Unusual presentation of giant cell tumor of phalanx.
CASE PRESENTATION: A 13-year-old female presented with swelling in middle of middle finger of left hand for last 4 months. There was no history of injury or any associated constitutional symptoms. The swelling had been gradually increasing in size with mild pain. The pain was dull, continuous, and limited to the site of the lesion. There was no history of acute episodes of pain.
Examination revealed localized swelling of middle phalanx of left middle finger with no tenderness in the affected area. There were no signs of inflammation. The skin over the lesion was mobile. The movements at the proximal and Distal inter Phalangeal joints of the middle finger were terminally restricted but pain free. There was no associated lymphadenopathy. Capillary refilling in the nail bed was good. Allen's test showed that both digital vessels were patent. There was no sensory deficit. Distal movements were present. Radiography showed expansile, osteolytic lobulated soap bubble appearance of the tumor involving proximal end of metaphysis as well as diaphysis of middle phalanx.
There was no breach of the articular surface of MP joint or any periosteal reaction. No other focus of the tumor was seen. Laboratory findings, including serum calcium, phosphorus, and alkaline phosphatase were within normal ranges. Cytological Findings on Fine-needle aspiration of the lesion was done and was shown as cartilaginous lesion, Enchondroma. In view this benignity we proceeded to curettage and bone grafting. Intra-op findings were it is a clear fluid filled in an expansile bony walled cyst. Cortical and cancellous graft was filled in the void and closed. Post-operative period was uneventful. After 3 months Patient presented again with increase in swelling and pain. X-ray shown the graft was absorbed and breech in cortex. In view of aggressiveness, Amputation of finger through proximal phalanx was done. Histopathology of specimen, confirmed osteoclastic giant cell tumor. The patient recovered well and no further complaints.
DISCUSSION: Giant cell tumor of phalanx though uncommon, in this case it presented as enchondroma. If malignant transformation of Enchondroma occurs, it is to chondrosarcoma is usual. The diagnosis of osteolytic lesions especially giant cell and its variants can be surprising and as they are fluid filled spaces it is difficult to get proper sample, by which cytological diagnosis also biased at times. Histology of the lesion revealed osteoid formation. Kumar and Tuli  and Dahlin et al.  reported similar histological findings in their series, which should be taken cautiously against enchonroma.
CONCLUSION: Enchondroma later presenting as giant cell tumor is commonly thought of due to inadequate sample / site of FNAC but if rely on facts, a very rare possibility of transformation cannot be excluded.
[1.] Averill RM, Smith RJ, Campbell CJ. Giant cell tumours of the bones of the hand. J Hand Surg. 1980; 5: 39-50. [PubMed]
[2.] Athanasian EA, Wold LE, Amadio PC. Giant cell tumour of the bones of the hand. J Hand Surg. 1997; 22A: 91-98. [PubMed]
[3.] Kumar S, Tuli SM. Giant cell tumour of the middle phalanx of the left fifth finger. Int Surg. 1971; 55 (4): 288-292. [PubMed]
[4.] Dahlin DC (1996) Dahlins bone tumours: general aspects and data of 11, 087 cases, 5th edn. Lippincott-Raven, Philadelphia.
K. Ramkumar Reddy (1), P. Sivananda (2), J. Venkateswarlu (3), R. Jaisingh (4)
(1.) K. Ramkumar Reddy
(2.) P. Sivananda
(3.) J. Venkateswarlu
(4.) R. Jaisingh
PARTICULARS OF CONTRIBUTORS:
(1.) Associate Professor, Department of Orthopaedics, Kakateya Medical College, Warangal.
(2.) Associate Professor, Department of Orthopaedics, Andhra Medical College, Vizag.
(3.) Associate Professor, Department of Orthopaedics, Kakateya Medical College, Warangal.
FINANCIAL OR OTHER
COMPETING INTERESTS: None
(4.) Assistant Professor, Department of Orthopaedics, Kakateya Medical College, Warangal.
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. K. Ramkumar Reddy, # 6-2-337, Opp. Vijaya Talkies, Hanamkonda, Warangal. Telangana.
Date of Submission: 13/05/2015.
Date of Peer Review: 14/05/2015.
Date of Acceptance: 19/06/2015.
Date of Publishing: 25/06/2015.
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|Title Annotation:||CASE REPORT|
|Author:||Reddy, K. Ramkumar; Sivananda, P.; Venkateswarlu, J.; Jaisingh, R.|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Jun 25, 2015|
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