中華放射醫誌 Chin J Radiol 2001; 26: 61-67 61

ORIGINAL ARTICLE

Giant Cell Tumor of the Bone: Radiography,

CT, MRI, and Angiography Findings
1,2 1 1 1 1
L IANG -K UANG C HEN C HENG -TAU S U Y UH -F ENG T SAI H SU -Y I C HEN H UI -L ING P ERNG
C HIN -C HU W U 1 M IN -S ZU YAO 1 S AN -M ING L AI 1

Department of Diagnostic Radiology, Shin Kong Wu Ho-Su Memorial Hospital1, Taipei

2
Yuanpei Institute of Science and Technology , Hsinchu, Taiwan

Giant cell tumors (GCTs) account for
4%~5% of all primary bone tumors, and
radiography shows radiolucent expansile,
eccentric lesions at the end of long bones.
Twelve patients with primary GCTs of the bone
were studied. In some cases, the complex
anatomy and extent of the lesion could not be
clearly depicted on conventional radiography,
thus, computed tomography, magnetic
resonance imaging, and digital subtraction
angiography were helpful. The clinical course,
radiographic findings, and differential
diagnoses were discussed.
Key words: Bone, neoplasm; Bone, CT; MRI;
DSA
Giant cell tumors (GCTs) are aggressive tumors
of unknown origin that develop within bone and
apparently arise from mesenchymal cells in the
connective tissue framework. Some GCTs are
benign histologically, while behaving
aggressively; others appear “aggressive”
histologically, but behave in a benign manner [1].
GCTs are potentially malignant; 60% of lesions
recur after curettage, and 10% metastasize to the
lungs. Surgeons recommend en bloc excision or
amputation as the treatment of choice for this
tumor.
The purpose of this paper is to describe the
characteristic radiographic features of GCT and
the use of computed tomography (CT), magnetic
resonance imaging (MRI), and digital subtraction
angiography (DSA) in the diagnosis and treatment
of GCT.

MATERIALS AND METHODS

Reprint requests to: Dr Liang-Kuang Chen
Department of Diagnostic Radiology, Shin Kong Wu Ho-Su
Memorial Hospital, 95, Wen Chang Road, Shihlin, Taipei
111, Taiwan, R.O.C.
From December 1993 to July 2000, twelve
patients with primary giant cell tumors of the
bone were studied. The ages of these patients
ranged from 17 to 58 years (mean, 37.5 years).
Nine patients were women, and 3 were men. All
patients had conventional radiographs
(anteroposterior with or without lateral view or
oblique view). Eleven of the 12 patients showed
abnormal findings. In one patient, the lesion was
not clearly shown by conventional radiography.
Seven patients also received computed
tomography (Siemens Somaton HiQ-S or
Somatom plus 4A) with intravenous contrast
medium infusion. Five patients received magnetic
resonance imaging (Philips Gyroscan T5, 0.5T or
Siemens Magnetom Symphony, 1.5T) with
intravenous infusion of gadolinium (Gd-DTPA).
62 Giant cell tumor of the bone

Table 1. Tumor location and radiographic findings for 12 cases of GCT of the bone
Case Age
1 31
2 40
3 29
4 44
5 33
6 22
7 20
8 25
9 31
10 58
11 41
12 17
Sex Tumor location
F distal femur
M distal femur
F distal ulna
F distal femur lateral condyle
F proximal humerus
F distal tibia
F sacrum
F 1st metatarsal
F distal radius
M temporal bone
F sacrum
M proximal tibia
Radiographic appearance
pathologic fracture
expansile radiolucent lesion
expansile radiolucent lesion
pathologic fracture
pathologic fracture
expansile radiolucent lesion
expansile radiolucent lesion
soft tissue mass with expansile radiolucent lesion
expansile radiolucent lesion
soft tissue mass with expansile radiolucent lesion
soft tissue mass with expansile radiolucent lesion
radiolucent eccentric lesion

1a

1b 1c

Figure 1. Giant cell tumor in the distal radius of a 31-year-old woman. a. Anteroposterior and lateral radiographs
showing an expansile radiolucent lesion in the distal radius (arrows). b. Tumor showed moderate inhomogeneous
enhancement on CT with contrast medium infusion (arrow) and cortical breakthrough in the distal radius. c. Coronal
T1WI (TR: 450 ms, TE: 25 ms) with contrast infusion demonstrate heterogeneous enhancement of the tumor (arrows)
and thinning bone cortex in the distal radius.

Three patients received digital subtraction
angiography (Siemens Angiostar).
RESULTS
The 12 cases of primary giant cell tumors of
the bone occurred in the following sites: 3 were
located in the distal femur, 2 were located in the
sacrum, 1 each was located in the proximal tibia,
humerus, distal tibia, ulna, radius, skull base, and
1st metatarsal. Radiological features revealed that
5 were radiolucent expansile lesions, 3 were soft
tissue masses with radiolucent expansile lesions,
3 were pathologic fractures, 1 was radiolucent
 Giant cell tumor of the bone 63

with a soft tissue mass, and 1 was a radiolucent All tumors were proven to be GCTs by
eccentric lesion. The location and radiographic histology from surgical specimens of biopsy or
features of the 12 giant cell tumors were shown in curettage, and only 1 tumor showed malignant
table 1. behavior.

Figure 2. Giant cell tumor with pathologic fracture of the
proximal humerus in a 29-year-old woman who had pain
in her right shoulder for 3 months.
DISCUSSION
Giant cell tumors (GCTs) of the bone comprise
4%-5% of primary bone tumors. Of these tumors,
70% to 90% are located at the epiphysis of long
bones, while the remaining 10% to 30% are found
in the sacrum, patella, vertebrae, tarsal,
metacarpal, metatarsal bones, and skull. There is
a female predominance, and the age at
presentation is usually between 20 and 50 years.
The tumors are rare in patients under 16 or over
70 years of age [1-3].
Jaffe stated that GCTs may be classified into
grades I, II, or III based on the atypism of the
stroma cells. Grade I represents normal mature

3b

3a 3c

Figure 3. Giant cell tumor in the sacrum of a 41-year-old woman. a. Anteroposterior radiograph revealing expansile
radiolucent lesion over the sacrum, right side (arrowheads). b. CT showing a huge soft tissue tumor with expansile lytic
lesion (arrowheads) and cortex erosion at the sacrum, right side. c. Digital subtraction angiogram with selective
injection into the right common iliac artery showing hypervascularity with tumor supplied by the right internal iliac
artery at the sacrum, right side (white arrowheads).
64 Giant cell tumor of the bone

4a 4c

Figure 4. Giant cell tumor in the right temporal region of a 58-year-old

man who had right facial palsy for 3 years and vertigo for 1 month. a.
Anteroposterior view of the skull showing suspicious bony erosion of the
cranial base on the right side (arrow), but the mastoid air cells were
preserved. b. HRCT of temporal bones with bone window setting
coronal view shows a soft tissue tumor involving the right middle
cranium and infratemporal fossa (arrowheads). c. Axial T1WI (525/15 )
with contrast infusion showing heterogeneous enhancement of the tumor
which involves the right middle cranial fossa as well as the infratemporal
fossa. The multiseptated cystic component is noted at the anterior aspect
of this tumor (white arrow).
4b

5a 5b

Figure 5. Giant cell tumor in the right 1st metatarsal of a 25-year-old woman. a. Anteroposterior and oblique
radiographs showing a soft tissue mass with expansile radiolucent lesion and bony cortex destruction in the right 1st
metatarsal (arrows). b. Tumor showing inhomogeneous enhancement on CT with contrast infusion (arrows) and
irregular erosion of the cortex and abnormal soft tissue outside the bone in the right 1st metatarsal.
 Giant cell tumor of the bone
Figure 6. Photomicrograph showing numerous
multinucleated giant cells scattered throughout a
moderate cellular stroma characteristic of a giant cell
tumor. (Hematoxylin and eosin stain, X100)
stroma cells. Grade II contains moderately
atypical cells, and grade III has pronounced
atypism, indicating a frankly malignant neoplasm
[2].
GCTs grow insidiously and are likely to attain
a large size before clinical symptoms occur. Dull
aching pain may be the early complaint. A
pathologic fracture may be the initial finding
(10%). As the tumor grows, it encroaches on
joints resulting in restricted and painful motion,
and its mass usually becomes large enough to be
palpated, eliciting local tenderness [1, 2, 3, 4].
Radiographically, GCTs appear as solitary
radiolucent or expansile radiolucent lesions
without bony sclerosis or periosteal reaction
(Figs. 1a, 3a, 4a, 5a). There may be little
periosteal reaction and faint trabeculation.
Pathologic fractures are even present with
radiolucent lesions (Fig. 2).
The tumor begins as an eccentric lesion but
may progress to involve the entire bone. It arises
in the epiphysis and secondarily involves
metaphysis of the long bone.
Multicentric GCT of the bone is uncommon and
most frequently occurs because of direct
extension of the tumor to contiguous bone, either
directly or across a synovial which differs from a
solitary lesion [2].
Sacral GCT is uncommon and represents 3%-
7% of all primary GCTs of bone. Pain is common,
and neurologic deficit is a frequently associated
finding. Plain radiography reveals an expansile
lytic lesion without calcification which is
associated with a presacral soft tissue mass (Fig.
65
3a).
GCT in the cranial bone is rare and represents
1% of all primary GCTs of bone. The most
commonly involved sites are the sphenoid bones,
followed by the temporal bone (Fig. 4a). Other
sites include the occipital, frontal, and parietal
bones. Clinical symptoms vary widely, depending
on tumor size, location, and involvement of
intracranial neurovascular structures [4-6].
GCT is rarely encountered in metatarsal bone.
Pain is the most common presenting symptom,
and a palpable mass is a frequently associated
finding. Plain radiography shows a radiolucent
expansile lesion without calcification (Fig. 5a). In
small bones such as a metacarpal, ulna, fibula, or
metatarsal, GCTs reveal expansile and ballooning
radiographic findings [1, 3].
CT of GCT reveals the integrity of the cortex,
and the presence and extent of any soft tissue
component and can assess the extent of
intraosseous involvement (Fig. 1b, 3b, 4b, 5b). A
CT scan provides the most complete and accurate
anatomic evaluation including the tumor’s
relationship to major vessels and nerves. Contrast
enhancement contributes to good vessel
opacification and striking tumor enhancement.
However, some CT scans are difficult to interpret
with respect to cortical penetration and soft tissue
invasion [1, 7].
MRI with its multiplanar capability reveals
excellent soft tissue contrast and has contributed
to its effectiveness in evaluating bone tumors
(Fig. 1c, 4c). MRI is useful in determining the
extent of marrow and cortical bone thinning or
destruction, joint involvement, and soft tissue
extension.
MRI is the best modality for demonstrating
tissue homogenicity. GCTs produce low to
intermediate signals on T1-weighted spin echo
images and intermediate to high signals on T2-
weighted images with homogeneous or
inhomogeneous enhancement after intravenous
administration of Gd-DTPA on T1-weighted
images. These findings are nonspecific,
depending on the amount of coexistent
hemorrhage, necrosis, or cystic content [1, 8].
Angiography was performed in 3 of our 12
cases and showed hypervascular tumor staining
and venous pooling of contrast material (Fig. 3c).
One case showed hypovascularity with a faint
tumor stain. Transcatheter arterial embolization
using Gelfoam was performed and was successful
in a preoperative GCT of the sacrum in 1 of our
66 Giant cell tumor of the bone
cases.
Prando et al. reported that 90% of GCTs are
hypervascular, and 10% are hypovascular or
avascular. Although its features are non-specific,
angiography has an important role in the
preoperative evaluation of GCT, as it accurately
depicts the intraosseous extent of the tumor and
defines the extraosseous extent in 89% of patients
[2, 9].
Differential diagnoses with GCT include
aneurysmal bone cyst, chondroblastoma,
enchondroma, osteogenisarcoma, hemangioma,
fibrous dysplasia, non-mineralized osteoblastoma,
“brown tumor” of hyperparathyroidism, and other
fibro-osseous lesions [1, 2, 3, 6]. Aneurysmal
bone cysts have an irregular “soap bubble”
appearance. Ninety percent of lesions occur in
patients under 20 years of age with preferred sites
at the metaphysis of long bones.
Chondroblastomas have a subtle benign
appearance with a periosteal reaction and contain
a punctate mineralized matrix. They are often
located in the epiphysis. Enchondromas rarely
extend to the subarticular end of the affected
bone, and their preferred location is at the
metaphysis or diametaphyseal region. There are 3
forms of this lesion: 1) pedunculated, 2) sessile,
and 3) calcified; it has an irregular cauliflower or
coat hanger exostosis appearance on radiographs.
A “ground-glass” radiological appearance favors
fibrous dysplasia. Osteogenic sarcomas
occasionally appear as an osteolytic lesion on
radiographs and may be associated with soft
tissue masses, sometimes mimicking a GCT,
depending on the amount of osteoblastic and
osteolytic activity. Osteoblastomas are common
in vertebral arches and in tubular bones. Lesions
are eccentrically located in the metaphysis or
shaft, and the epiphysis is not involved. The
characteristic radiographic feature is a well-
circumscribed, expansile lesion which may be
surrounded by a fine calcified margin [1, 6].
In our patients, serum alkaline phosphatase and
calcium levels were normal, excluding a
diagnosis of “brown” tumor of
hyperparathyroidism. Enchondromatosis,
polystotic fibrous dysplasia, metastasis, and
“brown” tumors of hyperparathyroidism are
multiple lesions, but GCT is rarely multiple.
Clinical laboratory data and specific radiologic
findings can be helpful in the differential
diagnosis [1, 6].
GCT is a potentially malignant, aggressive
lesion and 30% to 60% recur after curettage.
Treatment modalities include curettage, packing
with bone graft and cement, excision, resection,
amputation, and radiotherapy [1, 2, 10]. Nearly
all our cases were treated with curettage and bone
allografts with occasional use of cement fixation.
Only 1 patient received cryotherapy and
radiotherapy.
On histology, GCT shows a predominance of
large multinucleated giant cells, dispersed in
spindle-shaped stroma cells. However,
multinucleated giant cells may be found in
neoplastic and non-neoplastic bone lesions; so a
correct pathological diagnosis is difficult [1-3, 6].
The histological differential diagnosis includes
aneurysmal bone cysts, chondroblastomas, and
fibrous dysplasia [1].
In conclusion, although conventional
radiography can show the characteristics of
GCTs, some atypical lesions can be missed. CT,
MRI, and DSA are more sensitive than
conventional radiography in demonstrating
intraosseous and extraosseous components. A
combination of these imaging modalities is
helpful in the preoperative assessment and
postoperative follow-up. ◆
REFERENCES
1. Moster RP, Kransdorf MJ, Gilbey FW, Manaster BJ.
Giant cell tumor of the upper extremity. Radiographics
1990; 10: 83-102
2. Wory LY, Yang TC. Giant cell tumor of bone: a report
of 24 cases. J Radiol 1985; 10: 87-94
3. Dahlin DC, Diepps RE, Johnson EW. Giant cell tumors:
a study of 195 cases. Cancer 1970; 25: 1001-1070
4. Dahlin DC. Giant cell tumor of bone: highlights of 407
cases. AJR Am J Roentgenol 1985; 144: 955-960
5. Emely WE. Giant cell tumor of sphenoid: a case report
and review of the literature. Arch Otolaryngol/Head
Neck Surg 1971; 94: 369-374
6. Lee JA, Bank WO, Gonzales-Melendez, et al. Giant cell
tumor of the skull. Radiographics 1998; 18: 1295-1302
7. Hudson TM, Schiebler M, Springfield DS, Enneking
WF, Hawkins IF, Spanner SS. Radiology of giant cell
tumor of bone: computed tomography, arthro-
tomography, and scintigraphy. Skeletal Radiol 1984; 11:
85-95
8. Herman SD, Mesgarzadeh M, Bonakdorpour A, Dalinka
MK. The role of magnetic resonance imaging in giant
cell tumor of bone. Skelet Radiol 1987; 16: 635-643
9. Prando A, de Santos LA, Wallace S, Murray JA.
Angiography in giant cell bone tumors. Diagn Radiol
1979; 130: 323-331
10. Shin HN, Chen YJ, Huang TJ, HO WP, Hsueh S, Hsu
RWW. Treatment of giant tumor of long bone. Chang
Gung Med J 1996; 19: 16-23.
 Giant cell tumor of the bone 67

骨骼巨細胞瘤

1,2 1 1 1 1
陳良光 蘇誠道 蔡裕豐 陳旭漪 彭惠玲
1 1 1
吳金珠 姚敏思 賴善鳴
1
新光吳火獅紀念醫院　放射診斷科
2
元培科學技術學院

骨巨細胞瘤佔 4 ∼ 5 ％之所有原發性骨骼腫瘤，其初期發生是良性，極少惡性，但經過刮除
術後有 60 ％會復發且 10 ％會轉移至肺部。
其發生年齡由 20 至 50 歲，少許低於 16 和高於 70 歲，女性多於男性。於臨床上其會產生極
痛，腫塊和病理性骨折，另外，如侵犯至關節會造成行動受到限制和痛覺。
其最常侵犯部位為長骨近端和端，並有少許侵犯坁骨，髖骨，椎骨，頭骨，蹠骨等。於常規
放射線攝影所顯示為擴張蝕骨性病灶，有時破壞皮質而侵入鄰近的軟組織。另外會有病理性骨
折，但很少有骨膜反應或鈣化。
新光吳火獅紀念醫院由 1993 年 12 月至 2000 年 7 月共收集了 12 例疑似巨細胞瘤，年齡由 17
歲至 58 歲，平均年齡為 37.5 歲； 9 女 3 男。這些病患都接受常規放射線攝影，其中 7 例接受電
腦斷層攝影， 5 例接受磁共振造影， 3 例接受數位消像血管攝影，並且經過開刀和病理組織診
斷為骨巨細胞瘤。因此我們將其放射線上之變化提出討論，並提供給大家參考指教。

關鍵詞：骨，腫瘤；電腦斷層攝影；磁共振造影；數位消像血管攝影