-marrow aspirate showed slight erythroid hyperplasia, and abundant megakaryocytes with normal morphology. The patient was diagnosed as ITP and was placed on oral corticosteroid (16 mg. methylprednisolone, tid) therapy. She showed marked improvement with thrombocyte counts rising to 105,000/mm³ at the end of the first week and to 147,000/mm³ at the end of the second week of treatment. She is accepted as in remission and was taken to follow-up by haematologists. A thru-cut needle biopsy was done but could not be interpreted due to insufficient biopsy material. Then, a proximal femoral resection and prosthetic reconstruction was done. Macroscopic and microscopic evaluation of the resected mass revealed a para-articular osteochondroma (Figs. 5 and 6). The defect was managed with modular endoprosthetic reconstruction (prosthesis designed by Dr. Kotz) (Fig. 7). After the operation, there was postoperative bleeding from the incision, which could not be controlled by compressive bandages. The haematological parameters were checked again and the case was consulted with the haematologists. The blood tests were normal so a surgical cause of bleeding was contemplated. A second-look exploration was performed with evacuation of the haematoma and search for possible bleeding vessels, but none was found. There were recurrent bleeding episodes with intervals in-between. A catheter embolisation under fluoroscopic guidance was done at the end of the first postoperative month which stopped the bleeding instantly. A subcutaneous infection developed secondary to haematoma contamination. The bacteriological study revealed pseudomonas mirabilis and alpha-haemolytic streptococci as the infecting microorganisms. The infection resolved within one
month under appropriate antibiotic therapy. The patient was discharged from the hospital at 4.5 months postoperatively. She ambulates instantly and is still under follow-up with no local recurrence. Also,

Relapse of ITP was not detected.
DISCUSSION



A variety of osteocartilaginous outgrowths are found near joints. Osteophytes occurring in degenerative arthritis are the most frequent. Proper osteochondromas, although near to the joint, are attached by a stalk to the cortical surface of the "parent" bone and so are metaphyseal nonarticular lesions. However, they may occasionally protrude into the joint cavity. Differentiating between conventional osteochondromas, synovial chondromatosis, para-articular osteochondromas and even parosteal chondrosarcomas and osteosarcomas can be difficult. A conventional osteochondroma arises from a developmental defect in the growth plate and grows away from the nearest joint. Synovial chondromatosis, in
contrast, is characterised by numerous cartilaginous nodules arising from a synovial membrane such as in a joint or a bursa

8. Although their cause remains unknown, some authors have proposed that there is cartilaginous metaplasia of the connective tissue with subsequent ossification. The pathogenesis and classification of paraarticular osteochondromas are controversial. However histological features can make the distinction from chondrosarcoma difficult on morphological basis alone

6. An osteochondroma that continues to grow after skeletal maturity should be strongly considered to have undergone malignant degeneration. Features suggesting malignancy such as pain and growth after skeletal maturity should be recognized early. The risk of malignant degeneration is said to be approximately 1% per osteochondroma

9. Imaging studies such as Magnetic Resonance Imaging (MRI) or Computerised Tomography are useful for evaluating adult osteochondroma. A cartilage cap greater than 0.5 cm may suggest a malignant transformation


10. Radionuclide bone scanning may also be performed and it may show increased uptake at the site of the lesion
11. If malignant degeneration is suggested by imaging studies, biopsy is usually not advised to be done before surgery as there is a significant risk of a nonrepresentative biopsy and seeding of the biopsy track

9. In our patient, sophisticated imaging techniques could not be obtained because of social and paramedical problems. The treatment algorithm of such a lesion should include a bone scanning and MRI of the lesion, in order to obtain adequate data. Although local resection of the lesion preserving the joint is the preferred method of treatment of such a lesion, proximal femoral excision and total joint replacement had to be performed because of the accompanying coxafemoral arthrosis and limited ROM. Para-articular osteochondromas are extremely rare lesions. When literature is searched, only case reports of this lesion could be detected 12-14. The most favoured sites of occurrence are the knee and the foot

6. In our review of the relevant literature we could not find any case where a giant-cell tumor and a para-articular osteochondroma occurred in the same patient. Furthermore, our patient had a haematologic disorder superimposed that made the surgical management quite difficult. The patient was more than satisfied with the procedure that had been performed for the GCT of the left proximal tibia and there had been no remarkable postoperative occurrence. Unlike the first one, the second hospitalization was quite lengthy (4.5 months) because of intercurrent complications. Nevertheless, all the problems had been resolved and the patient was walking with crutches at the time of the discharge. At the latest follow-up; she was able to perform her daily activities without any problem.



REFERENCES


1. Eckardt JJ, Grogan TJ. Giant cell tumor of bone. Clin Orthop 1986; 204: 45-58.
2. Cheng JC, Johnston JO. Giant cell tumor of bone. Prognosis and treatment of pulmonary metastases. Clin Orthop 1997; 338: 205-14.
3. Campanacci M. Giant Cell Tumor. In: Campanacci M. Ed. Bone and soft tissue tumors. Wien-New York: Springer Verlag, 1990: 17-51.
4. Campanacci M, Baldini N, Boriani S, Sudanese A. Giantcell tumor of bone. J Bone Joint Surg 1987; 69-A: 106-14.
5. Steiner GC, Meushar N, Norman A, Present D. Intracapsular and paraarticular chondromas. Clin Orthop 1994; 303: 231-6.
6. Reith JD, Bauer TW, Joyce MJ. Paraarticular osteochondroma of the knee: report of two cases and review of the literature. Clin Orthop 1997; 334: 225-32.
7. Handin R. Disorders of Platelet and Vessel Wall. In: Fauci AS, Braunwald E, Isselbacher KJ, Wilson JD. Eds. Harrison’s Principles of Internal Medicine, New York: Mc Graw Hill 1997: 734.
8. Milgram JW, Dunn EJ. Para-articular chondromas and osteochondromas: a report of three cases. Clin Orthop 1980; 148: 147-51.

9. Gitelis S, McDonald DJ. Common benign bone tumors and usual treatment. In: Simon MA, Springfeld D. Eds. Surgery for bone and soft-tissue tumors. Philadelphia, New York: Lippincott-Raven, 1998: 181-205.

10. Robbins SG, Glasser DB, Lane JM, Cammisa FP. Malignant and benign primary tumors of the proximal femur. In: Lewis MM. Ed. Musculoskeletal oncology. Philadelphia: W. B. Saunders, 1992: 307-26.
11. Greenspan A, Klein MJ. Radiology and pathology of bone tumors. In: Lewis MM. Ed. Musculoskeletal oncology. Philadelphia: W.B. Saunders, 1992: 13-72.
12. Sakai H, Tamai K, Iwamoto A, Saotome K. Paraarticular chondroma and osteochondroma of the infrapatellar fat pad: a report of three cases. Int Orthop 1999; 23: 114-7.
13. Sansone V, De Ponti A, Ravasi F. An extra-articular cause of locking knee. Int Orthop 1999; 23: 118-9.
14. Hagan PF, Schoenecker PL. Para-articular osteochondroma. Skeletal Radiol 1983; 10: 121-5.

Yazan
Bu makaleden alıntı yapmak için alıntı yapılan yazıya aşağıdaki ibare eklenmelidir:
"The Coexıstence Of Gıant Cell Tumor, Paraartıcular" başlıklı makalenin tüm hakları yazarı Prof.Dr.Fahri ERDOĞAN'e aittir ve makale, yazarı tarafından TavsiyeEdiyorum.com (http://www.tavsiyeediyorum.com) kütüphanesinde yayınlanmıştır.
Bu ibare eklenmek şartıyla, makaleden Fikir ve Sanat Eserleri Kanununa uygun kısa alıntılar yapılabilir, ancak Prof.Dr.Fahri ERDOĞAN'ın izni olmaksızın makalenin tamamı başka bir mecraya kopyalanamaz veya başka yerde yayınlanamaz.
     Beğenin    
Facebook'ta paylaş Twitter'da paylaş Linkin'de paylaş Pinterest'de paylaş Epostayla Paylaş
Yazan Uzman
Fahri ERDOĞAN Fotoğraf
Prof.Dr.Fahri ERDOĞAN
İstanbul
Doktor "Ortopedi ve Travmatoloji"
TavsiyeEdiyorum.com Üyesi12 kez tavsiye edildiİş Adresi Kayıtlı
Makale Kütüphanemizden
İlgili Makaleler Prof.Dr.Fahri ERDOĞAN'ın Makaleleri
TavsiyeEdiyorum.com Bilimsel Makaleler Kütüphanemizdeki 19,973 uzman makalesi arasında 'The Coexıstence Of Gıant Cell Tumor, Paraartıcular' başlığıyla eşleşen başka makale bulunamadı.
Sitemizde yer alan döküman ve yazılar uzman üyelerimiz tarafından hazırlanmış ve pek çoğu bilimsel düzeyde yapılmış çalışmalar olduğundan güvenilir mahiyette eserlerdir. Bununla birlikte TavsiyeEdiyorum.com sitesi ve çalışma sahipleri, yazıların içerdiği bilgilerin güvenilirliği veya güncelliği konusunda hukuki bir güvence vermezler. Sitemizde yayınlanan yazılar bilgi amaçlı kaleme alınmış ve profesyonellere yönelik olarak hazırlanmıştır. Site ziyaretçilerimizin o meslekle ilgili bir uzmanla görüşmeden, yazı içindeki bilgileri kendi başlarına kullanmamaları gerekmektedir. Yazıların telif hakkı tamamen yazarlarına aittir, eserler sahiplerinin muvaffakatı olmadan hiçbir suretle çoğaltılamaz, başka bir yerde kullanılamaz, kopyala yapıştır yöntemiyle başka mecralara aktarılamaz. Sitemizde yer alan herhangi bir yazı başkasına ait telif haklarını ihlal ediyor, intihal içeriyor veya yazarın mensubu bulunduğu mesleğin meslek için etik kurallarına aykırılıklar taşıyorsa, yazının kaldırılabilmesi için site yönetimimize bilgi verilmelidir.


01:56
Top