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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 24  |  Issue : 4  |  Page : 250-253

Giant cell tumour of the clavicle: A rare presentation of a locally aggressive tumour


1 Department of Orthopaedics and Trauma, Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Surgery, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria

Date of Web Publication18-Jan-2018

Correspondence Address:
Dr. Adewole Tayo Akinsulire
Department of Orthopaedics and Trauma, Lagos University Teaching Hospital, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_133_17

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  Abstract 


We report a case of a 28-year-old female who presents with painless, progressively increasing left upper chest swelling of 6 months duration. Examination revealed a 20 by 10 cm firm mass arising from the clavicle. She was investigated and a diagnosis established based on the histological report. The tumour was excised with a wide margin and reconstruction done with an autogenous fibula graft. Full functional ability was restored in limb with the radiological union. After 5 years of regular follow-up, there was no evidence of recurrence and shoulder function remained excellent. The successful management of this patient shows wide local excision and reconstruction as an excellent surgical option in treating giant cell tumour of the clavicle.

Keywords: Clavicle, fibula graft, giant cell tumour, reconstruction


How to cite this article:
Akinsulire AT, Badmus OO, Giwa SO. Giant cell tumour of the clavicle: A rare presentation of a locally aggressive tumour. Niger Postgrad Med J 2017;24:250-3

How to cite this URL:
Akinsulire AT, Badmus OO, Giwa SO. Giant cell tumour of the clavicle: A rare presentation of a locally aggressive tumour. Niger Postgrad Med J [serial online] 2017 [cited 2019 Dec 12];24:250-3. Available from: http://www.npmj.org/text.asp?2017/24/4/250/223459


  Introduction Top


Giant cell tumour is a rare benign but locally aggressive tumour [1] which occurs relatively commonly in bones of young adults. It was first reported by Cooper and Travers in 1881[2] and further characterised by Jaffe et al. in 1940.[3] They are classified as 'intermediate locally aggressive rarely metastasising' tumours.[1] Giant cell tumours account for over 20% of all benign bone tumours [1] and about 4%–9.5% of all primary bone tumours.[1],[4] The most common locations include the distal femur, proximal tibia and the distal radius. Less common sites include the sacrum, ilium, spine and the phalanges. Rarer sites include the clavicle, ribs, skull and sternum. The clavicle is a rare site for bone tumours of which giant cell tumour of the clavicle is quite uncommon among the tumours occurring in the clavicle.[4]


  Case Report Top


A 28-year-old female patient presented at the Lagos University Teaching Hospital, Lagos on August 2011 with 6 months history of a painless progressively increasing left upper chest swelling. The patient had not noticed any weakness or neurologic deficit in the left upper limb. On physical examination, there was a firm mass of about 20 by 10 cm in the left upper chest arising from the middle third of the left clavicle [Figure 1] and [Figure 2]. The skin over the swelling was normal in colour with no dilated veins. No pallor, lymphadenopathy or organomegaly was detected. Upper limb examination did not reveal any neurologic or vascular abnormality.
Figure 1: Swelling over middle third of clavicle

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Figure 2: Swelling over middle third of clavicle (after incisional biopsy)

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Chest radiograph showed a lytic lesion arising from the middle third of the left clavicle [Figure 3]. Computed tomographic scan of the chest demonstrated a multiseptated expansile lesion arising from the middle third of the clavicle [Figure 4]. The tumour was graded as Campanacci grade II. Incisional biopsy showed numerous multinucleated osteoclast-like giant cells disposed in a highly cellular stroma. The stromal cells in some areas were plump with round to oval nuclei identical to that seen in the giant cells and in other areas had spindle-shaped nuclei. The tumour was pathologically diagnosed as giant cell tumour of the clavicle and treatment was planned.
Figure 3: Radiograph of the left shoulder

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Figure 4: Computer tomography showing swelling arising from clavicle

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The patient had wide local excision of the lesion with a 3 cm margin medially and 3 cm margin laterally which included the clavicular end of the acromioclavicular joint [Figure 5]. The 14 cm defect created was bridged with a non-vascularised fibula graft harvested from the ipsilateral leg. This was fixed to the medial clavicle by plate and screws medially and laterally to the acromion with plates and screws [Figure 6] and [Figure 7]. Intraoperative blood loss was 300 ml. Post-operative state was uneventful. Physiotherapy exercises were commenced 4 days after surgery with a gradual increase in activity tolerance level until she achieved full range of movement of the left shoulder.
Figure 5: Intraoperative picture of the mass

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Figure 6: Intraoperative picture with non-vascularised fibula graft and internal fixation for defect reconstruction

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Figure 7: Immediate post-operative radiograph

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The patient was followed up for 5 years post-excision with no deterioration in functional status. Recent radiographs show graft union and consolidation with no evidence of tumour recurrence [Figure 8] or pulmonary metastasis. Shoulder function has remained excellent [Figure 9].
Figure 8: Good shoulder function 5 years post-surgical excision

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Figure 9: Radiograph done 5 years post-surgery

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  Discussion Top


The clavicle is a very rare site for bone tumours accounting for about 0.45%–1% of all tumours.[4] Tumours of the clavicle are more likely to be malignant than benign.[4],[5],[6] Giant cell tumour of the clavicle is quite rare with just a few number of case reports describing its occurrence.[7],[8],[9],[10] The oncological properties of giant cell tumour of the clavicle closely resemble that of flat bones.[11]

Clinical diagnosis of giant cell tumour of the clavicle is difficult to make, and histology is usually the gold standard. Notable differentials include tuberculous osteomyelitis, 'brown tumour' associated with hyperparathyroidism, aneurysmal bone cyst and non-ossifying fibroma. Histologically, they are identified as comprising of osteoclast-like multinuclear cells and hyperplastic mononuclear interstitial cells.

Due to its rarity, the best treatment modality has not been fully described. While there is agreement on the need for excision of the tumour which could either be a subtotal claviculectomy or a total claviculectomy, there is no consensus on the requirement for reconstruction or defect replacement. Since the clavicle is a non-weight bearing bone and said to be functionally expendable, some authors have advocated excision of the clavicle with no attempt at reconstruction based on good functional results of the patient following claviculectomy alone.[12],[13] However, Rubright et al. when examining long-term shoulder function after total claviculectomy reported a gradual loss of some compensatory ability.[14]

Other authors have advocated for defect reconstruction with the benefit of correcting any cosmetic defect, possible protection of vital structures and pain relief.[15],[16] Defect reconstruction following claviculectomy has been done with an autologous fibula graft (vascularised and non-vascularised), clavicle bone cement prosthesis and allograft all with good results.[15],[16],[17] Any attempt at biologic reconstruction for clavicular tumours should be reserved for benign tumours and should be avoided in malignant tumours.[14],[18],[19] Furthermore, proper follow-up is essential to detect any recurrence. There, however, has not been long-term studies evaluating shoulder function after reconstruction surgery. In our case, the patient was followed up for 5 years with no evidence of recurrence or pulmonary metastasis and radiologic evidence of graft incorporation while retaining excellent shoulder function.

Declaration of consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fletcher CD, Unni KK, Mertens F. Pathology and Genetics of Tumours of Soft Tissue and Bone. Lyon: International Agency for Research on Cancer Press; 2002. p. 309-13.  Back to cited text no. 1
    
2.
Cooper AP, Travers B. Surgical Essays. London: Cox; 1818.  Back to cited text no. 2
    
3.
Jaffe HL, Lichtenstein L, Portis RB. Giant cell tumor of bone. Its pathologic appearance, grading, supposed variants and treatment. Arch Pathol 1940;30:993-1031.  Back to cited text no. 3
    
4.
Dahlin D, Unni K. Bone Tumors: General Aspects and Data on 8542 Cases. 4th ed. Springfield, IL: Thomas; 1986. p. 181-5.  Back to cited text no. 4
    
5.
Smith J, McLachlan DL, Huvos AG, Higinbotham NL. Primary tumors of the clavicle and scapula. Am J Roentgenol Radium Ther Nucl Med 1975;124:113-23.  Back to cited text no. 5
[PUBMED]    
6.
Pratt GF, Dahlin DC, Ghormley RK. Tumors of the scapula and clavicle. Surg Gynecol Obstet 1958;106:536-44.  Back to cited text no. 6
[PUBMED]    
7.
Friedman B, Nerubay J, Lokiec F, Horoszowski H, Yelin A. Giant cell tumour occurring in the clavicle: A report of two cases. Respir Med 1989;83:145-8.  Back to cited text no. 7
[PUBMED]    
8.
Beg MH, Ansari MM, Uddin R, Naim M. A case of giant-cell tumor of the clavicle. Acta Orthop Scand 1989;60:122.  Back to cited text no. 8
[PUBMED]    
9.
Nagano S, Tsuchimochi T, Yokouchi M, Setoguchi T, Sasaki H, Shimada H, et al. Giant cell tumor of the clavicle: Report of a case in a rare location with consideration of surgical method. BMC Musculoskelet Disord 2015;16:142.  Back to cited text no. 9
    
10.
Baryluk M. Giant-cell tumor of the distal end of the clavicle treated by anatomical resection. Chir Narzadow Ruchu Ortop Pol 1967;32:73-5.  Back to cited text no. 10
    
11.
Minard-Colin V, Kalifa C, Guinebretiere JM, Brugieres L, Dubousset J, Habrand JL, et al. Outcome of flat bone sarcomas (other than ewing's) in children and adolescents: A study of 25 cases. Br J Cancer 2004;90:613-9.  Back to cited text no. 11
    
12.
Wessel RN, Schaap GR. Outcome of total claviculectomy in six cases. J Shoulder Elbow Surg 2007;16:312-5.  Back to cited text no. 12
    
13.
Wood VE. The results of total claviculectomy. Clin Orthop Relat Res 1986;207:186-90.  Back to cited text no. 13
    
14.
Rubright J, Kelleher P, Beardsley C, Paller D, Shackford S, Beynnon B, et al. Long-term clinical outcomes, motion, strength, and function after total claviculectomy. J Shoulder Elbow Surg 2014;23:236-44.  Back to cited text no. 14
    
15.
Vartanian SM, Colaco S, Orloff LE, Theodore PR. Oklahoma prosthesis: Resection of tumor of clavicle and chest wall reconstructed with a custom composite graft. Ann Thorac Surg 2006;82:332-4.  Back to cited text no. 15
    
16.
Lin B, He Y, Xu Y, Sha M. Outcome of bone defect reconstruction with clavicle bone cement prosthesis after tumor resection: A case series study. BMC Musculoskelet Disord 2014;15:183.  Back to cited text no. 16
    
17.
Guo Z, Wang Z, Wang Z, Zhang Y. Allograft of clavicle for reconstruction of bone defect after tumor resection. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2008;22:102-5.  Back to cited text no. 17
    
18.
Li J, Wang Z, Fu J, Shi L, Pei G, Guo Z, et al. Surgical treatment of clavicular malignancies. J Shoulder Elbow Surg 2011;20:295-300.  Back to cited text no. 18
    
19.
Krieg AH, Hefti F. Reconstruction with non-vascularised fibular grafts after resection of bone tumours. J Bone Joint Surg Br 2007;89:215-21.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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