DOI: 10.1148/radiol.2451031776
(Radiology 2007;245:288-291.)
Case 122: Giant Cell Tumor of the Second Metatarsal1
Justin Q. Ly, MD,
Gavin W. Arnett, MSII and
Douglas P. Beall, MD
1 From the Department of Radiology, Wilford Hall Medical Center, 2200 Bergquist Dr, Suite 1, Lackland AFB, TX 78236 (J.Q.L., D.P.B.); and Uniformed Services University of the Health Sciences, Bethesda, Md (G.W.A.). Received November 4, 2003; revision requested January 28, 2004; final revision received January 3, 2005; final version accepted January 25.
Address correspondence to J.Q.L.
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HISTORY
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A 28-year-old woman presented with increasing pain and swelling of 2 months duration in her medial right forefoot. The patient was in good health and had an unremarkable medical history. At physical examination, she did not appear to be in acute distress, and she was afebrile. Evaluation of the right foot was notable for mild diffuse erythema over the medial aspect of the dorsum of the forefoot, with maximal tenderness noted over the second metatarsal. Radiography was performed in the right foot and revealed an abnormality that prompted further evaluation with magnetic resonance (MR) imaging. The results of laboratory blood tests, which included white blood cell count, were normal.
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IMAGING FINDINGS
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Radiography of the foot (Fig 1) revealed nearly complete destruction of the entire second metatarsal by a uniformly radiolucent and expansile process that did not involve any adjacent osseous structures. MR imaging (Fig 2) demonstrated a solitary solid enhancing tumor that caused almost complete destruction of the second metatarsal, with expansion of the residual osseous margin.
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Figure 1: Anteroposterior radiograph of the right foot shows an expansile and uniformly radiolucent process involving and destroying the majority of the visible second metatarsal, with a residual thin rim of medial cortex (arrows). No other bones are involved.
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Figure 2a: (a) Transverse T1-weighted MR image (repetition time msec/echo time msec, 650/16) of the right medial forefoot shows a homogeneous intermediate-signal-intensity mass (arrows) expanding the second metatarsal. (b) Coronal T2-weighted fat-suppressed MR image (5200/105) obtained at the mid-metatarsal level shows an intermediate-signal-intensity solid lesion (*) without cystic spaces. Note the surrounding soft-tissue edema (arrows). (c) Sagittal T1-weighted fat-suppressed contrast material–enhanced MR image (500/16) of the right second metatarsal shows heterogeneous enhancement of the tumor, which is noted to extend (arrows) beyond the remnant cortical confines in some areas.
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Figure 2b: (a) Transverse T1-weighted MR image (repetition time msec/echo time msec, 650/16) of the right medial forefoot shows a homogeneous intermediate-signal-intensity mass (arrows) expanding the second metatarsal. (b) Coronal T2-weighted fat-suppressed MR image (5200/105) obtained at the mid-metatarsal level shows an intermediate-signal-intensity solid lesion (*) without cystic spaces. Note the surrounding soft-tissue edema (arrows). (c) Sagittal T1-weighted fat-suppressed contrast material–enhanced MR image (500/16) of the right second metatarsal shows heterogeneous enhancement of the tumor, which is noted to extend (arrows) beyond the remnant cortical confines in some areas.
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Figure 2c: (a) Transverse T1-weighted MR image (repetition time msec/echo time msec, 650/16) of the right medial forefoot shows a homogeneous intermediate-signal-intensity mass (arrows) expanding the second metatarsal. (b) Coronal T2-weighted fat-suppressed MR image (5200/105) obtained at the mid-metatarsal level shows an intermediate-signal-intensity solid lesion (*) without cystic spaces. Note the surrounding soft-tissue edema (arrows). (c) Sagittal T1-weighted fat-suppressed contrast material–enhanced MR image (500/16) of the right second metatarsal shows heterogeneous enhancement of the tumor, which is noted to extend (arrows) beyond the remnant cortical confines in some areas.
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DISCUSSION
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Differential considerations based on the appearance and location of this tumor included giant cell tumor, giant cell reparative granuloma, aneursymal bone cyst, chondromyxoid fibroma, brown tumor of hyperparathyroidism, angiosarcoma, myeloma, and an expansile metastatic lesion, such as renal cell carcinoma. Giant cell reparative granuloma is a reactive process (as its name implies) that can occur in the hands, feet, jaw, and mandible. It often has imaging features similar to those of a giant cell tumor, and it can be difficult to distinguish from a giant cell tumor without histologic evaluation. A history of trauma can point toward a diagnosis of giant cell reparative granuloma, but tissue diagnosis is ultimately required. A diagnosis of aneurysmal bone cyst was virtually excluded given the absence of a substantial cystic component on MR images. A diagnosis of chondromyxoid fibroma was eliminated because of the absence of characteristic lobular growth, internal trabeculation, and high T2 signal intensity on MR images. A diagnosis of brown tumor of hyperparathyroidism was considered on the basis of the radiographic appearance; however, this diagnosis was excluded because of the patient's clinical history. Angiosarcomas typically have a more aggressive appearance and often show a large soft-tissue component. They tend to involve the long tubular bones. Solitary myeloma can be purely osteolytic and without reactive sclerosis, as demonstrated in this case; however, this was a less likely consideration because this was an uncommon location for myeloma. An expansile metastatic lesion was less likely, given the young age of the patient and the absence of a known primary malignancy; this diagnosis can be virtually excluded on the basis of the location since acrometastases are exceedingly rare.
The radiologic features of the described case led us to narrow the differential considerations to giant cell tumor and giant cell reparative granuloma, although the cortex in giant cell reparative granuloma—while being expanded—usually remains intact. The patient underwent successful second-ray resection, with findings at histologic analysis enabling us to exclude giant cell reparative granuloma. The final pathologic diagnosis was giant cell tumor.
Giant cell tumors are relatively common, representing approximately 5% of all primary bone tumors (1). The majority of giant cell tumors are solitary and occur at the end of long bones. Approximately 50%–70% of giant cell tumors occur near the knee (the femur is involved more frequently than the tibia) (2); the next most frequently involved bone is the radius, followed by the sacrum and the proximal humerus. Less commonly affected sites include the vertebral body, hand, foot, and patella (3). The majority of giant cell tumors occur in skeletally mature patients, with 80% occurring in patients aged 20–50 years (3). Giant cell tumors rarely occur in patients younger than 15 years or older than 50 years. There is a slightly greater frequency in women (2).
Giant cell tumors are uncommon in the hands and feet; tumors in these locations reportedly comprise only 4% of all giant cell tumors (3). Despite their scarcity, tumors in the hands and feet may represent a more aggressive form of giant cell tumor (4). They tend to occur in slightly younger patients and are believed to recur more frequently after surgical excision (5). Additionally, giant cell tumors of the short bones of the hands and feet are more likely to be both multifocal and multicentric and as such, should be examined with a skeletal survey (5). A skeletal survey and bone scan were obtained in this patient and revealed no other skeletal involvement. Multicentric disease reportedly occurs in less than 1% of patients with giant cell tumors (6).
A limited number of giant cell tumors of the metatarsals have been reported in the literature (4,5,7–10). In the reports we reviewed, all patients shared the following characteristics with the patient described in this report: young-adult age (21–35 years); presentation with pain, swelling, or both; involvement of the first or second metatarsal; and radiographic findings of an expansile lytic lesion involving most, if not all, of the metatarsal bone (4,7,9,10). As in the described case, most of the reviewed cases showed evidence of cortical disruption with varying degrees of extension into the soft tissues (4,7,10). To our knowledge, intermediate signal intensity on T1-weighted MR images similar to the signal intensity seen on the MR images obtained in this patient has been described in only one case (9).
Clinical manifestations of giant cell tumors are nonspecific. They commonly include pain, local swelling, arthritic symptoms (due to location near joints), and limited range of motion. Acute pain is a concern because it could indicate a pathologic fracture. Involvement of smaller bones, such as the metatarsal bone in the described patient, can result in presentation with a mass and loss of function prior to onset of pain (9).
Radiographic features include a large and often aggressive-appearing osteolytic tumor that is usually eccentric and located at the end of a bone or involves the entire shaft of small tubular bones, such as the metatarsals. Although giant cell tumors begin on the metaphyseal aspect of the growth plate, they typically extend into the epiphysis and to within 1 cm of the adjacent subchondral bone at the time of presentation. This latter feature has been reported to occur in 84%–99% of giant cell tumors and can aid in the differentiation of these tumors from other osteolytic lesions (3). Giant cell tumors show a zone of transition that is characteristically narrow but lacks sclerotic margins. Moreover, cortical thinning is relatively common, and there are varying degrees of cortical destruction and extension into the adjacent joint or soft tissues, mimicking a malignant process. Tumor matrix mineralization is characteristically absent. In the described case, characteristic radiographic features included expansile remodeling of the involved metacarpal, absence of mineralization, and evidence of cortical thinning and destruction.
Skeletal scintigraphy is nonspecific and usually reveals either increased radioisotope uptake or peripheral uptake with central photopenia. Computed tomography is excellent in the further evaluation of cortical involvement, suspected pathologic fracture, periosteal change, absence of mineralization, and other osseous abnormalities (3).
MR imaging, with its excellent soft-tissue contrast and multiplanar imaging capability, is superior to all other modalities in the evaluation of the extent of marrow and adjacent soft-tissue involvement. T1- and T2-weighted imaging reveals a mass with low to intermediate signal intensity. The low-signal-intensity areas are believed to be caused by hemosiderin deposition. After administration of an intravenous gadolinium chelate, the tumor usually enhances heterogeneously. Contrast-enhanced MR imaging may lead to overestimation of the true extent of the tumor (10). The described case had these characteristic MR imaging features of a giant cell tumor.
Giant cell tumors are usually classified as benign; however, they are aggressive locally and show high rates of recurrence after excision. Although most giant cell tumors are benign, malignant forms comprise 5%–10% of all cases and occur more commonly in male subjects by a 3:1 ratio (8). Patients who have undergone radiation therapy have an increased risk of developing a malignant giant cell tumor. It is not generally possible to determine whether a tumor is benign or malignant on the basis of clinical or imaging findings. Recurrent disease suggests malignancy. Metastasis is unusual, but it has been reported to most frequently involve the lungs (3%) and less frequently involve the lymph nodes, pelvis, scalp, and extremities (5). Local recurrence is more common than distal recurrence. Benign giant cell tumors may also transform into fibrosarcomas and osteosarcomas (11).
Fine-needle aspiration cytology may be useful in the diagnosis of giant cell tumors, even at unusual sites of occurrence, such as the metatarsal bone (12). Traditional therapy consisted of curettage and bone grafting, with less recurrence after wide resection than after marginal resection. The current therapy is curettage and cryotherapy with methacrylate placement, which is associated with a recurrence rate of 2%–25% (3). Radiation therapy can be associated with sarcomatous transformation and is recommended only in inoperable cases. Because of the increased aggressiveness of hand and foot giant cell tumors, wide local excision with or without autogenous graft, arthrodesis, or both—not curettage—should be the initial treatment considered (5). If recurrence happens, it usually occurs within the first 3 years after initial therapy (3). Radiographic appearances that indicate recurrence include destruction of bone at the site of repair or resorption of bone graft material (13,14). Some authors believe that MR imaging is the optimal modality with which to determine if residual or recurrent disease is present (10). MR findings that suggest recurrence include abnormally increased signal intensity indicating round or mass like morphology and eccentric growth.
In summary, the final diagnosis in this patient was giant cell tumor, but giant cell reparative granuloma could not be excluded without histologic analysis.
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FOOTNOTES
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Authors stated no financial relationship to disclose.
| Part one of this case appeared 4 months previously and may contain larger images.
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The views expressed in this article are those of the authors and do not necessarily represent the official policy or position of the Department of the Air Force or the U.S. government.
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References
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- Huvos AG. Bone tumors: diagnosis, treatment, and prognosis. Philadelphia, Pa: Saunders, 1991;429–467.
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- Cummins CA, Scarborough MT, Enneking WF. Multicentric giant cell tumor of bone. Clin Orthop Relat Res 1996;322:245–252. [Medline]
- Khanna AK, Sharma SV, Kumar M. A large metatarsal giant-cell tumor. Acta Orthop Scand 1990;61:271–272. [Medline]
- Mohan V, Gupta SK, Sharma OP, Varma DN. Giant cell tumor of short tubular bones of the hands and feet. Indian J Radiol 1980;34:14–17.
- Mendicino SS. Giant cell tumor of the first metatarsal bone en bloc resection with autogenous middle fibular strut graft. J Foot Ankle Surg 1993;32:405–410. [Medline]
- Burns TP, Weiss M, Snyder M, Hopson CN. Giant cell tumor of the metatarsal. Foot Ankle 1988;8:223–226. [Medline]
- Lee MJ, Sallomi DF, Munk PL, et al. Giant cell tumor of bones. Clin Radiol 1998;53:481–489. [CrossRef][Medline]
- Dorfman HD, Czerniak B. Giant-cell lesions. In: Dorfman HD, Czerniak B, eds. Bone tumors. St Louis, Mo: Mosby, 1998; 559–606.
- Tubbs WS, Brown LR, Beabout JW, Rock MG, Unni KK. Benign giant cell tumor of bone with pulmonary metastases. AJR Am J Roentgenol 1992;158:331–334.[Abstract/Free Full Text]
Congratulations to the 68 individuals and one resident group that submitted the most likely diagnosis (giant cell tumor of the second metatarsal) for Diagnosis Please, Case 122. The names and locations of the individuals and resident group, as submitted, are as follows:
Individual responses
- Hisashi Abe, MD, Suita City, Osaka, Japan
- Gholamali Afshang, MD, Tinley Park, Ill
- Erhan Akpinar, Ankara, Turkey
- Mosleh M. Al Raddadi, MD, Madina, Saudi Arabia
- Jason B. Ashley, MD, London, Ontario, Canada
- Kenneth F. Baliga, MD, Rockford, Ill
- Monica Ballesta Moratalla, MD, Valencia, Spain
- Marcos Busto, Barcelona, Spain
- Marcelo Cabrini, Lomas de Zamora, Argentina
- Antonio A. Cavalcanti, MD, São Paulo, Brazil
- Honorio Chiminazzo, MD, Campinas, Brazil
- Ming-Tsung Chuang, MD, Kaohsiung, Taiwan
- Daniel N. Costa, MD, Boston, Mass
- Marco A. Cura, MD, San Antonio, Tex
- Peter De Baets, Damme, Belgium
- Johannes F. De Villiers, MBChB, MMed, Gisborne, New Zealand
- Mustafa Kemal Demir, MD, Istanbul, Turkey
- Thaworn Dendumrongsup, MD, Songkla, Thailand
- Walter T. Depaulaneto III, MD, Rio de Janeiro, Brazil
- Gerd Diederichs, MD, Berlin, Germany
- Jorge Docampo, Buenos Aires, Argentina
- Sathish Kumar Dundamadappa, MD, Worcester, Mass
- Michael D. Edwards, MD, Knoxville, Tenn
- Seyed A. Emamian, MD, PhD, Rockville, Md
- Susan M. Fanapour, DO, Lombard, Ill
- Virginia Fattal Jaef, MD, Rosario, Argentina
- Brett D. Ferdinand, MD, Livingston, NJ
- Ram P. Galwa, MD, Chandigarh, India
- Douglas J. Gardner, MD, Windsor, Ontario, Canada
- Carlos R. Gimenez, MD, New Orleans, La
- Francisco Jose Gonzalez, Santander, Spain
- Dan G. Gridley, MD, Phoenix, Ariz
- Waleed M. Ibrahim, MD, Columbus, Ohio
- Kiriakos Kalampoukas, MD, Halandri, Greece
- Masako Kataoka, MD, Cambridge, United Kingdom
- Yasuhiro Kawahara, Nagasaki, Japan
- Ulku Kerimoglu, MD, Ankara, Turkey
- Stefanos Lachanis, Athens, Greece
- David A. Lisle, MBBS, Brisbane, Australia
- Jaime Llauger, MD, Barcelona, Spain
- Patricia A. Lowry, MD, Chattanooga, Tenn
- Waldir H. Maymone, MD, Rio de Janeiro, Brazil
- Frank J. McKowne, MD, Vancouver, Wash
- Thomas Moser, MD, Strasbourg, France
- Vijayanadh Ojili, MD, Montreal, Quebec, Canada
- Anietie E. Okon, MD, North Liberty, Iowa
- Laura Oleaga, Philadelphia, Pa
- Sanford M. Ornstein, MD, Paradise Valley, Ariz
- David M. Panicek, MD, New York, NY
- Naveen Parasu, MBBS, Hamilton, Ontario, Canada
- Suresh K. Patel, MD, Chicago, Ill
- Yeliz Pekcevik, Izmir, Turkey
- Ilias Primetis, MD, Athens, Greece
- Tsutomu Sakamoto, MD, Tokyo, Japan
- Anthony J. Scuderi, MD, Johnstown, Pa
- Hidekazu Seo, MD, Hamamatsu, Shizuoka, Japan
- Taro Shimono, MD, Osaka, Sayama, Japan
- Ken Simmons, MD, Sydney, Australia
- Annemie Snoeckx, MD, Zandhoven, Belgium
- David F. Sobel, MD, La Jolla, Calif
- James D. Sprinkle, Jr, MD, Spotsylvania, Va
- Subramanian Subramanian, MD, New Delhi, India
- Rogério Teles de Melo, Belo Horizonte, Brazil
- Ozgur Tosun, Ankara, Turkey
- Nanda Venkatanarasimha, MBBS, MRCP, Plymouth, United Kingdom
- Michael Weber, MD, Berlin, Germany
- Stanko Yovichevich, MD, Sydney, Australia
- Joe Yut, Olathe, Kan
Resident group responses
- University of Pennsylvania Radiology Residents, Philadelphia, Pa
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HISTORY
IMAGING FINDINGS 
