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case_images: (A) Initial radiography shows an osteolytic lesion in the proximal radius. (B) In enhanced magnetic resonance imaging, the lesion is enhanced by gadolinium. (C) Histology of the specimen of the radius shows proliferation of spindle cells and multinucleated osteoclast-like cells, which is consistent with diagnosis of GCTB. (D) Immunohistological staining of H3.3G34W. (E) The lesion is curetted and augmented with alpha-tricalcium phosphate.
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case_images: Radiography revealed osteolytic lesions and scalloping in the right proximal radius ( Figure 1A ). Magnetic resonance imaging showed a tumor lesion in the proximal radius with iso intensity on T1-weighted images and high intensity on T2-weighted images, and the lesion was enhanced by gadolinium ( Figure 1B ). 201Thallium (201Tl) scintigraphy and 99mTc-methylene diphosphonate (99mTc-MDP) scintigraphy showed an increased uptake of the 201Tl and 99mTc-MDP in the proximal radius. Open biopsy was performed, and the histology of the tumor showed proliferation of spindle cells and multinuclear osteoclast-like cells with collagen fibers and deposition of hemosiderin ( Figure 1C ). Immunohistological staining showed positivity for H3.3G34W in the tumor cells ( Figure 1D ). He underwent curettage with adjuvant treatment with ethanol and phenol, and the bone defect was augmented with alpha-tricalcium phosphate (alphaTCP) ( Figure 1E ).
case_images: (A) At the time of second surgery, no pulmonary lesion was detected on radiography. (B) Three years after the second surgery, radiography showed multiple lung nodules.
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case_images: At the time of the second surgery, no pulmonary nodules were detected on chest radiography ( Figure 2A ). Radiography and CT revealed 31 nodules, including the largest lesion (15 x 13 cm) in the lungs ( Figure 2B ).
case_images: (A) Positron emission tomography/computed tomography shows high accumulation of 18F-fluoro-2-deoxy-D-glucose in the multiple lung lesions. (B, C). The maximum standardized uptake values are 11.8-12.2. (D) Histology of specimen of the lung nodule shows proliferation of spindle cells and multinuclear cells, which is similar to the findings of specimen of the radius. (E) Immunohistological staining of H3.3G34W.
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case_images: PET/CT revealed a markedly increased uptake of 18F-FDG in the lesions (SUVmax = 11.8-12.2) ( Figures 3A-C ). Histological examination of the specimen revealed proliferation of spindle cells and multinuclear osteoclast-like cells without malignant changes ( Figure 3D ), and the tumor cells were positive for H3.3G34W on immunohistological staining ( Figure 3E ).
case_images: Radiography examination before treatment (A), 1 month (B), 3 months (C), and 18 months (D) after the initial treatment of denosumab. The pulmonary lesions show response to the treatment of denosumab.
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case_images: One month after the initiation of denosumab treatment, shrinkages of the lung nodules and gradual improvement in pulmonary symptoms were observed ( Figure 4 ). Eighteen months after the initial treatment with denosumab, the patient showed no symptoms or disease progression and continued to undergo denosumab treatment ( Figure 4 ).