AJR 2003; 181:1583-1589
© American Roentgen Ray Society
Mimics on Radiography of Giant Cell Tumor of Bone
Gregory S. Stacy1,
Terrance D. Peabody2 and
Larry B. Dixon1
1 Department of Radiology, University of Chicago Hospitals, 5841 S Maryland
Ave., MC 2026, Chicago, IL 60637.
2 Department of Orthopedic Surgery, University of Chicago Hospitals, MC 3079,
Chicago, IL 60637.
Received December 30, 2002;
accepted after revision April 29, 2003.
Address correspondence to G. S. Stacy.
Introduction
Giant cell tumor of bone often presents with specific imaging features.
Many patients are referred to the orthopedic oncology clinic of our
institution with a preliminary diagnosis of giant cell tumor based on a
radiologist's interpretation of imaging studies showing features typical of
this lesion. Although most of these lesions were subsequently confirmed to be
giant cell tumors, we have encountered several similar-appearing lesions that
were ultimately diagnosed as another entity.
The Typical Giant Cell Tumor of Bone
Giant cell tumor of bone tends to affect patients more than 20 years old,
with the peak incidence occurring during the third decade of life
[1]. Patients usually present
with pain. Radiographically, the lesion is purely lytic, exhibiting geographic
bone destruction. Most have well-defined but nonsclerotic margins
(Fig. 1A). A minority
(10–20%) have less well-defined margins
(Fig. 1B), and sclerotic
margins are rare (Fig. 1C).
When present in long bones, the lesions arise in the metaphysis, with
characteristic extension across a fused physis into the epiphysis (or
apophysis). Radiographs may show internal "pseudotrabeculae"
representing osseous ridges formed by endosteal scalloping. Although
periosteal reaction is atypical, expansile remodeling, cortical penetration,
and soft-tissue extension are frequent
[1]
(Fig. 1D).
Cartilage-Forming Tumors Mimicking Giant Cell Tumor of Bone
Chondroblastomas are radiolucent lesions that typically occupy the
epiphysis (or apophysis) of long bones
(Fig. 2A). They tend to be
small (< 4 cm) with most (
75%) exhibiting a sclerotic border
[2,
3]. A calcified matrix is seen
on radiographs in one third of patients
[4]. Chondroblastomas may mimic
giant cell tumor when they extend into the metaphysis and lack sclerotic
margins and calcification (Fig.
2B). Unlike giant cell tumor, chondroblastomas present in a
younger age group, usually before skeletal maturity. Extension of tumor into
soft tissues is rare with chondroblastoma.
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Fig. 2B. —Chondroblastoma. Radiograph of 16-year-old boy shows
geographic radiolucent lesion with nonsclerotic margins in proximal tibial
metaphysis and epiphysis (arrowheads). No calcifications were seen,
even on CT (not shown). Although radiographic appearance suggests giant cell
tumor, youth of patient makes diagnosis atypical.
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Chondromyxoid fibromas are rare tumors that occur predominantly in the
second and third decades of life. They usually arise within the metaphysis of
long bones with occasional diaphyseal extension. They characteristically have
sclerotic margins and appear lobulated and "bubbly"
(Fig. 3A). Calcification is
uncommon [2]. Rarely,
chondromyxoid fibromas lack sclerotic margins and extend into the epiphysis of
long bones, resembling giant cell tumor
(Fig. 3B). The average age of
patients with chondromyxoid fibroma ( 25 years) is only slightly younger
than that of patients with giant cell tumor, with sufficient overlap.
Soft-tissue extension is uncommon
[5].
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Fig. 3A. —Chondromyxoid fibroma. Radiograph of 16-year-old boy shows
typical chondromyxoid fibroma (arrowheads) of metadiaphysis of fifth
metatarsal. Lesion is well defined with characteristic "bubbly"
lobulated appearance and sclerotic margin.
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Fig. 3B. —Chondromyxoid fibroma. Radiograph of 42-year-old man shows
geographic radiolucent lesion with nonsclerotic margin in metaphysis and
epiphysis of proximal tibia (arrowheads). No calcifications are
visible. Although radiographic appearance suggests giant cell tumor, findings
of pathology revealed diagnosis of chondromyxoid fibroma.
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Enchondromas are seldom confused with giant cell tumors on radiographs of
long bones, but differentiating the two entities in the small bones of the
hands (Fig. 4) and feet may be
difficult. Both tumors can appear purely lytic and involve most of the volume
of a small bone, including the subarticular portion. The margins of
enchondromas are commonly sclerotic, however, and enchondromas are
asymptomatic unless fractured
[2].
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Fig. 4. —Enchondroma. Radiograph of 52-year-old man shows slightly
expansile radiolucent lesion (arrowheads) in proximal phalanx of
middle finger approaching articular surface of proximal interphalangeal
joint.
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Medullary chondrosarcomas, when present in long bones, have a predilection
for metadiaphysis or diaphysis; extension to the articular surface may
occasionally occur, suggesting the diagnosis of giant cell tumor
(Fig. 5). Most medullary
chondrosarcomas are low-grade lesions that may have a deceptively benign
radiographic appearance. Identifying calcification supports the diagnosis of a
cartilage-producing tumor; however, calcification may not be visible on
radiographs. Chondrosarcomas tend to occur more often in an older age group
than do giant cell tumors
[2].
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Fig. 5. —Chondrosarcoma. Radiograph of 32-year-old man shows
geographic radiolucent lesion (arrowheads) in proximal humeral
metaphysis and epiphysis. Small foci of calcification (arrows)
effectively exclude giant cell tumor as potential diagnosis. Results of
pathology revealed chondrosarcoma.
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Lesions with sclerotic margins may appear to have matrix mineralization
when, in fact, the suspected internal calcification is actually due to the
density of peripheral septations of the margin itself. CT allows confident
assessment of matrix mineralization.
Bone-Forming Tumors Mimicking Giant Cell Tumor
Bone-forming neoplasms are rarely mistaken for giant cell tumor. Unusual
examples of osteoblastoma (Fig.
6) and osteosarcoma (Fig.
7) mimicking giant cell tumor are included
[6,
7].
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Fig. 6. —Radiograph of 38-year-old woman with osteoblastoma. This case
is unusual, in which well-defined radiolucent lesion with nonsclerotic margin
(arrowheads) in proximal humerus mimics giant cell tumor. Only rarely
do osteoblastomas have this appearance.
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Fig. 7. —Radiograph of 18-year-old woman with osteosarcoma. This case
is unusual, in which radiolucent lesion (arrowheads) in distal ulna
extends to articular surface, with radiographic appearance indistinguishable
from giant cell tumor. Only rarely do osteosarcomas have this appearance.
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Other Tumors and Tumorlike Lesions
The diagnosis of metastases or multiple myeloma is straightforward if
numerous lesions are noted throughout the skeleton. A solitary lesion may
mimic giant cell tumor if located in the subchondral region of a long bone
(Fig. 8). Metastasis or
myeloma is likely if the lesion occurs in an elderly individual, beyond the
typical age range of patients with giant cell tumor.
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Fig. 8. —Radiograph of 78-year-old woman with metastasis of renal cell
carcinoma. Radiolucent lesion in distal tibia (arrowheads) extends to
articular surface. Although radiographic appearance is compatible with giant
cell tumor, advanced age of patient argues otherwise. Results of pathologic
examination confirmed metastasis from primary kidney tumor.
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Aneurysmal bone cysts are lytic, often expansile lesions most commonly
occurring in the metaphysis of long bones. They arise in a younger group
(usually between 5 and 20 years old) than do giant cell tumors. If the cyst
occurs or persists after physeal closure, then it may extend into the
epiphysis and be indistinguishable from giant cell tumor
(Fig. 9A). CT or MRI may
reveal fluid levels, representing layering blood products
(Fig. 9B). Lack of enhancing
solid components would also support the diagnosis of aneurysmal bone cyst over
giant cell tumor.
An aneurysmal bone cyst may form within a giant cell tumor
[1]. This should be suspected
if the age of the patient and the radiographic appearance of the lesion are
suggestive of giant cell tumor (Fig.
10A) and if findings of CT, MRI, or both reveal fluid levels in
addition to an enhancing solid component
(Fig. 10B).
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Fig. 10B. —25-year-old woman with giant cell tumor with secondary
aneurysmal bone cyst formation. T1-weighted axial image with fat saturation
reveals fluid–fluid levels (arrowheads) in addition to
enhancing solid component (arrow) of lesion.
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Giant cell reparative granuloma is a reactive process that occurs in the
small bones of the hands and feet (more frequently in the mandible and
maxilla) and mimics giant cell tumor radiographically
(Fig. 11). The lesions are
lytic and expansile, but extension to the epiphysis is unusual. They tend to
occur in a slightly younger age group (second and third decades of life) than
do giant cell tumors and do not usually appear as aggressive on radiographs
[1].
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Fig. 11. —Radiograph of 26-year-old woman with giant cell reparative
granuloma shows expansile lytic lesion (arrow) of second metacarpal
with internal trabeculation extending to metacarpophalangeal joint.
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Mimics of Giant Cell Tumor Caused by Articular Processes
Intraosseous ganglionic cysts are benign lesions located in the subchondral
bone adjacent to the joint and are usually found incidentally in young adults.
Although the exact pathogenesis of these lesions is unknown, trauma, aseptic
necrosis, and idiopathic connective tissue transformation are possible causes.
Unlike the typical giant cell tumor, intraosseous ganglia are usually
asymptomatic, are surrounded by a sclerotic border on radiographs
(Fig. 12A), and are smaller
than the average giant cell tumor. Favored sites include the proximal tibia
(near the attachments of the cruciate ligaments) and the medial malleolus
(Fig. 12B). On MRI,
intraosseous ganglia are of homogeneous fluid signal intensity but may be
loculate (Fig. 12C). Although
the gelatinous cyst contents should not enhance after IV gadolinium
administration, a peripheral rim of enhancement, due to surrounding connective
tissue, is common. MRI may also reveal adjacent soft-tissue cysts.
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Fig. 12A. —Intraosseous ganglionic cysts. Radiograph of 23-year-old man
shows radiolucent lesion (arrowheads) of proximal tibia. Small size
of lesion and sclerotic margin argue against giant cell tumor.
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Fig. 12C. —Intraosseous ganglionic cysts. T2-weighted coronal image with
fat saturation shows medial malleolus lesion (B) to be of loculate
fluid signal intensity (arrow). Medial malleolus is common location
for intraosseous ganglionic cysts.
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Arthritides such as rheumatoid arthritis (Fig.
13A,
13B) and pigmented
villonodular synovitis (Fig.
14A,
14B,
14C) uncommonly produce giant
synovial cysts or pseudocysts that mimic giant cell tumor
[8].
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Fig. 13A. —51-year-old man with rheumatoid arthritis. Radiograph shows
large, geographic radiolucent lesion (arrow) in proximal humerus
extending to articular surface, mimicking giant cell tumor. Glenohumeral joint
space is narrowed. Radiograph of contralateral shoulder (not shown) revealed
similar findings. Only rarely do synovial cysts achieve this size and mimic
neoplasm.
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Fig. 13B. —51-year-old man with rheumatoid arthritis. Radiograph of hand
shows typical findings of rheumatoid arthritis, including narrowing and
erosions involving multiple joints. Note soft-tissue swelling around third and
fourth proximal interphalangeal joints and ankylosis of second
metacarpophalangeal joint.
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Fig. 14A. —66-year-old man with pigmented villonodular synovitis.
Radiograph shows large, geographic radiolucent lesion (arrowheads) in
proximal tibia extending to articular surface, mimicking giant cell tumor.
This lesion represents atypically large synovial protrusion of pigmented
villonodular synovitis.
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Fig. 14C. —66-year-old man with pigmented villonodular synovitis.
T2-weighted sagittal image shows tibial lesion (A) (black
arrow) as well as multiple intraarticular masses of low signal intensity
(white arrows) representing hemosiderin-laden pigmented villonodular
synovitis.
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Mimics of Giant Cell Tumor Caused by Systemic Processes
Brown tumors of hyperparathyroidism are expansile and well marginated and
can mimic giant cell tumors when they occur in the small bones of the hands
(Fig. 15A) and feet, in flat
bones, or at the ends of long bones. Patients with brown tumors inevitably
have additional radiographic features of hyperparathyroidism
(Fig. 15B). Adult hemophilic
pseudotumor may mimic giant cell tumor radiographically as an expansile lesion
with endosteal scalloping (Fig.
16A). Unlike giant cell tumors, pseudotumors typically have
sclerotic margins. Additional findings compatible with repeated intraarticular
hemorrhage may be seen (Fig.
16B).
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Fig. 15A. —Brown tumors of hyperparathyroidism. Radiograph of
71-year-old man shows pathologic fracture through radiolucent lesion
(arrow) of proximal phalanx of middle finger. Brown tumor was
suspected on basis of subtle subperiosteal resorption along radial aspect of
middle phalanges (arrowheads), indicating hyperparathyroidism.
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Fig. 15B. —Brown tumors of hyperparathyroidism. Radiograph of
55-year-old woman shows pathologic fracture through large lytic lesion
(arrow) of proximal tibia. Scalloping of medial border of proximal
tibia (arrowheads) suggests subperiosteal resorption of
hyperparathyroidism. Results of pathology revealed diagnosis of brown
tumor.
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Fig. 16A. —30-year-old man with pseudotumor of hemophilia. Radiograph
shows eccentric radiolucent lesion (arrowheads) of proximal tibia
with sclerotic margins extending to articular surface. Moderate degenerative
changes are noted in knee joint for patient of this age.
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Fig. 16B. —30-year-old man with pseudotumor of hemophilia. Lateral
radiograph of same knee as show in A depicts proximal tibial lesion
(arrow) as well as small but unusually dense joint effusion (or
synovium) suggestive of hemosiderin deposition.
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Introduction
The Typical Giant Cell...
