Case Report
Resection of
Lumbar Giant Cell
Tumor
By Benjamin R. Cohen, MD
Neurosurgeon
Winthrop-University Hospital
fter failing all
means of
conservative
treatment for back
pain, a man in his 40s
presented with
intractable, worsening
pain that traveled from
his right hip and
buttock down the
posterolateral aspect of
his right leg to the foot.
The left lower and
upper extremities were
normal.
A
He complained of
difficulty walking and
episodes of right lower
extremity paralysis, as
well as being unable to
function independently
because of the pain and
neurological problems.
An MRI of the lumbar
spine showed a lytic
lesion consuming the
body of L4 with
extradural extension
and compression of the
thecal sac. The
Giant cell tumors (GCT) of the spine are uncommon, accounting
for approximately 2%-4% of bone neoplasms.1 While technically
benign, these lesions can be aggressive, resulting from overproliferation of osteoclasts.
With a high rate of recurrence,2 GCTs are typically seen in men
and women between ages 20-45. Most patients present with
debilitating back pain. However, the condition is usually
diagnosed after development of a neurological deficit caused by
the tumor’s compression of the spinal cord or nerve roots at the
site of involvement.
Given the complicated structure of the spine, diagnosis can be
challenging, requiring the exclusion of degenerative disease,
infections, muscular strains and neurologic impingements. In
addition to pain, symptoms can range from slight weakness or
an abnormal reflex to complete paraplegia, as well as bladder
and bowel incontinence.
MRI imaging studies are critical to pinpointing the tumor’s size,
location, local extension and extent of neurological
compression. For histological confirmation — and to exclude the
leading differential diagnosis of aneurysmal bone cyst — a CTguided needle biopsy is necessary.
While management of long bone GCTs usually involves
curettage and filling the defect with bone cement,3 the
treatment of choice for spinal GCTs is complex surgery,
requiring careful preoperative planning and a multidisciplinary
approach. The procedure — en bloc resection — offers the
greatest chance for a cure.4 The role of adjuvant chemotherapy
and/or radiation is controversial.
Since tumors in this region frequently do not present until the
mass has grown very large, surgery carries the potential for
mechanical and neurological complications. Moreover, GCTs can
be hypervascular, often mandating preoperative arterial
embolization to reduce the potential for hemorrhaging during
surgery.
Ongoing multidisciplinary follow-up care — with routine X-rays
and MRI studies — is crucial to monitoring for recurrence.
remaining L4 vertebral body had deteriorated to nothing more than an “egg shell.”
A needle biopsy confirmed that the lesion was a benign giant cell tumor (GCT) that
needed to be excised in order to address the patient’s neurological deficits and
spinal instability.
Angiogram and Embolization
Given the vascular nature of most GCTs, a preoperative angiogram was conducted,
revealing a hypervascular mass at L4. Embolization was performed to reduce the
tumor’s vascularity and the potential for extensive blood loss during surgery. Using
the right transfemoral approach, a catheter was placed in the L4 lumbar artery,
where a small amount of polyvinyl alcohol (PVA) glue was instilled to achieve
devascularization of the tumor.
Resection and Stabilization
The surgery consisted of an intricate two-stage procedure conducted over two days.
Stage one involved a complete posterior laminectomy from the bottom of L3 to the
top of L5, with stabilization and fusion. The procedure resulted in the removal of a
good portion of the L4 vertebral body, a wide surgical resection of the tumor and
decompression of the nerves.
Stage two, involved an anterior corpectomy at L4 for resection of the remaining
tumor with reconstruction using an expandable cage. Near-complete resection of
the tumor was completed. Since the lesion was contained in one area and near total
resection was achieved, adjuvant therapy was not recommended.
Two weeks postoperatively, the patient reported significant improvement of his
symptoms, with the preoperative right lower extremity pain, weakness and
dysfunction completely resolved.
To help determine this patient’s future care and ensure timely treatment should the
GCT recur, postoperative monitoring will involve regular examinations with interval
X-rays, CT scans and MRI studies.
For more information call the Institute for Neurosciences at 1-866NEURO-RX or visit
www.winthrop.org.
REFERENCES
1. Mendenhall WM, Zlotecki RA, Scarborough MT, et al. Giant cell tumor of bone. AJCOnc 2006;
29:96-99.
2. Abbas AK, Kumar V. Fausto N, et al. Robbins and Cotran Pathologic Basis of Disease,
Professional Edition E-Book, W.B. Saunders Co. 2010 ISBN:1437721826.
3. Turcotte RE. Giant cell tumor of bone. OrthoClinNorthAm 2006;37:35-51.
4. Martin C, McCarthy EF. Giant cell tumor of the sacrum and spine:series of 23 cases and a review
of the literature. IowaOrthoJ 2006;30:69-75.