Investigating the Challenges in Diagnosis and Management of Giant Cell Tumors in the Distal Phalanx: A Case Report

Abstract

Giant cell tumors (GCTs) of bone are locally aggressive neoplasms that typically occur in the distal femur or proximal tibia. Infrequently, they may develop in the bones of the hand, including the distal phalanx. This case highlights the importance of a thorough and systematic diagnostic workup of GCTs presenting in rare and challenging locations such as the distal phalanx. A 53-year-old male presented to the clinic with a several-month history of left middle fingertip enlargement, pain, and limited mobility. Plain film X-ray and magnetic resonance imaging revealed a lesion in the left middle distal phalanx. The patient underwent curettage with a working diagnosis of giant cell reparative granuloma with focal fracture callus. Eight months later the mass recurred and amputation of the distal phalanx tip was performed. The histopathological evaluation confirmed a diagnosis of a giant cell tumor of bone. The postoperative course was unremarkable. No further treatment was required. In rare and difficult-to-diagnose tumors clinicians should consult with experienced pathologists to improve diagnostic accuracy. This approach is essential for optimizing patient outcomes, preventing treatment delays, and reducing the risk of adverse events.

Keywords: amputation; consultation; curettage; distal phalanx; giant cell reparative granuloma; giant cell tumor of bone; orthopedic hand surgery; orthopedic surgery.

Figure 1. A) A posteroanterior and B) lateral radiograph of the left hand demonstrating an erosive lesion at the fingertip involving the tuft of the distal phalanx of the middle finger.

Figure 2. A) Sagittal T1 MRI of the left third distal phalanx, demonstrating an intraosseous mass of the distal phalanx that does not extend into the joint space.

B) Sagittal T1 fat sat post-contrast MRI of the left third distal phalanx, demonstrating a solid enhancing lesion.

Figure 3. A) Coronal STIR MRI of the left third distal phalanx, demonstrating an intraosseous mass with an expansile bulbous appearance at the tuft.

B) Coronal T1 MRI of the left third distal phalanx, revealing no edema within the mass and the adjacent normal bone. STIR: Short tau inversion recovery

Figure 4. A) Axial T1 fat sat MRI of the left third distal phalanx demonstrating a solid lesion.

B) Axial T1 fat sat post-contrast MRI of the left third distal phalanx of the distal phalanx, demonstrating a solid enhancing lesion.

Figure 5. A) Micrographs of the lesion (H&E 40×), composed of an abundance of multinucleated osteoclast-like giant cells.

Osteoclast-like giant cells display mitosis. The white arrow shows a multinucleated giant cell. The black arrow displays a mononuclear stromal cell. B) Zoomed-in micrograph of the lesion (H&E), displaying osteoclast-like giant cells. The white arrow shows a multinucleated giant cell. The white arrowheads point to individual nuclei within the multinucleated giant cell. (Imaging of the gross specimen was not able to be obtained but was described as consisting of multiple fragments of pink, soft tan tissue with a measurement of 1.0 × 0.7 × 0.4 cm).