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Pt is a 74 yr old  Male

 Family medicine out pt visit

HPI

Pt is here to followup on chronic problems and w new complaints of sinus problems and left thumb pain and swelling.

Left thumb swelling - He has had this for almost a month. It was painful initially but then the pain is improving. No drainage in the past.

Sinus problems - nasal congestion, low-grade fever, ear fullness, greenish expectorationfor the last one week.

The following portions of the patient's history were reviewed and updated as appropriate: allergies, current medications, past medical history, past social history and problem list.

Review of Systems Rest of ROS negative.

has a past medical history of Insomnia .

has no past surgical history on file.

Reports that he has never smoked. He does not have any smokeless tobacco history on file. He reports that he does not drink  alcohol or use illicit drugs.

Problem List Items Addressed This V isit

Acute non-recurrent maxillary sinusitis

Relevant Med1cat1ons

Fluticasone (FLONASE) 50 mcg/actuation nasalspray doxycycline (VIBRA-TABS) 100 MG tablet

SWelling of left thumb

Relevant Orders

Ambulatory Referralto Orthopedic Surgery

Objective: To describe the case of giant cell tumor (GCT) of bones at the distal phalanx of the left thumb in a 74 year old male patient who showed pain and swelling in the left thumb.

Case Report

Case summary: 74 year old white male patient with past history of neoplasm of the skin, represented with pain and swelling in his left thumb that had been there for almost a month. X-ray and MRI tests confirmed the presence of lytic lesion and an osseous neoplasm along with GCT, respectively. Amputation of the proximal phalanx of the left thumb was performed. Although the pathological tests showed inter-osseous GCT of bone and GCT invasion of the proximal phalanx, post-operative progress stated that the patient had been healing properly.

Discussion: GCT is usually not reported in adults over the age of 55 and is mostly seen at the end of the long bones, but this case involves the GCT at finger bones. The patient also had previous history of having skin cancer. Although researches showed that there is no significant difference between the GCT of young and older individuals, GCT of hand bones have been reported to be much more aggressive in nature rather than the GCT occurring at any other position.

Conclusions: Metastasis of GCT has not been pathologically determined, but several factors have been indicated that are associated with the theory of metastasis. Previous occurrence of cancers such as skin neoplasms, can lead to GCT of bones, even at unusual locations such as the finger bones.

Giant cell tumor (GCT) of the bone is known to be a, intermediate and locally aggressive tumor which rarely metastasizes. GCT is a type of primary bone tumor which tends to become more aggressive locally. Giant cell tumors are so named due to their appearance as large multinucleated osteoclast-like giant cells which remain distributed together with stromal cells and monocytes. Macroscopic images have revealed that GCT is quite vascularized and consists of bands of cellular or collagen fibrous tissues. These cells are the reason behind the excessive bone resorption done by the tumor. The stromal cells predominantly promotes the fusion of the monocytes with the giant cells (Raskin et al. 2013). Thus, GCT attributes to the process of giant cell formation and thereby the mechanism of bone resorption.

The patient is a 74 year old male who has had painful swelling in his left thumb for almost a month along with sinus problems for a week. He had a past medical history of suffering from insomnia. His medications include aspirin, calcium carbonate, Folic acid MV, pravastatin, psyllium seed and zolpidem. His physical exam reported of having maxillary sinus tenderness and erythematous nasal mucosa along with erythematous and mildly tense and swollen left thumb. He was further instructed to take fluticasone and doxycycline for acute non-recurrent maxillary sinusitis and had been referred to go through an ambulatory orthopaedic surgery for his left thumb swelling. He also needed to take the influenza vaccine.

The patient had history of other malignant neoplasm of the skin, actinic keratosis and other seborrheic keratosis. He had hypercholesterolemia, diverticulosis of colon that led to haemorrhage. The patient had a past medical history of insomnia. The problems of the patient that had been resolved include his insomnia, allergic rhinitis, Helicobacter pylori gastritis, conjunctivitis and rib pain. He also had an appendectomy surgery. The patient is married. Reports said that he has never smoked and never had any smokeless tobacco either. He did not have any past surgical history in his finger. He reported that he does not even drink alcohol or take illicit drugs.

Discussion

The orthopaedic consultant reported that the patient had developed swelling at the tip of his left thumb that gradually became numb. Although he did have a history of a solitary pulmonary nodule in his right lower lobe. X-ray tests diagnosed lytic changes at the tip of the left thumb which is interpreted to be an inclusion cyst. No change in the size of his pulmonary nodule was observed. To determine the cause of the lytic changes at the left thumb MRI was done to find out if it is an inclusion cyst or an infection or a distant metastases (Chan et al. 2015).

His X-ray showed soft tissue lesion in the left thumb. This lesion erupted from the tuft of the left thumb with cortical disruption. At the overlying region there is mild soft tissue fullness. X-ray of the chest revealed stable right basilar granuloma and no evidence of pleural effusions or pneumothorax was observed. There were no acute cardio-pulmonary process. MRI of the left thumb with and without the contrast was obtained. It showed an expansile lesion involving the tuft of the distal phalanx of the thumb. The lesion was well-circumscribed and demonstrated expansion and thinning of the cortex and homogenous post-contrast enhancement (Cowan and Singh 2013). This was considered to be an osseous neoplasm and this lesion included a giant cell tumor or GCT (Skubitz 2014).

At the follow up at an orthopaedic hand surgery clinic, the patient was noted to have a lytic lesion on his left thumb’s distal phalanx and his MRI showed large soft tissue mass that was expansile involving the distal phalanx. After summing up the results, the radiologist had confirmed that all the signs are related to an osseous neoplasm (van der Heijden et al. 2014). They had included GCT versus other primary or metastatic lesion in the differential diagnosis. The patient continued to have the numbness in his left thumb, but no change in the appearance of the lesion or in the remaining median, ulnar and radial nerve was observed.

After biopsy, disarticulation of the amputation of the proximal phalanx of the left thumb was suggested. The tip of the distal phalanx of the left thumb was sent for pathologic tests along with the articular margin and resection of the proximal phalanx of the left thumb. Proper care was taken to ensure no cross contamination results from the previous biopsy site to the site of the tumor (Oliveira et al. 2013). At the post-operative visit to the orthopaedics unit, it was found that the patient had been healing quite well and there have been no sign of infection. Although he showed some tenderness at the radial side of the left thumb stump. The pathological tests of the patient revealed inter-osseous GCT of bone and GCT invasion in the proximal phalanx; this clearly implicated that the tumor had spread between the finger bones. A repeat X-ray is considered after 6 months to check for any metastatic lesion from this tumor.

The Giant Cell Tumor (GCT) of the bones is usually seen among people of the age group of 20-40 and is extremely unusual in people who are aged above 55. Along with this, there have been some incidences found where GCT has been reported in patients aged 62-78 (Ansari, Prakash and Machhindra 2014). In the case reported above the patient had a medical history of skin carcinomas and is presently reported to have GCT of bones in his left thumb. This is a highly unusual place of occurrence of GCT since it has been mostly found to be occurring at the end of the long bones.

Assessment/Plan

GCT of hand bones are comparatively more aggressive and recurring than GCT in the rest of the skeleton. It also differs in nature from the GCT of the long bones and cannot be treated with simple curettage but with scintigraphy to minimize the chances of multicentricity (Meena et al. 2015). Also, it has been found that GCT of hand bones usually occurs in younger population. Most often GCT transforms into sarcoma after radiation, although its malignant transformation is less spontaneous. Without radiation therapy, GCT dedifferentiates into osteosarcoma. It is challenging to differentiate GCT from other entities of giant cells, and there are only a few morphologic features of GCT that are presented in 55 year or older patients. In such older patients, fibrosis is quite common although it results in diagnostic challenges. However, mitotic activity and necrosis of GCT in this age group has raised concerns for malignancy (Brien et al. 1997).

In another article the researchers tried to find out if the GCT of bones in elderly patients behave somewhat differently than when it occurs in the younger patients. They have also outlined the issues that are posed on the older people by diagnostic processes which are different from the usual procedures done with the younger patients (Chakarun et al. 2013). The report ultimately concluded that the GCT of bones in elderly people occur due to chromosomal imbalances and their treatment options are also limited. The study also demonstrated that the location and behaviour of the GCT of bone in elderly patients is identical in nature to younger patients. Although the lesions were less aggressive than in younger patients since no sign of recurrence was observed.

Conclusion

Understanding the pathogenesis of the giant cell tumor (GCT) disease of the bones is a prerequisite for the purpose of further research and development of novel medications and targeted treatments in this arena of medical biology. Although the pulmonary metastasis of GCT has not been pathologically determined, several factors have been indicated that are associated with the theory of pulmonary spread. Giant cell tumor of bone is typically considered as benign. Although at times, such tumors may demonstrate aggressive nature that mimics the lesions in other bones. The first mainstay treatment for GCT was mostly surgical, with a recurrence rate of almost 15-25%, but sophisticated research approaches have been able to develop a novel monoclonal antibody named denosumab that resulted in dramatic treatment responses in all the studies. The amputation of the proximal phalanx of the left thumb has been proven to be effective for the patient. Although further recovery and follow-up check-ups were required.

References

Ansari, M.T., Prakash P, K. and Machhindra, M.V., 2014. Wrist preserving surgery for multifocal giant cell tumor of carpal bones in a skeletally immature patient: a case report. Orthopaedic surgery, 6(4), pp.322-325.

Brien, E.W., Mirra, J.M., Kessler, S., Suen, M., Ho, J.K.S. and Yang, W.T., 1997. Benign giant cell tumor of bone with osteosarcomatous transformation (” dedifferentiated” primary malignant GCT): report of two cases. Skeletal radiology, 26(4), pp.246-255.

Chakarun, C.J., Forrester, D.M., Gottsegen, C.J., Patel, D.B., White, E.A. and Matcuk Jr, G.R., 2013. Giant cell tumor of bone: review, mimics, and new developments in treatment. Radiographics, 33(1), pp.197-211.

Chan, C.M., Adler, Z., Reith, J.D. and Gibbs Jr, C.P., 2015. Risk factors for pulmonary metastases from giant cell tumor of bone. JBJS, 97(5), pp.420-428.

Cowan, R.W. and Singh, G., 2013. Giant cell tumor of bone: a basic science perspective. Bone, 52(1), pp.238-246.

Meena, U.K., Sharma, Y.K., Saini, N., Meena, D.S. and Gahlot, N., 2015. Giant cell tumours of hand bones: A report of two cases. Journal of hand and microsurgery, 7(1), pp.177-181.

Oliveira, V.C., van der Heijden, L., van der Geest, I.C.M., Campanacci, D.A., Gibbons, C.L.M.H., van de Sande, M.A.J. and Dijkstra, P.D.S., 2013. Giant cell tumours of the small bones of the hands and feet: long-term results of 30 patients and a systematic literature review. The bone & joint journal, 95(6), pp.838-845.

Raskin, K.A., Schwab, J.H., Mankin, H.J., Springfield, D.S. and Hornicek, F.J., 2013. Giant cell tumor of bone. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 21(2), pp.118-126.

Skubitz, K.M., 2014. Giant cell tumor of bone: current treatment options. Current treatment options in oncology, 15(3), pp.507-518.

van der Heijden, L., Dijkstra, P.S., van de Sande, M.A., Kroep, J.R., Nout, R.A., van Rijswijk, C.S., Bovée, J.V., Hogendoorn, P.C. and Gelderblom, H., 2014. The clinical approach toward giant cell tumor of bone. The oncologist, pp.theoncologist-2013.

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