Arthroscopy procedures are commonly done to repair damage to ligaments and cartilage. Then I had 3 incidents of blood clots( dvt and PE). A large portion of benign bone tumors are found in children while their skeletons are still growing. It was indeed a giant cell tumor. Introduction. If you have any signs of a giant cell tumor, its important to see your healthcare provider right away. The reason for this is unknown., Tenosynovial giant cell tumors are caused by a translocation of certain parts of chromosomes 1 and 2. 2 wks into the pt I feel at my home and rushed to the er. They are quite rare, occurring in only about one out of every one million people per year. Skeletal Radiol. Hi Sandra I'm reading your story and I'm currently going through the same thing I'll be having surgery soon how was/is your recovery? American Academy of Orthopaedic Surgeons, 2013, pp. I have been missing out on so many things in my life. Tenosynovial giant cell tumor is a locally aggressive tumor arising from the synovia of the fibrous tissue surrounding the joints, tendon sheaths, mucosal bursas, and tendons [1-3].Tenosynovial giant cell tumor, first described by Jaffe et al in 1941, is also known as pigmented villonodular synovitis [].There are localized and diffuse forms. For diffuse or widespread tenosynovial giant cell tumors, this is 4 per million. The patient is also made to walk with the help of a walker. Nerve sheath tumors include schwannomas, neurofibromas and others. Giant cell tumors of the tendon sheath are the second most common tumors of the hand, with simple ganglion cysts being the most common. This year I insisted my Dr it really hurt and had to be something. The goal is to restore the body part so that the patient can do his or her normal everyday activities. It often grows near a joint at the end of the bone. In his office he said that I have a bone tumor, whether it is benign or malignant we do not know. Early diagnosis and treatment is best. This is different than an isolated, single giant cell tumor of bone. During the first two days after the surgery, the patient is made to stand with support and is made to do a few exercises. Increase of recovery time c. Skin and nails changes 11. Introduction. I really hope it will NOTE come back. HHS Vulnerability Disclosure, Help I'm so sorry to hear this. The side effects of the drug are minimal. The surgeon removed the tumor. Schwannoma. Just before I start having the knee pain I went through IVF. I went back to him in December and had an Xray and once again it shows that I am not healing. Never ignore professional medical advice in seeking treatment because of something you have read on the site. They are classified as osteoclastic giant cell-rich bone tumors of uncertain behavior 1. These procedures require anesthesia, are often done as a combined approach and involve orthopedic surgeons and radiologists. This can help you decide whether to have a knee operation or can help you make plans for your post-surgical recovery period. It haemorrhaged again 2 days before Christmas 2015. If available to you, you may wish to see an orthopaedic oncologist, who specializes in bone cancer. My surgeon said Ibuprofen, ice and elevate. Your doctor may also use a bone cement mixture to fill the hole. I was very depressed when I found out. Most often, the tumors occur close to the knee joint either in the lower end of the femur or the upper end of the tibia. Diana; Feel free to email me at diana.tynes@hotmail.com, So sorry to all that you guys have a lot of pain physically and mentally.I'm 24 yr from India and I was having the GCT in my left shoulder.I just fell from my bike 2 months back and the pain started at the place of tumour where I could not lift my hand completely.I went to local doctor and had a xray and this tumour was visible in that xray.but neither doctor or radiologist did not recognized it.I was given some pain killers and the pain was reduced.I started driving my bike after having a rest for 2 weeks but I could not lift or carry heavy weight with that hand.I thought it will be cured slowly,however I went to a good doctor as my shoulder was having reduced functionality.He again insisted me for new xray and then said that there is a bone tumour and this should removed by surgery.He was just like a god who recognized and diagnosed correctly.Everything was prepared for surgery this week.hope all goes well.please keep your prayers for me.-premkumar.ap129@gmail.com. Long bones giant cells tumors: treatment by curretage and cavity filling cementation. Chromosomes carry your genetic information. GCTs are often easier to treat when theyre found early. You may also have: TGCT symptoms affect the joint where the growth is. Anemia or abdominal pain may also be present in dogs whose . My orthopedic surgeon told me they will take out the tumor that is in my bone and replace it with bone cement and put a plaque on, hopefully the tumor does not come back :) Hoping for the best, I am sorry to hear about your condition and hope that you are well by now (July 25, 2015). Use of this website and any information contained herein is governed by the Healthgrades User Agreement. What will the use of a 4-cuffs . Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. Some benign bone tumors may need treatment to stop them from destroying bone. Giant cell tumors of bone are relatively common benign bone tumors and typically arise from the metaphysis of long bones, extend into the epiphysis adjacent to the joint surface. I'm so sad and afraid at this moment! Your doctor may order a magnetic resonance imaging (MRI) scan or computerized tomography (CT) scan to better evaluate the tumor and the area surrounding it. He told me go see my orthopedic Dr the next as this could be serious. Tenosynovial giant cell tumor is a group of rare tumors. If you have a condition called hyperparathyroidism, you may be more likely to get multiple GCTs throughout your body. PVNS is more likely to affect an entire joint and cause symptoms such as limited movement, but is generally found in larger joints, whereas tenosynovial giant cell tumors are more commonly found in small joints, such as the hand and fingers. Total Knee Replacement. I hated to have the Xray being pregnant but my OBGYN assured me everything would be ok. In general, open knee surgery recovery time is three months, but it takes six months to a year for full recovery and function of the joint. My name is Theresa I am 30 years old and living in NYC. From what I know Giant Cell Tumors are very rare and even more so in the first metatarsal. There are two primary ways to treat tumors of the hand: observation or surgical intervention. Most benign tumors respond well to surgical removal. Expect to spend about 3 to 6 days in the hospital for open knee surgery. I had pains in my right knee and thought it was just normal pains but dec 2015 I noticed a little swelling on the right leg from the knee down. He had given me anti-inflammatory and said take them for 3 weeks but if I were going to try to become pregnant then not to take them. Ask if your condition can be treated in other ways. The current standard treatment of choice is simple excision. My lil girl is healthy and happy 3 yesr old now xDon't give up xx Lottieboo@hotmail.com if you need support. We dont know why this happens in most cases. In many cases, the likelihood that the tumor will come back is low usually less than 5%. Get useful, helpful and relevant health + wellness information. Even though the tumors are benign, you may need treatment. Diarrhea. They can usually be safely removed, but they have a tendency to recur. My assignment is to complete a power-point about osteoclastoma. It was conventional knowledge that the intra-articular dwell time of proteins in joints is typically a few hours or less. They have a very high rate of recurrence especially if the tumor was as big as mine. Conclusion: Computerised tomography features of giant cell tumour of the knee are associated with local recurrence after extended curettage. sharing sensitive information, make sure youre on a federal My email is mhquinin@gmail.comI hope that everyone is feeling well now. Treatment is almost always surgery. From what i've been told so far, its usually seen in the lower half of your body and usually starts from the outside of the bone in, however mine starts from the inside working its way out and is right next to my spinal cord. A schwannoma is a type of nerve tumor of the nerve sheath. Coming to a Cleveland Clinic location?Hillcrest Cancer Center check-in changesCole Eye entrance closingVisitation, mask requirements and COVID-19 information, Notice of Intelligent Business Solutions data eventLearn more. Most occur in the long bones of the legs and arms. 14 male and 24 female patients were included in this study (mean age 28 years, range 13-56 years). It usually develops near a joint at the end of the bone. Giant cell tumor of bone is a rare, aggressive non-cancerous tumor. Benign bone tumors are most common in people who are under 30 years old. X-rays may show the shadow of the mass, and in 10-20% of the cases, may demonstrate bone erosion. Cleveland Clinic is a non-profit academic medical center. Most occur in the long bones of the legs and arms. The extension of the radiolucent zone after bone cement filling is a reliable indicator for a possible local recurrence. Doctor said I need a major knee replacement which I can't afford right now so I'm using a cane now to support my movement without bending the knee.It's been a very horrible experience. J Bone Joint Surg Br. Finally I took the decision to see a Dr. Your doctor will perform a thorough physical examination and use X-rays and other tests to diagnose a giant cell tumor. You likely will walk with a walker for the first week or two, followed by crutches until you can walk unaided or with a cane, which usually occurs within 2 to 3 weeks. Usually, this affects your smaller joints, like those in your hands and feet., Pigmented villonodular synovitis (PVNS). After curettage, the cavity is filled with a bone graft to help stabilize the bone. There is a lot of uncertainty around the data available for GCT as it is a rare disease. Seventeen patients were filled with cancellous bone or curettage alone. We are leaving for our third trip to TX tomorrow. Or to anyone reading I want to know how recovery went and how the Knee is functioning. The giant cell tumor of the tendon sheath (GCTTS) is a benign lesion which arises from the synovium of a joint, bursa or tendon sheath, with 85% of the tumors occurring in the fingers and 12% of the tumors located in large joints such as the knee and ankle. So she said I will be able to have an MRI and the results came back that I had a lesion 2.5 cm above my tibia and below the kneecap. Diagnostic tests, including radiology scans, help diagnose a giant cell tumor. Other treatments can be used for certain types of bone tumors. OMM and acupuncture helped with the pain and when I fell I figured I tore my meniscus. In January I went to the national orthopedic hospital here in lagos Nigeria where I live and the doctor said its trauma to the ligaments and gave some medication, 5 days later I fell and fractured my femur which the X-ray diagnosed.I went for surgery and it was discovered I had giant cell tumor. I walk again, I never had bladder/bowel problems, all my recent MRI have been clear. After treatment, youll have regular follow-up appointments with your healthcare provider. Her work has appeared in the AARP Bulletin, Chicago Tribune, U.S. News, CNN.com, the APAs Monitor on Psychology, and many others. I would also like to share my experience with someone. These tumors usually arise from joints or tendon sheaths and are yellow-brown in color. Mine have been in the thoracic spine. Tumor embolization. This was only diagnosed because of on and off pain in my knee where my acupuncturist insisted I see a Physiologist who thought was it was a torn meniscus and asked for the MRI.I am someone who never sees a doctor, only acupuncturists, chiropractors and naturopathic doctorswell I am humbled. Know why a test or procedure is recommended and what the results could mean. Theresa: My 19 year old son, Blake, also has a giant cell tumor of his sacrum. Curettage and bone grafting have a high recurrence, whereas wide resection has a reduced recurrence rate with the compromise of limb function. Introduction. The doctor said I probably won't be able to put weight on the leg until March but until then I am allowed to start actively bending my knee. Pigmented villonodular synovitis (PVNS), which is now known as tenosynovial giant cell tumor (TGCT), is a condition in which the synovium swells. 2022 Dec 22;38:100467. doi: 10.1016/j.jbo.2022.100467. In a sense the damn disease has forced me to live life to the fullest. It is given at UPenn and has had a good success rate. This tumor was once thought to be a cancer of a tendon sheath. I have an appt on the 19th nd from experience I'm certain my tumor has come back. Which was quite shocking for me. They block the CSF-1 receptors and are undergoing clinical trials.. Patients with giant cell tumor of bone near the knee joint can be treated satisfactorily with intralesional resection and bone cement packing. They often start in your bones or in the lining of your joints. Unauthorized use of these marks is strictly prohibited. I took 3 injections one every week then one injection every month for 6 months. Federal government websites often end in .gov or .mil. Epub 2021 Jan 22. I went into surgery on Jan 5 2016. In curettage, special instruments are used to scrape the tumor out of the bone. Vomiting. The surgeon inserts special surgical instruments through a second small incision to make the necessary repairs. Magnetic resonance imaging is the diagnostic tool of choice for both diagnosis and treatment planning. 2009 Oct;95(6):402-6. doi: 10.1016/j.otsr.2009.07.004. Giant cell tendon sheath tumors present as a solid lump on the palmar surface of a finger, and can make it difficult to fully flex the affected digit. I have to say this blog was helpful, I don't know anyone who has been through anything like this and it is nice to know I am not alone. Tenosynovial giant cell tumors tend to affect those between the ages of 25 and 40 years. In rare cases, it can spread to muscles and to the lymphatic system. I had terrible sciatica to my right leg, got worse during pregnancy and even more painful when I exercised. Would you like email updates of new search results? The medication works by targeting a special receptor on the giant cells. Have others been told this too? I too will have to be monitored for recurrence. This whole process has been so much worse then I have ever expected. We live in VA. My e-mail address is kristenhardison@yahoo.com We are about to begin fundraisers/awareness here in the next month or so for him. Chromosomes are the central part of your cell that contains DNA. Clipboard, Search History, and several other advanced features are temporarily unavailable. The diagnosis of a giant cell tumor is generally made by a pathologist following removal of the mass. Usually, additional chemicals, such as liquid nitrogen, hydrogen peroxide, or phenol, are placed inside the bone cavity to try to reduce the risk of recurrence. Treating benign bone tumors using surgery calls for removing the tumor as well as promoting the growth of new healthy bone at the site of the tumor. its very hard for me to accept so much realities in small period of time. Diffuse pigmented villonodular synovitis is characterized by synovial inflammation and hemosiderin deposition. Surgical treatment may include: Curettage. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. When you have a migraine, you'd try anything to feel better. Bring someone with you to help you ask questions and remember what your healthcare provider tells you. My daughter was just told she had GCT and we are going to see a surgeon on Monday. Imaging following surgery for primary appendicular bone tumours. Fu Z, Liu X. I am in a very similar situation and would like to share experience with you. Depression. Shes a member of the American Society of Journalists and Authors and the Association of Health Care Journalists. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. Table 3 . Most occur in the long bones of the legs and arms. This blog is just to keep family and friends up to date with my journey to get rid of this Giant Cell Tumor. Most tumors that start in your bones are benign (not cancer). A bone tumor specialist will likely order a bone scan, CT scan, MRI scan or biopsy. This pain usually increases with activity and decreases with rest. These tumors often affect younger people. The X-ray revealed 2 fractures on my distal femur and large lesion. Appointments & Access Contact Us Tenosynovial giant cell tumor encompasses a group of lesions most often arising from the synovium of joints, bursae and tendon sheaths and showing synovial differentiation Menu Chapters By Subspecialty Autopsy & forensics Bone, joints & soft tissue Bone & joints Soft tissue Breast Clinical pathology Chemistry, toxicology & UA Coagulation so i got operated 2 weeks back. This information is provided as an educational service and is not intended to serve as medical advice. Giant cell bone tumor. My surgery was scheduled for about 2 weeks after. Benign bone tumors rarely become cancerous (far less than a 1% chance). If youre concerned about a lump or swelling on a bone, first make an appointment with your healthcare provider. However, rare (but possible) risks include nerve injury, infection, bleeding, stiffness and an inability to return to a high level of sport. Retrieved from. Disclaimer. They will start with a complete physical examination and are likely to order tests, such as: Its rare that your provider will order blood or urine tests to diagnose a benign blood tumor. Sobti A, Agrawal P, Agarwala S, Agarwal M. To those who have been through something similar, how long did it take for you to regain range of motion in you knee (I am currently around 50 degrees during active range of motion)? Kelly :). O surgi In rare cases, a patient can have multiple giant cell tumors in different bones, a condition called multi-centric giant cell tumor of bone. The combination of these techniques allows people with benign bone tumors, especially young people, to be able to return to full and unlimited activities after treatment. Although GCTs arent cancer, they can damage your bones and tissues. American Association of Hip and Knee Surgeons. All material on this website is protected by copyright. Most often, embolization is performed prior to surgery, but it may also be used on its own in cases where surgery cannot be performed. While these types of tumors are not cancerous, they can be extremely painful and decrease hand function. I had an xray about 2 years ago and my physician said it was nothing. so i got operated 2 weeks back. Large TGCTs may cause your cartilage to wear away. Thanks for sharing I don't feel alone anymore. A biopsy may be needed to confirm the diagnosis of a giant cell tumor. I was diagnosed with a Giant Cell Tumor of the first metatarsal. One treatment for osteoid osteoma may include radiofrequency ablation or thermal necrosis. The plate can be removed in 2 years time.The range youve got is excellent. X-rays and magnetic resonance imaging (MRI) can help to diagnose these tumors., Your doctor may also take a sample of your synovial fluid. Singh J, Bahadur R, Garg S, Rajpal K, Chopra K. Int J Surg Case Rep. 2020;72:45-51. doi: 10.1016/j.ijscr.2020.05.033. But luckily the tumor is benign. If you have a tenosynovial giant cell tumor, this fluid may have blood in it., In some cases, a biopsy may be needed to confirm the diagnosis. Thank you for sharing your information! I too suffer from recurring Giant Cell Tumors. It can also damage the bone and cartilage that surrounds your affected joint. My surgery was scheduled for about 2 weeks after. Most often, they appear at the lower end of the femur (thighbone) or upper end of the tibia (shinbone), close to the knee joint. If a tumor has recurred or caused excessive bone or tissue damage, more complex surgical removal and reconstruction may be necessary. Who is your Ortho-Oncologist? Wishing you luck and a speedy recovery. Epub 2021 Nov 16. Your hospital stay may be 1 to 2 days, and you may be able to return to work and normal activities within a couple of weeks. The site is secure. There is no single treatment for benign bone tumors. A giant cell tumor (GCT) is a noncancerous growth. FOIA Hietaniemi K, Trovik C, Walloe A, Bauer HCF, et al. Giant Cell Tumour (GCT) of the distal fibula is extremely rare and poses challenges in the surgical management. I have a 20month old little boy and am desperate for another child in a year or two. i am 33 yr old and was planning to get pregnant. my surgeon told me i can plan a kid , but i took opinon of few more surgeons and they told me to wait.i am very depressed , how all of sudden this happened. National Library of Medicine i had small pain in my left leg from 2 months but as i thought that before getting pregnant i should have a norma x-ray. Still, estimates are available for several common knee procedures that can give you a general guideline to go by. How long is the recovery period after surgery. Orthopedic surgeons often perform these surgeries due to osteoarthritis, which worsens with age and can cause pain, stiffness and disability. The GCTTS is usually monoarticular, slowly proliferative and rarely locally aggressive. The surgeon caring for these tumors should try to remove the tumor with the least amount of trauma to surrounding normal bone tissue. I am absolutely petrified due to how close it is to my spinal cord and the risk of being paralysed from the neck down, should it go wrong! This study aimed to determine the level of awareness on the early diagnosis and management of Alzheimer's disease among primary care physicians and interns in Denizli, Turkey. My name is Beth, 30 year old mum of 1 living in the U.K.I was diagnosed with GCT to my sacrum Jan 2016 and had surgery April 2016. My surgery was done August 10 2007, today is January 30 2008 and I am still not healed. This type of surgery uses a smaller incision than with traditional open surgery, plus special instruments allowing your surgeon to approach the joint from the side, with minimal trauma to tissue, muscles and tendons, particularly the quadriceps tendon attached to the knee. Giant cell tumors are the second most common hand tumor. Hear from real doctors who treat orthopedic conditions and perform surgery. The physio didn't help at all, in fact the pain just got worse. Most giant cell tumors occur in patients between 20 and 40 years of age. Policy. I desperately want to finish nursing school, I want to be there to take my daughter to school, I miss doing things for myself! God bless! All rights reserved. Giant cell tumors are rarely life-threatening. Reproduced from Biermann S (ed): Orthopaedic Knowledge Update 3, Musculoskeletal Tumors. Do you mind if I use your story and pictures? The tumors can be removed by open surgery or arthroscopic surgery, which is a less invasive procedure. While most bone tumors occur in the flared area near the ends of the body's long bones (metaphysis), giant cell tumors occur almost exclusively in the end portion of the long bones (epiphysis), directly next to the joints. Last reviewed by a Cleveland Clinic medical professional on 07/12/2021. Advertising on our site helps support our mission. :'(. Please e-mail when you have the time! Even after treatment, about 8% to 20% of people with localized tenosynovial giant cell tumors may get it again. I got home and found out we were expecting a second child. She gave steroids, anti-inflammatory, a muscle relaxers, and ordered a month of physical therapy. Occasionally, the bone weakened by the tumor breaks and causes the sudden onset of severe pain. Giant cell tumors of bone are not inherited. I was told by my surgeon not to get pregnant within 2 years of having surgery. Giant cell tumor, which represents approximately 20% of benign bone tumors, is the most aggressive benign bone tumor (Fig. Follow-up with your healthcare provider may be required for several years. Some possible symptoms include the following: Diffuse-type tenosynovial giant cell tumor (pigmented villonodular synovitis) can cause degeneration of your joints. It causes excessive growth of the joint lining that leads to pain,. Thank you in advance and best wishes to all xxx, Hi I'm glad I stumbled on this page. I'll pray for you guys too. Some benign bone tumors, like giant cell tumors of bone, have a higher rate of return, but there are good methods to treat these tumors if they do come back. He gave me a bone stimulator which I use every night for 40 minutes. I wonfer if those crazy hormones have to do something with this Giant Cell Tumor???? I wasn't surprised because I had been experiencing knee pain for about 6 months that I attributed to my hips being unalligned. Lorna Collier has been reporting on health topicsespecially mental health and womens healthas well as technology and education for more than 25 years. Results: By the end of March my foot was excruciating. Also, we were never told it could be lift threatening. I have a wonderful husband a 2 1/2 year old daughter and I am 10 weeks pregnant. So I just ignored the pain thinking maybe I was exaggerating exactly how bad it was. The location of a giant cell tumor is often in the knee, but can also involve the bones of the arms and the legs. In rare cases, a giant cell tumor may spread to the lungs. However, arthroscopy may not be useful in treating some knee conditions, such as osteoarthritis. In the group with bone cement filling after curettage, the recurrence rate was 23.8%, whereas a recurrence rate of 52.9% was detected in the group with cancellous bone filling or curettage alone. and transmitted securely. Well, they got approval for this drug and two years later the tumor was small enough to remove and here I am. I awoke in recovery and was totally out of it. Experts estimate that each year about: Giant cell tumors usually occur for no known reason. At first I wasn't really worried, but now as I'm reading all of these stories I'm becoming more and more stressed about this. This will help your doctor differentiate between pigmented villonodular synovitis and giant cell tumor of the tendon sheath.. But they can damage your bones and tissues. Cells with the CSF-1 receptor are called macrophages, a type of white blood cell. I went to go see my primary Dr and he ordered X-ray's and referred me to an orthopedic Dr. By the time I went to see her I was unable to walk and keep my balance and had to use a cane. The patient may also have pain with movement of the nearby joint. During this test, a very small amount of radioactive dye is injected into the body intravenously. When viewed microscopically, the tumors consist of many unusually large or "giant" cells. It is slightly more common in women. Theresa, I really hope that your tumor has not returned. Some types of tumors are most common in specific locations, such as the spine or near the growth plates in your hip, knee or shoulder. This is my first ever blog so please forgive me I am just learning how to use this. The short-term recovery time after a knee replacement surgery spans somewhere between 6 to 12 weeks. 133-146. from the American Academy of Orthopaedic Surgeons, Shoulder (upper end of the upper arm bone), Lower back (connection of the spine and pelvis). Giant cell tumor of bone is a rare, fast-growing noncancer tumor. Its nice to hear that you were able to have another baby, but at the same time worrysome that you think your tumor has returned! J Bone Joint Surg Am. Bethesda, MD 20894, Web Policies Giant cell tumors usually occur in young adults, and are slightly more common in females. They can also occur deep inside the foot. government site. OMG I have never heard of anyone else have it in the foot like me. They mostly occur in the long bones found in the arms and legs. The big problem now was that I was pregnant. The ideal therapy needs to kill the solid tumor cells, inhibit or kill the giant cell-like osteoclasts, inhibit blood vessel growth called angiogenesis (VEGF activity), inhibit the destructive enzymes (MMPs) that destroy bone, and trigger the body to heal the weakened bone by stimulating the growth of healthy bone building cells called osteoblasts. Chassaignac first described these benign soft-tissue masses in 1852, and he overstated their biologic potential in referring to them as cancers of the tendon sheath. Please email me xhelyr@yahoo.com. Giant cell tumors represent approximately 5% to 7% of all bone tumors. A giant cell tumor of bone is a type of benign (noncancerous) tumor that has a wide range of behaviors. Giant cell tumor of tendon sheath is also named tenosynovial giant cell tumor. I can still feel the pain when im trying to lift it. I'm hopeful and pray that this thing does not return. Learn about Tenosynovial Giant Cell Tumor, including symptoms, causes, and treatments. He is a great kid and we are so sorry to hear that you also have this..Blake said he would not wish this on anyone! Hope this helps xx. Clinical history of the mass may give the surgeon an idea of what they might expect when removing the mass. GCTs of the bone are slightly more common in women. It's very important for radiologist to be familiar with this tumor. Careers. 10 Things to Know About Psoriatic Arthritis. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS).