Intrathoracic Extension of a Giant Cell Tumour of the Medial End of Clavicle: A Rare Case Report

The clavicle is a very rare site for primary bone tumours, and Giant cell tumours of the clavicle are even rarer. Very few cases have been reported in the literature. Shaswat Mishra et al report a rare presentation of intrathoracic extension of a giant cell tumour of the medial end of the clavicle, in an 18-year-old female. The patient had painful swelling at the sternal end of the clavicle associated with a painful shoulder range of motion. Complete resection of the mass was done, preserving the lateral half of the clavicle.

The case report has been published in Indian Journal of Orthopaedics.

An 18-year-old right-hand dominant female, student, presented with complaints of insidious onset of progressive swelling over her left upper chest region over the preceding 4 years, associated with pain which was aggravated with shoulder movements. There was no history of trauma or associated constitutional symptoms or any other systemic involvement.

At presentation, the patient had a well-defined mass of approximately 4 cm × 5 cm × 5 cm over the medial end of the left clavicle. The mass was tender, firm in consistency with crackling felt on pressing the swelling. It was firmly attached to the bone underneath. No local warmth or pulsation was felt over the swelling. The ipsilateral shoulder had a normal range of motion but was painful throughout. Axillary, brachial, and radial pulsations were well felt. There was no neuro-deficit in the extremity. Examination of the cardiovascular and respiratory systems was within normal limits. She had a Constant score of 68 and a Japanese Orthopedic Association Score of 74 at presentation.

Radiographs showed an eccentric, expansile, lytic lesion in the epiphysio-metaphyseal region of the medial end of the left clavicle. The margins of the lesion were not clearly demarcated and there was no evidence of sclerosis. The lateral end of the clavicle was apparently normal and so was the shoulder joint. MRI of the clavicle revealed an expansile lesion of the Medial End of Clavicle, the epicentre being metaphysis. It showed multi-loculated cystic lesions with multiple fluid levels within. The lesion was extending medially up to the subchondral bone with compression and medial displacement of the brachiocephalic vein and was in close proximity of the sternocleidomastoid muscle. Inferiorly it was abutting the apical lobe of the left lungs. Intrathoracic extension of 2×2 cm behind the manubrium sterni was noted. Posteriorly, it was in close proximity to the left subclavian artery, left common carotid artery, and internal jugular vein. A provisional diagnosis of GCT with secondary aneurysmal changes was given on MRI.

FNAC was done and cyto-morphological features confirmed the diagnosis of GCT. Surgery was planned for the patient in the form of en masse excision of the tumour with partial cleidectomy. Blood investigations of the patient including thyroid profile, serum calcium, serum phosphorous, liver, and renal function tests were within normal limits. Considering the proximity of the lesion with the major vessels, a contrast enhanced ct pulmonary angiography was done for better preoperative planning.

A team of orthopaedic and cardiothoracic surgeons operated on the patient. After exposure, tumour mass was separated from the surrounding structures with fine dissection. Corticotomy was done with a 2 cm margin of normal bone laterally. Mass was then gradually lifted from the lateral to the medial side to visualise the underlying structures. Blunt dissection was carried out to separate the entire mass of the soft tissue bed. The Intrathoracic Extension was removed at the end going behind the manubrium sterni. Myodesis of sub-clavious muscle was done to the free lateral end of the clavicle. Postoperatively, the patient was allowed shoulder movements as tolerated. Physiotherapy in the form of shoulder range of motion exercises and muscle strengthening exercises was ensured for 6 months. She is under follow-up for 3 years with good clinical outcome, no signs of recurrence, and is carrying out her personal and professional life with no limitations.

The authors concluded - " this report highlights the need for a careful and thorough assessment of clavicle tumours to rule out malignancy. Early detection and timely intervention can save the patient from high-risk surgeries. The need for complete removal of the GCT mass to prevent recurrence cannot be emphasised more. And lastly, partial cleidectomy alone, even in advanced cases, is an f and low-cost alternative to preoperative denosumab and subsequent resection of the clavicle, especially for economically weaker sections of our society who can't afford the high cost of treatment."

Further reading:

Intrathoracic Extension of a Giant Cell Tumour of the Medial End of Clavicle: A Case Report with Review of Literature Shaswat Mishra, Manish Jain et al Indian Journal of Orthopaedics (2022) 56:1834–1840 https://doi.org/10.1007/s43465-022-00726-0