Iatrogenic giant cell tumor at bone graft harvesting site
A 30-year-old female reported to orthopedic outpatient department with pain and swelling just above the right ankle joint and another swelling over the right iliac region for last 6 months. The patient had a surgery for the swelling of distal right leg 18 months ago by general orthopedic surgeon. Review of surgical records revealed that she was operated for a lytic lesion in distal tibia with preliminary diagnosis of benign bone lesion without preoperative biopsy. Curettage of the lesion was performed along with filling of surgical cavity with autologous bone grafts harvested from the right iliac crest. Histopathology revealed benign GCT of distal tibia. Below knee plaster was kept for 4 months postoperatively. Two months after the removal of plaster, she developed pain in the right leg just above the ankle, along with gradually increasing swelling. Two weeks later, she noticed another swelling over the right iliac crest, associated with mild pain and discomfort. The patient was finally referred to our oncologic clinic. The patient was clinically anemic. There was a swelling over the anterolateral aspect of distal part of right leg with painful restricted ankle movements and another swelling over the right iliac region with mild to moderate tenderness on palpation on both sites.\nPlain X-rays showed lytic lesion in distal tibia with ill defined margins without any evidence of pathological fracture. X-ray of right iliac wing showed large soft tissue mass with irregularity of the bone over the outer table of iliac crest []. Magnetic resonance imaging (MRI) of pelvis and distal tibia was done to delineate the extent of tumor and its extension [Figures and ]. Technetium-99 bone scan showed increased uptake around distal tibia and focally in the ipsilateral iliac region only at the graft harvest site and no additional foci in the body (i.e. ruling out metachronous lesions elsewhere). Core needle biopsy was performed at both sites to confirm the microscopic/tissue diagnosis. The histopathology revealed benign GCT at both sites with identical picture. Computed tomography of the lungs was normal.\nThe patient was taken up for planned surgery under spinal anesthesia after taking informed consent. Distal tibial lesion was widely resected and reconstruction was done with medialization of fibula and fixing it on the dome of talus and in the distal medullary canal of the resected tibia with Kirscher's wires. Wide resection of iliac wing along with soft tissue mass was performed. The iliac swelling was confined to soft tissue underneath the scar with irregularity over iliac crest. The histopathology of both sites reconfirmed GCT.\nPostoperative period was uneventful and the patient was discharged with a long leg cast for 4 months. Then, partial weight bearing was started with crutches. Patient achieved restoration of bone continuity with union at both ends. Hypertrophy of the grafted fibula was observed and patient was mobile with full unprotected weight bearing on the operated leg after 1 year. Two years after surgery, the patient was symptom free and walking without any aid and with no evidence of recurrence at both sites and no metachronous lesions or pulmonary metastasis. Fibula showed good hypertrophy and the iliac region healed well [].