26F RECURRENT GCT LEFT DISTAL FEMUR

 A 26-year-old female, born in India in 1996, achieved normal developmental milestones during childhood and had an overall pleasant upbringing. However, her medical history took a turn in 2014 when she started experiencing left knee pain towards the end of May. Pain was dull and heavy feeling with each step she takes, non radiating.Initially, she attributed the pain to physical training classes and tried using topical analgesics, but found no relief. Instead, the pain worsened over time, limiting her mobility. Seeking medical attention, she underwent an X-ray that revealed a hypodense lesion, prompting further evaluation with an MRI. This MRI confirmed the presence of an abnormal growth, leading to her admission to a hospital in China.

In June, her orthopedician recommended an open cut biopsy, which revealed the presence of giant cells, indicating a diagnosis of Giant Cell Tumor. A week later, she underwent surgery, during which the affected bone was resected and replaced with bone cement and nails. However, postoperatively, she experienced severe and excruciating pain even with minimal movement. Upon examination, the doctors discovered that the nails had been placed close to an artery. Consequently, on the second postoperative day, she underwent a minor surgery to remove the nails, while leaving the cement in place.

Following the initial surgery, the patient continued to experience persistent discomfort in her left femur, which persisted even at rest. Due to a lack of awareness, she believed this discomfort to be a normal part of the post-surgical recovery process. However, in March 2015, the discomfort gradually worsened, prompting a follow-up visit with her orthopedician. At this appointment, the doctor suspected a recurrence of the Giant Cell Tumor but advised waiting for three months before conducting an X-ray to confirm the recurrence. Three months later, the X-ray indeed showed an increase in the lesion, confirming the recurrence. A CT scan was performed for further evaluation, including ruling out pulmonary metastases associated with Giant Cell Tumors.

Concerned about the recurrence and seeking further evaluation and management she visited a renowned Orthopedician and underwent a surgical procedure involving the removal of the cement spacer, extended curettage, cryotherapy, contra-lateral proximal fibula bone grafting, and allografting under general anesthesia. Two weeks later, the sutures were removed, and she remained under follow-up care since then.

 However, during regular follow-up visits in July 2017, X-ray changes were observed, leading the doctor to suggest trying subcutaneous injections of Denosumab every 28 days. After reviewing relevant articles and consulting long-distance doctors and patients who had undergone Denosumab treatment for Giant Cell Tumor, the patient and her doctor decided to proceed with this treatment option.

In simple terms, the hypothesis behind using Denosumab in 2016 was that it would shrink the tumor and render it inactive, making surgical resection simpler and more effective. Alternatively, to put it in more layman's terms, Denosumab would "put the aggressive lion (tumor) to sleep" and make it easier to manage.

In July 2020, the patient presented with complaints of knee pain and limited mobility. Investigations revealed a recurrence of the condition. As a result, the patient was started on Denosumab 120mg and received 12 doses until June 2021, after which the treatment was discontinued. Fortunately, there were no side effects experienced from Denosumab 

In August 2021, the patient sought a second opinion due to similar complaints. During this consultation, she encountered a doctor who proposed a different hypothesis regarding Denosumab. According to this hypothesis, Denosumab can conceal cells within the cortex, making them undetectable in scans and resulting in a normal histopathology report. Consequently, the recurrence rate with Denosumab is higher.

Based on the recommendations from doctors, the patient was advised to consider a prosthesis as a potential treatment option. However, before resorting to this final intervention, the patient followed her mother's advice and began trying herbal medications from Ayurveda in November 2021. As a result, her symptoms gradually subsided, and she regained complete mobility in her leg.

The patient continued using Ayurvedic treatments for one year, and follow-up X-rays indicated a gradual decrease in the size of the lesion. Eventually, in December 2022, the patient decided to gradually discontinue Ayurvedic medications.

However, in February 2023, the patient began experiencing slight discomfort, which subsequently progressed. By April, she had developed restricted motion and underwent an MRI examination to further investigate her condition.The MRI revealed a large and heterogeneous expansile osseous lesion in the distal femur, displaying various cystic areas and areas of hemorrhage within it. The lesion was located approximately 1.0 cm proximal to the articular surface of the distal femur, with cortical thinning and a suspected breach on its anterior aspect. Adjacent soft tissue components and mild joint space extension were also noted, along with synovitis and partial disruption of the medial flexor retinaculum.

On May 15th, 2023, the patient underwent surgery involving curettage, placement of bone cement, and plating, and the procedure went smoothly. Although the procedure was smooth, recovery was suboptimal and patient experienced limping ultimately needing prosthesis

X ray in 2014 

MRI in 2014   

        

2014 post operative x ray with Nails

2014 June post operative without Nails(As nail is hitting the artery causing severe pain,removed ASAP)

Sep 2014

Jan 2015

2015 MARCH

2015 JUNE

2015 CT LEFT LEG

2015 CHEST CT- NORMAL

2015 June 

Post operative X-ray June 2015

Post fibular graft

July 2015

SEPTEMBER 2015

      OCTOBER 2015

Jan 2016

APRIL 2016

31st January 2017

02-02-2017 CT

11-07-2017

13-07-2017 PET CT

17-07-2017

USG GUIDED BIOPSY

18-01-2018

23-01-2018 

CT

02-02-2018

BIOPSY REPORT

05-02-2018

20-02-2018

22-02-2018 CT

17-07-2018

23-07-2018 CT

22-01-2019

23-02-2022

24-07-2023

04-09-2023

13-04-2024

17-05-2024

PATIENTS PERSPECTIVE 

"My journey with Giant Cell Tumour has been long and exhausting. The pain in my knee began as a small inconvenience, but it soon took over my life. Each surgery brought hope, only to be followed by disappointment and fear of recurrence. When I tried Denosumab, I was hopeful it would be the answer, but the uncertainty of its effectiveness left me anxious. Turning to Ayurveda was a desperate attempt to find relief, and while it helped for a time, it wasn’t a lasting solution.

Throughout this ordeal, I've faced constant physical pain and the emotional toll of navigating complex medical decisions. The recurring nature of my tumour has made me feel like I'm in a never-ending battle. The thought of more surgeries is daunting, but I am determined to fight for my mobility and quality of life. Each setback has been a reminder of the fragility of my health, but also of my resilience. I’ve learned to appreciate the small victories and the support of my family and medical team. This journey has been filled with uncertainty and fear, but also moments of hope and strength. My story is one of perseverance, and I hold onto the belief that, despite the challenges, I will continue to move forward.”