Curettage and radiotherapy of giant cell tumour of the sacrum: A case report with a 10-year follow-up

CASE REPORT

A 53-year-old woman presented at Toyama Medical and Pharmaceutical University in August 1993 with continuous lower back pain, which had progressively become more severe during the 2 months prior to presentation. She also complained of numbness on the posterior aspect of the left thigh a week before presentation. Apart from these symptoms, she claimed to be in good health with the exception of having constipation. Physical examination revealed tenderness over the posterior aspect of sacrum. Neurological deficit was not present. Radiographie examination revealed a defect of sacrum below S1 level. Computed tomography (CT) showed a large, lytic, and destructive bone lesion below the level of the first sacral segment. No calcifications were noted within the mass. There was no reactive bone. Magnetic resonance image (MRI) demonstrated a sacral lesion showing the isointensity to the vertebra in T1 image, with cystic-like lesion (Fig. a). T2 image showed high signal intensity. An angiogram revealed hypervascularity, but a bone scan showed a decreased uptake in the sacrum. Chest radiographs and CT were normal. Available laboratory data were: red blood cell count, 3.97x10^sup 12^/l; white blood cell count, 7.05x10^sup 9^/l; C-reactive protein, 17 mg/l; erythrocyte sedimentation rate, 55 mm/h. The pathological diagnosis through needle biopsy was typical giant cell tumour (GCT). The microscopic features of the tumour indicated a background of proliferating, homogeneous, mononuclear cells with multinucleated giant cells dispersed evenly throughout. The cytoplasm was faintly eosinophilic and foamy in appearance. Mitotic figures were few.

The patient underwent embolisation of the sacral area on the day before operation. She underwent curettage using a posterior approach. We selected this surgical method because we were afraid of causing paralysis below Sl including bowel and bladder incontinence if the whole sacrum was resected. After laminectomy from S1 to S4, the tumour was removed, weighing 220 g. On gross inspection, the dorsal cortex of the sacrum was exceedingly thin with softening. The tumour was yellow-red in colour and fragile. Microscopically, the histological feature confirmed the diagnosis of GCT. The intra-operative bleeding volume was 3960 ml. Postoperatively, the patient was gradually relieved of pain and was discharged from hospital one month later, with complete relief of pain. No neurological deficit was present on discharge.

Six months later, however, the pain rapidly worsened again, and she was again admitted to the hospital. She complained of muscle weakness in both lower limbs. Neurological signs indicated incomplete flaccid paraplegia below L5. Motor power of the tibialis anterior, extensor hallucis longus, and gastrocnemius were evaluated as O to 1 by the manual muscle test. Achilles tendon reflexes were absent bilaterally. Hypoaesthesia was present below L5 level bilaterally. But vesicoureteral function was normal. MRI showed tumour progression towards L5 (Fig. b). The patient underwent another curettage and received adjuvant radiotherapy of 51 Gy postoperatively. Following this procedure, the tumour gradually reduced in size and her symptoms became less severe. Follow-up MRI showed a reduction in size of the tumour (Figs, c-f), and she began to walk with a cane. Ten years after the first operation, the patient had no evidence of metastasis or recurrence.

DISCUSSION

GCT of the sacrum is uncommon, with a 2% to 8.2% of incidence rate. 1-4 Management of GCT of the sacrum is difficult. Some surgeons recommend wide excision (ie total sacrectomy).5,6 However, this procedure is often associated with many complications such as massive bleeding, infection, severe pain, or neurological deficits. Others recommend conservative surgery in the form of intralesional curettage or limited excision with adjunct of cryosurgery.7 Even though the patient might need additional surgery for recurrence as in our case, spinal stability could be maintained without instrumentation, and severe neurological deterioration can be avoided. Most recurrences of GCT are expected to occur within the first 2 years.15 In case of benign tumours such as GCT, it is probably better to consider the quality of life of the patients over tumour recurrence. Intralesional procedure is expected to give better functional results with fewer complications compared with en bloc resection.8 Adjuvant radiotherapy may help control recurrence, although this is known to trigger malignant transformation.

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