|Year : 2020 | Volume
| Issue : 4 | Page : 399-402
Giant cell tumor of the cervico-dorsal junction with compressive myelopathy: A rare presentation with review of literature
Maneet Gill1, Vikas Maheshwari2, Aishik Mukherjee2, Rushikesh Gadhavi2
1 Department of Neurosurgery, R and R Hospital, New Delhi, India
2 Department of Neurosurgery, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||24-May-2019|
|Date of Decision||15-Aug-2019|
|Date of Acceptance||15-Oct-2019|
|Date of Web Publication||20-Jul-2020|
Department of Neurosurgery, Armed Forces Medical College, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Giant cell tumor (GCT) of bone, although benign in its nature, is aggressive in its course. It has a predilection for the epiphysis of long bones. Although it can affect any vertebra in the body, it has propensity to affect the fixed spine more than the mobile segments. It occurs infrequently above the sacrum, and involvement of the cervical spine is still rarer. However, sparse case reports of upper cervical spine GCT have been reported in literature. We report a case of GCT involving the C7 and D1 vertebrae in a 50-year-old woman who presented with the features of compressive myelopathy. She underwent corpectomy of C7–D1 with cage fixation and cervical plating via an anterior approach. The patient showed significant neurological improvement postoperatively.
Keywords: Cervico-dorsal junction, corpectomy, giant cell tumor
|How to cite this article:|
Gill M, Maheshwari V, Mukherjee A, Gadhavi R. Giant cell tumor of the cervico-dorsal junction with compressive myelopathy: A rare presentation with review of literature. Med J DY Patil Vidyapeeth 2020;13:399-402
|How to cite this URL:|
Gill M, Maheshwari V, Mukherjee A, Gadhavi R. Giant cell tumor of the cervico-dorsal junction with compressive myelopathy: A rare presentation with review of literature. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Aug 6];13:399-402. Available from: http://www.mjdrdypv.org/text.asp?2020/13/4/399/290156
| Introduction|| |
Giant cell tumor (GCT) of bone, although a benign tumor, is aggressive in its nature. It accounts for 5% of all primary bone tumors in adults and occurs most frequently in the ends of long bones., It occurs infrequently in the spine and has a predilection for the fixed spine. The mobile spine is affected in only 1.4%–9.4% of cases. They rarely affect the spine above the sacrum, and their incidence in the cervical spine is still rarer. They mostly occur in the third to fourth decades of life. Although they are locally malignant, metastasis can occur in up to 3% of these tumors. Lung is the most common site of metastasis. They mostly involve the vertebral body; however, posterior elements can also be involved. Modalities of treatment are varied and range from intralesional excision to en bloc spondylectomy. Embolization and medical management with denosumab and bisphosphonates are also known to be effective. GCT of the cervico-dorsal junction is unique in that it is not only rare in literature, but also a challenge to deal with surgically. We report a case of GCT involving the C7 and D1 vertebrae in a 50-year-old woman who presented to us with paraparesis and underwent corpectomy of C7–D1 along cage fixation via an anterior approach. The patient showed significant neurological improvement postoperatively.
| Case Report|| |
A 50-year-old woman presented with insidious-onset, gradually progressive pain over the left side of the chest and the back of the neck of 6 months' duration. She had progressively increasing weakness and paresthesias of bilateral lower limb (left > right) for 4 months. There was a history of urinary incontinence and constipation of 2 months' duration. She also had a history of weight loss of 5 kg over 2 months and intermittent fever. Clinically, she had increased tone in both lower limbs (Modified Ashworth Scale III). Power was Medical Research Council (MRC) Grade 2/5 in both lower limbs. Bilateral ankle and knee jerks were exaggerated. There was ankle clonus, and both plantars were extensor. There was 60%–70% sensory loss in C8, D1, and D2 dermatomes. X-ray of the cervico-dorsal spine showed lytic lesion of the cervico-dorsal junction. Noncontrast computed tomography cervico-dorsal spine with three-dimensional reconstruction revealed an expansile lytic lesion epicentered at the D1 vertebra with characteristic soap bubble appearance [Figure 1]a and [Figure 1]b.
|Figure 1: (a) Noncontrast computed tomography cervico-dorsal spine sagittal cuts showing the lesion centered at D1, (b) characteristic soap bubble appearance (white arrow) in the axial section|
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Contrast-enhanced magnetic resonance imaging (CEMRI) cervico-dorsal spine revealed well–defined, contrast-enhancing expansile lytic lesion causing complete collapse of the D1 vertebral body with severe cord compression [Figure 2]a and [Figure 2]b.
|Figure 2: (a) Contrast-enhanced magnetic resonance imaging sagittal section showing contrast enhancing expansile lytic lesion measuring 40 mm × 56 mm × 39 mm involving the D1 vertebral body, (b) axial section showing the lesion causing severe cord compression involving the D1 vertebral body|
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Anterior approach to cervicothoracic junction was done by right-sided Smith–Robinson approach with skin incision reaching up to the sternal notch [Figure 3]. The sternomastoid, sternohyoid, and sternothyroid muscles were sectioned, allowing a connection of the lower cervical region to the upper thoracic spine. Through this approach, T2 is readily accessible in 88% of cases and T1 in almost all cases. The patient underwent corpectomy in the C7 and D1 vertebrae along with dural decompression. Intraoperatively, the tumor was bluish-red, was moderately vascular, was bony hard in consistency, and caused severe cord compression. Reconstruction was done with expandable cage, and anterior plating from C6 to D2 was done [Figure 4].
The postoperative recovery was uneventful. At 4-week follow-up, her lower limb power improved to MRC grade 4/5. She regained her urinary continence and was ambulant with support. She was given 45 Gy for 5 days a week for 4 weeks, and two such cycles were given. At 3-month follow-up, she was ambulant without support. Her histopathology report showed GCT Grade I (Jaffe et al.) [Figure 5]. Postoperative CEMRI showed gross total excision of tumor with no epidural compression [Figure 6].
|Figure 5: Photomicrograph of the lesion (H and E, ×400) showing multinucleated osteoclast giant cells (white arrow) in a background stroma of mononuclear spindle cells (black arrows)|
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|Figure 6: Postoperative magnetic resonance imaging sagittal section showing gross total excision with expanded cord|
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There has been no locoregional recurrence at 1-year follow-up.
| Discussion|| |
GCT is known to affect the epiphysis of the long bones in the younger population. There can be infrequent involvement of spine, and literature mentions sacrum as the most common site. Involvement of the spine above the sacrum is rare and that of the cervical spine is still rarer as was seen in our case. GCTs, although are benign, slow-growing tumors, can have an aggressive course. They occur more commonly in the third and fourth decades of life and are more common in women. Our patient, though a female, was in her fifth decade. GCT of the spinal region can present with localized pain, weakness, and paresthesias due to compression of the nerve roots or features of myelopathy. Our patient had the features of myelo-radiculopathy along with severe bony pain. Histologically, an abundance of mononuclear stromal cells and multi-nucleated giant osteoclast-like cells distributed evenly in the tissue characterizes these tumors. Although GCT is a benign tumor, 1%–9% of cases can undergo malignant transformation.,,, Distant metastasis can occur in 2%–9% of cases, with lung being the most common site. Radiologically, these need to be distinguished from aneurysmal bone cyst, Brown tumor of hyperparathyroidism, osteoid osteoma, and plasmocytoma., Surgical options include radical en bloc resection or intralesional curettage tailored according to the nature of the lesion and the proximity of the surrounding vital structures. Intralesional curettage can be done for low-grade lesions; however, high-grade lesions require en bloc resection.En bloc spondylectomy can be done at cervical region. However, the cervico-thoracic region entails special challenges and en bloc spondylectomy may not be technically feasible in all cases.
There is no clear evidence in literature of the benefit of en bloc resection over intralesional resection along with adjuvant treatment in regions with difficult access. Conservative resection of GCT of the spine has been recommended by various authors with satisfactory results. Jaffe et al. proposed intralesional resection followed by radiation to be an acceptable form of management in GCTs of the cervical spine. According to Hart et al. in tumors extending into the posterior elements or into soft tissues as seen in our case, achieving en bloc removal is more difficult with higher recurrence rates. In our case, en bloc spondylectomy was not feasible as the tumor had already breached the capsule and was causing compression of the C7 and D1 nerve roots with significant epidural extension. Gross total resection along with dural decompression and reconstruction was done in our patient. She was given adjuvant radiotherapy. Although radiotherapy is the preferred mode of adjuvant therapy, some authors doubt its effectiveness, whereas others believe that it could cause malignant transformation of GCT., Other adjuvant therapies in the form of cryotherapy, preoperative embolization, bone cement injections, biphosphonates, and denosumab have shown encouraging results. However, literature reviews showing their effectiveness are hardly extensive.,, Cervico-thoracic junction is a rare site for GCT and while the inaccessibility of the region makes intralesional removal the most feasible option, it leaves a definite risk of recurrence of GCT. This requires radiation or other adjuvant modalities. While en bloc spondylectomy is ideal, neurological outcome of the patient should take precedence in the management of GCTs located in relatively difficult-to-access regions of the spine such as the cervico-thoracic region.
| Conclusion|| |
The cervico-thoracic region is an uncommon location of a GCT with very few case reports in literature. The relative inaccessibility of the region makes it surgically challenging. Aggressive en bloc resection of the tumor remains a gold standard. Intralesional resection is a suitable alternative for multisegment GCTs of the cervico-thoracic region. For GCTs of this region, neurological outcome is of paramount importance and should not be sacrificed for the sake of en bloc resection. Adjuvant radiotherapy and a close follow-up is essential for the prevention of recurrence.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]