Giant Cell Tumor of the Bone in Patients Under 15 Years Old: a Single Institution Case-series
Conditions: Giant Cell Tumor of Bone
Sponsor: Istituto Ortopedico Rizzoli

Pediatric GCTB 
 
 
 
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“Giant Cell Tumor of the bone in patients under 15 years old: a single institution 
case-series” 
 
Study code 
Pediatric GCTB 
Sponsor’s 
Name 
and 
Address: 
Istituto Ortopedico Rizzoli 
Via di Barbiano 1/10 
40136 Bologna 
Italy 
Study 
Number/Version/Date: 
Vers 1.0  
03 Apr 2019 
Coordinating Center: 
IRCCS Istituto Ortopedico Rizzoli 
Pathology Unit 
Via Pupilli 1 
40136 Bologna, Italy 
Coordinating 
Investigator 
and address: 
Marco Gambarotti MD 
Phone: 051-6366.652 
Email: marco.gambarotti@ior.it 
Methodology: 
Experimental study with biological material 
(Single insitution case series review of clinical and histological data) 
Type: 
Academic 
 
Founding: 
None 
 
Principal 
Investigator 
Signature 
I confirm that I’ve read this protocol and I accept to run the study in 
compliance with what is stated in the protocol and with the ICh-GCP 
and all applicable law 
 
Marco Gambarotti MD 
 
Firma 
 
 
 
 
 
 
 

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TABLE of CONTENTS 
Background 
 
 
 
 
 
 
 
 
 
pg. 3 
Objective of the study 
 
 
 
 
 
 
 
pg.  4 
Study design   
 
 
 
 
 
 
 
 
pg.  4 
Population     
 
 
 
 
 
 
 
 
pg.  4 
Material and Methods  
 
 
 
 
 
 
 
pg.  5 
Statistics 
 
  
 
 
 
 
 
 
 
pg.  5 
Enrolment procedure   
 
 
 
 
 
 
 
pg.  5 
Data Collection            
  
 
 
 
 
 
 
pg.  5 
Ethic and quality assurance   
 
 
 
 
 
 
pg.  6 
Informed Consent  
 
  
 
 
 
 
 
 
pg.  6 
General principles for human biological material (HBM) collection 
 
pg.  7 
Confidentiality                                                                                       
 
 
pg.  7 
Publication of results                                                        
 
 
             pg.  8 
Sponsor role and responsibility                                                        
 
 
 pg.  8 
References 
                                                                                       
 
 
pg.  8 
 
 

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BACKGROUND 
 
Giant cell tumor of the bone (GCTB) is a locally aggressive tumor composed by oval to spindle cells, 
with a monomorphic appearance with multinucleated giant cells (osteoclast-like) uniformly 
distributed. 
GCTB is around 4% of primary bone tumors, and it occur mostly in skeletally mature patients 
(between 20 and 55 years old). However, sporadic GCTB has been reported in older patients, as 
well as in the first two decades. 
GCTB is generally located in the epiphysis of the long bones, especially the distal femur, proximal 
tibia and distal radius; contrary it is uncommon in short tubular bones of the hands and feet. 
GCTBs are a part of a group of lesions, that could be traditionally divided into true neoplastic and 
those with a reactive nature. Especially in young patients, it is important to differentiate the true 
neoplastic from giant cell reparative granuloma, because these two categories could present some 
overlapping morphological features. In this cases correlation with clinical and radiological features 
is crucial. Moreover, the minority of these lesions can develop a secondary malignant 
transformation and sporadic case may give distant metastasis. Multifocal metachronous and/or 
synchronous cases are rare, as well as GCTB can be observed in a specific setting of Paget’s 
disease. 
Radiologically, GCTB has characteristic and diagnostic features, especially in adult patients and in 
common site. It appears as a well-defined bordered, eccentric, lytic, subchondral lesion that 
involves epiphysis and metaphysis with the typical “soap bubble” appearance; while the bone 
cortex is expanded and could be focally destroyed. Usually, borders do not showed margins of 
sclerosis or trabeculation.  
Microscopically, mononuclear, spindle-shaped to intermediate-sized oval cells are uniformly 
dispersed with multinuclear, giant cells (osteoclast-like). Mononuclear cell could be elongated or 
spindle, with plum nuclei, the mitotic rate of these mononuclear stromal cells can be quite high, 
but no atypical one is seen. The classic setting of GCTB is modified by a secondary reactive 
proliferation of fibro-histiocytic tissue, areas of hemorrhage, necrosis and secondary aneurysmal 
bone cyst-like formation. Malignant transformation has been reported in few cases; however, lung 
metastasis has been found also in morphological benign cases [. 

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Differential diagnosis is giant cell reparative granuloma and other possible reactive giant cell lesion 
(brown tumor of hyperparathyroidism). Recently, driver mutations in the two histone 3.3 (H3.3) 
genes, H3F3A has been identified in 92% GCTB [Behjati S, 2013] and giant cell sarcomas secondary 
to GCTB. In addition, the diagnostic value was evaluated in order to differentiate giant cell lesions 
(aneurysmal bone cyst, nonossifying fibroma, giant cell granuloma, and osteoclast‐rich malignant 
bone tumors) from true GCTB. H3F3A immunohistochemical expression has been demonstrated in 
97.8% and mutations has been demonstrated to be essential feature of GCTB that improve 
pathological evaluation especially in borderline lesions with a not clear cut clinical and radiological 
contest. Rare case of GCTB have been reported in young patients. A recent Serie reviewed 63 
patients under 18 years old, and only 5 TCG harbored H3F3A mutations, confirmed by PCR analysis  
OBJECTIVE OF THE STUDY  
Primary Objective 
Primary objective is to present our series of GCTB, with its clinical, histological, 
immunohistochemical and/or molecular characteristics of these tumors, in order to collect the 
largest pediatric series.  
Secondary Objective 
Secondary objective is to reproduce and confirm the results of H3F3A immunohistochemical 
expression from the study of Amary et al. 2017 on our series of pediatric GCTB under 15 years old. 
 
STUDY DESIGN 
This is single institution cases series review of histological and clinical data 
 
POPULATION 
Inclusion criteria 
1) Male and female patients under 15 years old treated at Rizzoli Institute from 01 January 
1982 to 31 December 2018. 
2) Diagnosis of GCTB, aneurysmatic bone cysts with solid features and  giant cell 
reparative granuloma.  
3) Histological slides/formalin-fixed paraffin-embedded tissue tumor (FFPE) blocks from 
archive available to perform the histology analysis 
4) Written informed consent prior to any study-specific analysis and/or data collection  
 

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Exclusion criteria 
1) Patients with histological diagnosis different from diagnosis of giant cell tumor, 
aneurysmatic bone cysts with solid features, and giant cell reparative granuloma. 
2) Patients with no available material for additional immunohistochemical and molecular 
analysis 
 
MATERIAL AND METHODS 
We will retrieve from the archives of the Rizzoli Institute all the cases with a histological diagnosis 
of GCTB, aneurysmatic bone cysts with solid features, and giant cell reparative granuloma. By 
reviewing our database, we aspect to find approximately 50 cases We will review all the medical 
records, radiological imaging, and histological slides of all of these cases.  In all cases with enough 
available material, immunohistochemistry will be performed on FFPE material.  Histone 3.3 (H3.3) 
genes, H3F3A and mutation will be analyzed with immunohistochemistry and/or by allele specific-
PCR analysis. 
 
STATISTICS 
To the case series will be applied a descriptive statistic. 
 
ENROLLMENT PROCEDURE 
Patients considered eligible will be included in the study, after providing a written informed 
consent.  
 
DATA COLLECTION 
Clinical data will be retrieved by patient charts. 
A protocol-specific CRF reporting the results of the review will be provided. 
A CRF is required and should be completed for each included subject. 
 
ETHICS AND QUALITY ASSURANCE 
The clinical trial protocol and its documents will be sent before initiating the study to the 
competent Authorities and Ethics Committees of each participating country for its approval. 

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The responsible investigator will ensure that this study is conducted in agreement with either the 
most updated Declaration of Helsinki and all the international and local laws that apply to clinical 
trials and to patient protection.  
The protocol has been written, and the study will be conducted according to the principles of the 
ICH Harmonized Tripartite Guideline for Good Clinical Practice  
(ref: http://www.emea.eu.int/pdfs/human/ich/013595en.pdf).  
 
INFORMED CONSENT 
All patients will be informed, by the investigator, of the aims of the study, the possible risks and 
benefits that will derive from the study participation.  
The Investigator must clearly inform that the patient is free to refuse participation in the study and 
that can withdraw consent at any time and for any reason.  
They will be informed as to the strict confidentiality of their patient data, but that their medical 
records may be reviewed for trial purposes by authorized individuals other than their treating 
physician.  
The informed consent procedure must conform to the ICH guidelines on Good Clinical Practice. 
This implies that "the written informed consent form should be signed and personally dated by the 
patient or by the patient's legally acceptable representative".   
The Investigator must also sign the Informed Consent form and will keep the original at the site 
and a copy of the original must be handed to the patient.  
The competent ethics committee for each Institution participating to the study must validate local 
informed consent documents before the study can be opened. It will be emphasized that the 
participation is voluntary and that the patient is allowed to refuse further participation in the 
study whenever he/she wants. This will not prejudice the patient's subsequent care.  
Due to the high incidence of mortality of the disease under investigation, it would be possible that 
some potential eligible subjects will be deceased.  
 
GENERAL PRINCIPLES FOR HUMAN BIOLOGICAL MATERIAL (HBM) COLLECTION 
Human biological material (HBM) collection involves the collection and storage of biological 
material, residual biological material or derivatives in compliance with ethical and technical 
requirements.  

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Biological material (FFPE blocks of tumor sample) are already stored in the archive of the Istituto 
Ortopedico Rizzoli, Pathology Department. 
The biological material will be used and stored according with the sample characteristic and 
applicable regulation. 
 The Istituto Ortopedico Rizzoli will have a designated person responsible for collection and 
will act as a communication point  
 The collected HBM should be documented, i.e. the amount remaining and its location. act 
as a communication point  
 
CONFIDENTIALITY 
In order to ensure confidentiality of clinical trial data as disposed the national and European 
applicable regulation, data will be only accessible for the trial Sponsor and its designees, for 
monitoring/auditing procedures, the Investigator and collaborators, the Ethics Committee of each 
corresponding site and the Health Authority. 
Investigator and the Institution will allow access to data and source documentation for 
monitoring, auditing, Ethic Committee revision and inspections of Health Authority, but 
maintaining at all times subject personal data confidentiality as specified in the “Directive 
95/46/EC of the European Parliament and of the Council of 24 October 1995”.  
 The Investigator must guarantee that patient anonymity is kept at all times and their identity 
must be protected from unauthorized persons and institutions.  
All patients included in the study will be identified with a numeric code, so that no identifiable 
personal data will be collected (pseudo anonymization) 
The Investigator must have and conserve a patients’ inclusion registry where it figures the 
personal data of the patient: name, surname, address and corresponding identification code into 
the study, this register will be kept on the Investigator File. 
 
 
 
PUBBLICATION OF RESULTS  
The results from this study will be published or shown at scientific conferences. The final 
publication of the study results will be written by the Principal Investigator. 
 

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SPONSOR ROLE AND RESPONSIBILITY 
The sponsor is the sole owner of the data and is responsible of all the clinical trial activities from 
study design, development, data collection, management, analysis, interpretation of data, writing 
and the decision to submit the report for publication written by the Principal Investigator,  
 
REFERENCES 
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PCW, et al, eds. WHO Classification of Tumours of Soft Tissue and Bone. Lyon, France: IARC Press; 
2013:320. 
Campanacci, M., Baldini, N., Boriani, S. and Sudanese, A., 1987. Giant-cell tumor of bone. The 
Journal of bone and joint surgery. American volume, 69(1), pp.106-114. 
Al-Ibraheemi, A., Inwards, C.Y., Zreik, R.T., Wenger, D.E., Jenkins, S.M., Carter, J.M., Boland, J.M., 
Rose, P.S., Jin, L., Oliveira, A.M. and Fritchie, K.J., 2016. Histologic Spectrum of Giant Cell Tumor 
(GCT) of Bone in Patients 18 Years of Age and Below. The American journal of surgical pathology, 
40(12), pp.1702-1712. 
Dahlin, D.C., Cupps, R.E. and Johnson Jr, E.W., 1970. Giant‐cell tumor: A study of 195 cases. 
Cancer, 25(5), pp.1061-1070. 
Salzer-Kuntschik, M., 1998. Differential diagnosis of giant cell tumor of bone. Verhandlungen der 
Deutschen Gesellschaft fur Pathologie, 82, pp.154-159.  
Bertoni F, Bacchini P, Staals EL. Malignancy in giant cell tumor of bone. Cancer. 2003; 97:2520–
2529. 
Dumford, K., Moore, T., Walker, C. and Jaksha, J., 2003. Multifocal, metachronous, giant cell tumor 
of the lower limb. Skeletal radiology, 32(3), pp.147-150. 
Rendina, D., Gennari, L., De Filippo, G., Merlotti, D., De Campora, E., Fazioli, F., Scarano, G., Nuti, 
R., Strazzullo, P. and Mossetti, G., 2006. Evidence for increased clinical severity of familial and 
sporadic Paget's disease of bone in Campania, southern Italy. Journal of Bone and Mineral 
Research, 21(12), pp.1828-1835. 

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Murphey, M.D., Nomikos, G.C., Flemming, D.J., Gannon, F.H., Temple, H.T. and Kransdorf, M.J., 
2001. Imaging of giant cell tumor and giant cell reparative granuloma of bone: radiologic-
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Gong, L., Liu, W., Sun, X., Sajdik, C., Tian, X., Niu, X. and Huang, X., 2012. Histological and clinical 
characteristics of malignant giant cell tumor of bone. Virchows Archiv, 460(3), pp.327-334. 
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institution. International orthopaedics, 30(6), pp.499-504. 
Behjati S, Tarpey PS, Presneau N, et al. Distinct H3F3A and H3F3B driver mutations define 
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Righi, A., Mancini, I., Gambarotti, M., Picci, P., Gamberi, G., Marraccini, C., Dei Tos, A.P., Simi, L., 
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