Higher local recurrence rates after intralesional surgery for giant cell tumor of the proximal femur compared to other sites

Purpose

The treatment of giant cell tumor (GCT) of bone remains controversial. Intralesional surgery (curettage) results in a higher rate of local recurrence, but better functional results compared to resection. The aim of this study was to assess whether the use of curettage was successful in the treatment of GCT of long bones. We evaluated the influence of adjuvant treatment, local tumor presentation, and demographic factors on the risk of recurrence.

Methods

We retrospectively reviewed the records of patients treated for GCT of long bones between 1990 and 2013, using curettage. No patient had any treatment other than surgery. After detailed curettage, the bone cavity was filled with bone allografts and/or cement. Recurrence rates, risk factors for recurrence and the development of pulmonary metastases were determined. The minimum follow-up was 24 months.

Results

We enrolled 210 patients with GCT of long bones treated by curettage. The rate of local recurrence was 16.2% (34/210 patients). The median follow-up was 89.2 months. In the multivariate analysis, no significant statistical effect on the local recurrence rate could be identified for gender, patient’s age, Campanacci’s grading, or cement versus bone allografts. The only independent risk factor related to the local recurrence was the site, with a statistically significant higher risk for patients with GCT of the proximal femur.

Conclusions

Our observation on the correlation of tumor location and risk of local recurrence is new. We suggest that patients with GCT of bone in the proximal femur should be followed closely soon after surgery to identify any possible recurrence.

     

Factors Affecting Prognosis of Patients with Giant Cell Tumors of the Mobile Spine: Retrospective Analysis of 102 Patients in a Single Center

Background

Giant cell tumor (GCT) of the mobile spine is a benign tumor, but it can be potentially aggressive. There is not much published information on GCT of the mobile spine as a result of rarity of the disease, and there are controversies over prognostic factors of the condition.

Methods

A retrospective analysis of GCT of the mobile spine was performed by survival analysis. Recurrence-free survival (RFS) was defined as the interval between the date of surgery and the date of recurrence. The postoperative RFS rate was estimated by the Kaplan–Meier method. Factors with P values of ≤0.1 were subjected to multivariate analysis for RFS by proportional hazard analysis. P values of ≤0.5 were considered statistically significant.

Results

A total of 102 patients with GCT of the mobile spine were included in the study. The mean follow-up period was 39.9 (median 26.0, range 2–153) months. Thirty-eight patients developed recurrence. The univariate and multivariate analysis suggested that age less than 40 years, total spondylectomy either by en bloc or piecemeal method, and administration of bisphosphonate were independent favorable prognostic factors. Subgroup analysis by excluding patients before the year 2000 further confirmed our findings.

Conclusions

The removal of the entire osseous compartment either by en bloc or piecemeal method in combination with the long-term use of bisphosphonate could significantly reduce the recurrence rate of GCT of the mobile spine. Age less than 40 years is a favorable prognostic factor for GCT in the mobile spine.     

Giant cell tumor: Curettage and bone grafting

Background:

Curettage and wide resection are accepted methods of treatment of giant cell tumor (GCT) of bone. The success rate with curettage in different reports varies widely. There is a paucity in the literature regarding selection of cases for curettage. Present study is an analysis of outcome of 34 cases treated by curettage and bone grafting.

Materials and Methods:

Thirty-four cases of GCT of bone, 28 fresh and six with recurrence were treated by curettage and bone grafting. All cases of Campanancci grade 1, 2 and grade 3 which on computerized tomography scan showed break in the cortex confined to one surface and cortical break less than one third of circumference were treated by curettage and bone grafting.

Results:

4 (14%) of these lesions treated primarily by us showed recurrence after one and half year.

Conclusion:

Curettage and bone grafting is a reliable method in the treatment of GCT, provided guidelines regarding selection of cases and principles of tumor surgery are strictly adhered to.     

Giant cell tumor of bone. An evaluation of 87 patients

AIM: Giant cell tumor (GCT) of bone is a very peculiar and interesting tumor due to of its biological behavior and the phenomenon of pulmonary metastases of a histologically benign tumor. We present the results of a retrospective study. METHODS: Between 1965 and 2002 we treated 87 patients, 54 women and 33 men, for a GCT of bone. The average age of the patients was 28.2 (range 8-72) years. The median follow-up time was 91 months. 63 patients (72.4%) were hospitalized with a primary tumor. Twelve of these patients (19 %) had a pathological fracture. 24 patients (27.6%) presented with local recurrence. 7 tumors were malignant GCT of bone, 80 tumors were benign. According to the classification of Campanacci, 9 patients (10.3%) were diagnosed in stage I, 42 (48.3%) in stage II, and 36 (41.4%) in stage III. Surgical procedures were intralesional curettage and packing with cement in 36 patients, and bone-grafting in 7. In 35 cases we performed a wide resection, and in nine an amputation. RESULTS: Local recurrence was observed in 11 patients (12.6%), all of them were benign GCT. Local recurrences were followed by an intralesional curettage and bone-grafting in three cases (42.8%), packing with cement in seven (19.4%). Three patients with local recurrence (27.3%) also had synchronous pulmonary metastases. All patients diagnosed with benign GCT are still alive. 3 out of 7 patients with malignant GCT died from progression of metastatic disease. CONCLUSION: To reduce the risk of local recurrence and pulmonary metastases, we recommend an adjuvant therapy of GCT.     

Giant cell tumors of the distal radius: resection: reconstruction by long avascular fibular graft (a case report)

Giant cell tumors (GCT) are locally aggressive tumors with a preference for epiphyses and metaphyses of long bones. They represent 5%-10% of all primary bone tumors. They affect mostly young adults between 20 and 40. Their origin remains uncertain. GCT is a purely lytic tumor, recurrent and can even lead to fracture. The distal radius is the third location after the distal femur and proximal tibia. Tumors are benign on histopathology, but "benign" lung metastases can sometimes be seen. Their treatment remains controversial because of the high rate of recurrence; oncological resection of the diseased bone segment with reconstruction reduces the rate of recurrence. Several techniques of resection and reconstruction of the wrist have been proposed. We report a case of giant cell tumor of the distal radius treated by resection and reconstruction by avascular fibular graft to a length of 12cm, and we evaluate the use of this reconstruction to salvage the wrist with this pathology.     

Bisphosphonates reduce local recurrence in extremity giant cell tumor of bone: a case-control study

BACKGROUND: Giant cell tumor (GCT) of bone is a benign but locally aggressive tumor that is characterized by the presence of mononuclear stromal cells and multinucleated giant cells. Although topical adjuvants have been used in the past, local recurrence following intralesional excision of GCT of bone continues to remain a problem. The use of bisphosphonates as an anti-osteoclastic agent in the management of osteolytic bone metastases is well accepted. Furthermore in vitro studies have shown that bisphosphonates also induce apoptosis in GCT stromal cells. Therefore our clinical study aims to investigate whether the administration of bisphosphonate as an adjuvant can further decrease local recurrence following the surgical treatment of GCT of bone. METHOD: A retrospective case-control study was performed between 1988 and 2004. Forty-four patients with histological diagnosed appendicular GCT were included. Intralesional curettage or wide excision of the lesions was followed with cementation or biological reconstruction. Additional intravenous and oral bisphosphonates were given peri-operatively to 24 patients who were treated between 1998 and 2004. The average follow-up of the control group was 115 months while that of the treatment group was 48 months. RESULTS: In the bisphosphonate treated group, 1 of 24 patients (4.2%) developed local recurrence. In the control group, 6 of 20 patients (30%) developed local recurrence. The difference in the recurrence rate was statistically significant between the bisphosphonate treatment group and the control group (Log Rank test p=0.056). The effect of reduction of local recurrence was significant in patients with stage III diseases. Patients treated with bisphosphonate did not report any untoward effects. CONCLUSION: Clinical use of bisphosphonates as an adjuvant therapy for giant cell tumor of bone demonstrated a lower local recurrence rate. The clinical response seems to be more promising in stage III diseases.     

Metachronous multicentric giant cell tumour of the upper extremity in a skeletally immature girl : A rare presentation

Giant Cell tumour (GCT) or Osteoclastoma is a benign locally aggressive tumour with a tendency for local recurrence. Long tubular bones (75-90%) are frequent sites of involvement. GCT constitutes 5% of all primary bone tumours. Metachronous multicentric giant cell tumour of bone is a rare entity. Multicentric GCT, in contrast to unifocal GCT, has a tendency to involve the small bones of hands and feet, involving the metaphysis/diaphysis of long bones and tends to occur in a slightly younger population. We report a young girl presenting with metachronous multicentric recurrent benign GCT, with the lesions involving the ipsilateral right hand and distal humerus. She was successfully treated with an aggressive surgical approach (en-bloc resection).     

The dilemma of denosumab: Salvage of a femoral head giant cell tumour

INTRODUCTION

Denosumab is a monoclonal RANKL antibody which has been shown to be highly effective in treating giant cell tumour (GCT) of bone. We report on its use as a neo-adjuvant agent to avoid morbid surgery for an adolescent.

PRESENTATION OF CASE

We report a case of a15-year old female with a Campanacci 3 GCT involving the femoral head and neck.

DISCUSSION

To preserve bone stock and avoid an outright hip replacement, the patient was given denosumab pre-operatively to consolidate the tumour. After receiving 6 months of treatment, a rim of cortical bone had developed to allow an extended curettage of the tumour to be performed without fear of collapse of the articular surface.

CONCLUSION

This is the first reported case of the use of denosumab in GCT of the femoral head and neck. We describe our experience in the neo-adjuvant use of denosumab and offer suggestions for future use. Further studies will be needed to see if denosumab has a role in conventional GCT and whether it can lead to a lowering of local recurrence rates.     

CD147、PCNA、VEGF和MMPs在骨巨细胞瘤中的表达及临床意义

背景：骨巨细胞瘤（giant cell tumor of bone,GCT）是一种具有低度恶性潜能的肿瘤,目前的主要治疗方法为临床手术治疗,局部侵袭性生长和术后复发率40％-50％,其病理学分级与影像学分型均不能对临床表现进行精确的预测,找到其他影响GCT生物学行为和预后的相关因素并寻找新的治疗途径尤为重要。目的：研究CD147、PCNA、VEGF、MMPs等分子在GCT组织中的表达,探讨其相互关系及与临床病理和预后的关系。方法：运用免疫组织化学S-P法,检测CD147、PCNA、VEGF、MMPs等分子在68例GCT患者中的表达,分析其相互关系以及与肿瘤临床病理资料、Jaffe分级及复发的关系。结果：CD147、MMP-2、MMP-9、VEGF阳性表达与患者年龄、性别等因素无关;CD147、MMP-2阳性表达在Jaffe各级之间有显著性差异（P〈0．05）,CD147、MMP-2、MMP-9在预后各分组间表达有显著性差异（P〈0．05）;CD147与MMP-9、VEGF、MVD、PCNA表达呈正相关（r=0．271,P=0．025;r=0．411,P=0．000;r=0．872,P=0．000;r=0．394,P=0．001）。结论：CD147与GCT的恶变、复发有关,并且和MMP-9、VEGF、MVD、PCNA的表达密切相关,可作为评价GCT恶性程度和判断预后的重要指标,并可作为化学治疗的新靶点。     

病灶切刮骨水泥填充治疗肢体骨巨细胞瘤125例

目的 探讨病灶切刮骨水泥填充治疗肢体骨巨细胞瘤（ＧＣＴ）的临床应用价值,方法 对１９８０年３月～１９９７年１２月１２５例ＧＣＴ的治疗情况进行回顾分析。患者男６２例,女６３例,年龄１２－７１岁,平均年龄３１．５岁,其中原发ＧＣＴ１０１例,复发ＧＣＴ２４例。发病部位在膝关节周围者１００例（占８０％）。结果 １２５例患者均获随访,随访时间１３－１９４个月,平均９６个月。原发ＧＣＴＦ得,１３例复发,复发率     

骨盆骨巨细胞瘤临床治疗的系统文献综述

 目的 分析骨盆骨巨细胞瘤（giant cell tumor, GCT）的好发年龄、发病部位、不同治疗方式的复发率及并发症。方法 在医学常用外文数据库检索“giant cell tumor,pelvis”,在医学常用中文数据库检索“骨巨细胞瘤,骨盆”,时间选取1949至2012年,所有被检索的文献及参考文献均被用于分析,经文题、摘要、全文内容二次筛选,共筛选出38篇文献,将所涉及的骨盆GCT患者作为研究对象,删除重复报告的病例;收集每例入选患者的发病年龄、发病部位、手术方式、随访时间、并发症、复发率及死亡率等。采用系统分析的方法对数据进行分项研究。结果 筛选出的38篇文献中共165例骨盆GCT患者纳入研究进行系统分析,发病年龄14~73岁,平均33.2岁,高发年龄21~40岁;男、女比例为1∶1.7。发病部位：髂骨区（A区）48例,髋臼区（B区）60例,耻、坐骨区（C区）31例。随访时间1.5~35年,平均9.5年。27例（32.5%,27/83）患者出现治疗并发症,以病灶外整块切除方式进行治疗的患者（13/28）发生率最高;常见并发症为切口内感染、切口延迟愈合。9例（45.0%,9/20）接受单纯病灶放疗的患者术后复发,24例（33.3%,24/72）接受病灶内手术的患者术后复发,5例（35.7%,5/14）接受病灶内手术联合放疗或冷疗的患者术后复发,1例（2.0%,1/51）接受病灶外手术的患者术后复发,总复发率为24.6%（39/158）,死亡率为3.2%（5/158）。结论 骨盆GCT临床少见,常累及髋臼区（B区）,高发年龄为21~40岁,病灶外整块切除术后并发症最为常见,但术后复发率最低,骨盆GCT总体复发率较高,死亡率较低。     

Giant cell tumor of the sternum.

A primary giant cell tumor (GCT) originating from the sternum is extremely rare. We report a case of a GCT originating from the sternum in a 45-year-old man who was referred to us for a mass in the anterior chest wall that had been growing slowly. Computed tomography revealed a soft tissue mass involving a large osteolytic and destructive lesion of the sternum body. Subtotal sternectomy and reconstruction with methylmethacrylate were performed. The tumor was 8.5 x 4.5 x 2.5cm, and the histopathological examination confirmed GCT. Radical wide resection of primary sternum tumors and reconstruction with an appropriately rigid prosthetic material are necessary to minimize local recurrence.     

Malignant giant-cell tumor of the parietal bone: case report and review of the literature

OBJECTIVE AND IMPORTANCE: Giant-cell tumors (GCTs) are primary bone tumors that involve long bones in 75 to 90% of patients. They seldom develop in the cranium and are very rare in patients older than 60 years of age. A GCT rarely occurs with Paget's disease; when it does, however, it is most commonly associated with the polyostotic form and tends to involve the craniofacial bones. Pagetic GCTs are less aggressive than GCTs that are not associated with Paget's disease. CLINICAL PRESENTATION: We report the case of an 81-year-old woman with a painless left parietal mass and asymptomatic monostotic parietal Paget's disease. INTERVENTION: Surgical resection was performed, and histological examination of the lesion demonstrated Paget's disease with a malignant GCT. An incidental, low-grade, small-cell lymphocytic lymphoma also was noted. The patient experienced local recurrence of the malignant GCT and eventually died after developing pulmonary metastases of the malignant GCT. CONCLUSION: This case is the first reported example of a patient with a malignant GCT of the cranium associated with monostotic Paget's disease. It provides evidence that not all pagetic GCTs in the cranium are benign, as has been reported.     

Giant cell tumor of the sternum

A primary giant cell tumor (GCT) originating from the sternum is extremely rare. We report a case of a GCT originating from the sternum in a 45-year-old man who was referred to us for a mass in the anterior chest wall that had been growing slowly. Computed tomography revealed a soft tissue mass involving a large osteolytic and destructive lesion of the sternum body. Subtotal sternectomy and reconstruction with methylmethacrylate were performed. The tumor was 8.5 × 4.5 × 2.5?cm, and the histopathological examination confirmed GCT. Radical wide resection of primary sternum tumors and reconstruction with an appropriately rigid prosthetic material are necessary to minimize local recurrence.     

Metastatic behaviour of giant cell tumour of the spine

Lung metastases from giant cell tumours (GCT) of the spine have not been specifically addressed in the literature. We reviewed our cases and compared the incidence, treatment, and outcomes with those from the extremities. Between 1970 and 2006, we identified seven cases (three females and four males) of lung metastases from a total of 51 cases of GCT of the spine (13.7%). Four of the seven patients had presented to our institution with a spine recurrence after previous treatments and the rest developed recurrences later. The treatments for the lung nodules consisted of metastectomy in two and chemotherapy in six patients. At the latest follow-up (ranging from 18 to 126 months), two had died of the disease, two had no evidence of the disease, and three were alive with disease. Our series shows a higher metastatic rate from spine GCT as compared to those from the extremities, but the overall behaviour and treatment outcomes of the lung metastases are similar. When there is a recurrence of GCT, with or without metastases, the local and possibly the metastases should be biopsied to confirm the original diagnosis. Progression of benign GCT into an aggressive sarcoma has been documented, and the method of management should be altered.     

The Influence of Adjuvants on Local Recurrence Rate in Giant Cell Tumour of the Bone

Introduction: Intralesional surgery of giant cell tumour of the bone (GCT) may result in a high rate of local recurrence. The introduction of local adjuvants, such as cementation, cryosurgery or phenolization, has proved to be successful in the reduction of recurrence rates. This study presents the results of a single institution in surgery of GCT with an evolution in treatment strategies.

Material & Methods: Forty primary and 25 recurrent surgical procedures in 46 patients with GCT of the bone with a median follow-up of 72 months were reviewed retrospectively. The mean age was 32.6 years (range 13.6–57.9 years). Forty-seven curettages and 18 resections were performed. For the curettages, a large bone window was cut followed by high speed burring and bone grafting or cementation. In 34 of 47 curettages and 7 of 18 resections, phenol was additionally applied.

Results: Two patients showed pulmonary metastasis, one died due to metastatic disease. In total, a third of the patients developed local recurrence (32.3%). This was evenly spread among primary and recurrent diesease (32.5% vs. 32%). Seven of 13 curettages without adjuvant recurred (53.9%), compared to 11 of 34 curettages with adjuvant phenol (32.4%). Three of 18 resections developed a recurrence (16.7%). No complications in respect to the use of phenol were seen. Discussion: Phenolization is a safe local adjuvant therapy for GCT. Although the recurrence rate was lower with the use of phenol, this drop was not significant. The comparable high recurrence rate in our study, even if phenol was used, might be due to the fact that curettage was our favoured treatment, even in cases with an extensive juxta-articular tumour. We recommend adjuvant phenolization in the treatment of GCT of the bone after thorough curettage in applicable cases, including where cementation is used for defect filling.     

Serum total acid phosphatase for monitoring the clinical course of giant cell tumors of bone--26 patients with 5 local recurrences

Background Giant cell tumor of bone (GCT) is a bone-destroying tumor that sometimes recurs locally after treatment. A recent study showed increased levels of serum total acid phosphatase (TACP).

Methods We assessed TACP in the serum of 26 patients with primary GCT, and in 5 of them who developed a local recurrence.

Results We found a correlation between TACP level in serum and tumor size. TACP levels that were elevated preoperatively in patients with GCT became normalized after surgery, but increased in 3 of the 5 patients with local recurrence.

Interpretation TACP could be used as a tumor marker for monitoring response to treatment of GCT.     

Serum total acid phosphatase for monitoring the clinical course of giant cell tumors of bone—26 patients with 5 local recurrences

Background?Giant cell tumor of bone (GCT) is a bone-destroying tumor that sometimes recurs locally after treatment. A recent study showed increased levels of serum total acid phosphatase (TACP).

Methods?We assessed TACP in the serum of 26 patients with primary GCT, and in 5 of them who developed a local recurrence.

Results?We found a correlation between TACP level in serum and tumor size. TACP levels that were elevated preoperatively in patients with GCT became normalized after surgery, but increased in 3 of the 5 patients with local recurrence.

Interpretation?TACP could be used as a tumor marker for monitoring response to treatment of GCT.     

Hernia mesh prevent dislocation after wide excision and reconstruction of giant cell tumor distal radius

Giant cell tumor(GCT) remains as major health problem. GCT which located at the lower end of the radius tends to be more aggressive. Wide excision and reconstruction of the wrist in stage 3 of distal radius GCT lesion is an optimal modality to prevent tumor recurrence. However, dislocation often occurs as its complication. We are reporting patient with GCT of distal radius treated with wide excision and reconstruction using nonvascularized fibular graft and the addition of hernia mesh. Circumferential non-absorbable polypropylene hernia mesh was applied, covered radioulnar joint and volar aspect of radius, and served as additional support to prevent dislocation. During five years and two months of follow-up, we found no dislocation in our patient. Furthermore, good functional outcome was obtained. Our finding suggests that the addition of hernia mesh after wide excision and reconstruction with nonvascularized fibular graft may benefit to prevent dislocation and provides an excellent functional outcome.