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A novel three-dimensional-printed patient-specific sacral implant for spinopelvic reconstruction in sacral giant cell tumour. INTERNATIONAL ORTHOPAEDICS 2023; 47:1619-1628. [PMID: 36928708 DOI: 10.1007/s00264-023-05759-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/01/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE Spinopelvic reconstruction after sacral tumour resection is one of the most demanding procedures in sacral tumour surgery. The aims of this study were to evaluate the feasibility of spinopelvic reconstruction with 3D-printed prostheses in sacral giant cell tumours and the clinical outcomes and complications at follow-up. METHODS We retrospectively analyzed ten consecutive patients with giant cell tumors of the sacrum who underwent intralesional nerve-sparing resection with curative intent and custom implant reconstruction between 2016 and 2021. There were four males and six females with a mean age of 40.2 years (range, 25-62 years) at surgery. A computer-aided-design implant was prepared using 3D printing technology that was both matched to the bone defect and biomechanically evaluated. A 3D-printed surgical guide was used to replicate the resection procedure as planned. We analyzed operational outcomes, oncological outcomes, functional outcomes, complications, and prosthetic outcomes. Pain at rest was assessed according to a 10-cm VAS score. The results of functional improvement were evaluated using the MSTS-93 score at the final follow-up. RESULTS All patients were observed for 26 to 61 months, with an average follow-up of 43.8 months. No deep infection or prosthetic structural failure occurred in this study. A total of 80% of patients had good neurological function and normal urinary, bowel, and ambulatory functions. The mean MSTS score was 24.1 (range, 22-26). The mean VAS score was 2 (range 0 to 2). Delayed wound healing occurred in three patients, and the wounds healed after debridement. One case had local recurrence and survived tumour-free after resection of the recurrent lesion. An aseptic loosening was found in a patient that did not require secondary surgery. By radiographical assessments, we found that 90% of implants were well osseointegrated at the final follow-up examination. CONCLUSIONS The 3D-printed sacral implants might provide a promising strategy for spinopelvic reconstruction in sacral giant cell tumours undergoing intralesional nerve-sparing surgery with satisfactory clinical outcomes, osseointegration, and excellent durability.
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Raso J, Chi J, Labaran LA, Frank C, Shen FH. Carbon fiber lumbopelvic reconstruction following sacral giant cell tumor resection: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 5:CASE22555. [PMID: 36916526 PMCID: PMC10550644 DOI: 10.3171/case22555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 02/14/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND The use of carbon fiber or polyetheretherketone spine constructs has proven to be a safe and effective alternative to standard metal alloy. The mechanical properties of carbon fiber while unique provide a construct that is comparable in strength to previous titanium-based constructs and have additionally shown greater fatigue resistance. These constructs have been especially useful for the mechanical stabilization of the spine following tumor resection. The subsequent interference seen when imaging a patient with a traditional metallic construct is reduced and allows for improved tumor surveillance after the procedure, and a more accurate delivery of radiotherapy when indicated. OBSERVATIONS This case report details the treatment of a 25-year-old female diagnosed with a sacral giant cell tumor. The authors discuss the use of a carbon fiber-reinforced polyetheretherketone for lumbopelvic reconstruction. LESSONS Carbon fiber-reinforced polyetheretherketone with its radiolucency and rigidity is a reliable option for complex spinal reconstruction after tumor resection.
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Luo Y, Xiu P, Chen H, Zeng J, Song Y, Li T. Denosumab salvage therapy in an 11-year-old boy with locally recurrent unresectable giant cell tumor of the lumbar spine after surgery. Neurochirurgie 2023; 69:101427. [PMID: 36828057 DOI: 10.1016/j.neuchi.2023.101427] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/31/2022] [Accepted: 11/30/2022] [Indexed: 02/24/2023]
Abstract
Giant cell tumors (GCTs) of the bone are locally aggressive primary bone tumors with a benign character. Spinal involvement is rare which accounts for approximately 5% of all primary bone tumors and it is quite rare in the lumbar spine. An 11-year-old boy patient presented with pain of low back and bilateral low extremities. Lumbar CT and MRI revealed a lytic lesion of the L4 vertebra corpus. The patient earned remarkable and timely recovery with 2 surgical interventions and the use of denosumab. Surgical resection for GCTs is still preferable as the initial treatment, denosumab should be utilized after tumor resection whether based on the purpose of prevention or treatment of tumor recurrence.
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Affiliation(s)
- Y Luo
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Road, Chengdu 610041, China
| | - P Xiu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Road, Chengdu 610041, China
| | - H Chen
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Road, Chengdu 610041, China
| | - J Zeng
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Road, Chengdu 610041, China
| | - Y Song
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Road, Chengdu 610041, China
| | - T Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Road, Chengdu 610041, China.
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Muacevic A, Adler JR, Nurmukhametov R, Goncharov E, Ramirez MDJE, Bozkurt I, Ramirez Pena IJ. A Case Report of a Sacral Giant Cell Tumor Treated With Block Resection and Lumbo-Pelvic Fixation. Cureus 2022; 14:e31224. [PMID: 36505101 PMCID: PMC9729751 DOI: 10.7759/cureus.31224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 11/09/2022] Open
Abstract
Giant cell tumors (GCT) are benign but locally aggressive neoplasms composed of osteoclast-like giant cells and fusiform to ovoid mononuclear stromal cells. GCT generally comprise 5-10% of all benign bone tumors; they appear most frequently between the second and third decades of life. These tumors are also distributed throughout the vertebral column. Approximately half of all spinal GTCs develop in the sacrum. Many cases remain clinically silent and are discovered incidentally during the study of minor trauma. Symptomatic tumors often mimic other common spinal pathologies. Imaging studies ideal for diagnosis are CT and MRI. The techniques used in the treatment of giant cell tumors are curettage or intralesional surgery, block resection, radiotherapy, and chemotherapy. Herein, we report on a 23-year-old female patient diagnosed with a tumoral mass in the anterior part of the sacrum, suggestive of GCT. The lesion was completely excised in two consecutive surgeries, and lumbopelvic fixation was performed with favorable immediate postoperative results. Careful surgical planning with a multi-disciplinary approach leading to block resection still remains the most viable option for the treatment of vertebral GCT.
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Mohsen M, Osama H, Nicola M, Saeed H, Abdelrahim MEA. Effect of bisphosphonates on bone giant cell tumor recurrence: a meta-analysis. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2022. [DOI: 10.1186/s43088-022-00292-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
We examined the impact of bisphosphonates as adjuvant therapy on the recurrence of giant cell bone tumors and the impact of various tumor stages and surgical techniques on this effect. Following a thorough examination of the literature up to January 2022, 10 studies including 601 adults with giant cell tumors of the bone were reported; 295 of these subjects received bisphosphonates as adjuvant therapy following surgery, and 306 served as the control group. To examine the possibility of lowering the recurrence of giant cell bone tumors, a comparison between bisphosphonates and a control group was made. In order to evaluate the impact of bisphosphonates as adjuvant therapy on the recurrence of the giant cell bone tumor, odds ratios (OR) with 95% confidence intervals (CIs) were determined. Additionally, the dichotomous technique with a random or fixed-effect model was used to examine the effects of various tumor stages and pertinent surgical procedures.
Results
Patients with giant cell tumors of the bone who received bisphosphonates as adjuvant therapy had significantly lower postoperative recurrence rates outcomes in all subjects with giant cell tumor of bone (OR 0.19; 95% CI 0.12–0.31, p = 0.001), patients with stage I–II giant cell tumors of the bone (OR 0.29; 95% CI 0.11–0.76, p = 0.01), patients with stage III giant cell tumors of the bone (OR 0.17; 95% CI 0.07–0.42, p < 0.001); and post-intralesional curettage (OR 0.18; 95% CI 0.06–0.49, p < 0.001) compared to control. Bisphosphonates were used in participants with giant cell tumors of the bone after broad excision, but there was no discernible difference between the two groups in terms of postoperative recurrence outcomes (OR 0.66; 95% CI 0.11–3.91, p = 0.65).
Conclusions
In patients with giant cell tumors of the bone after intralesional curettage, the use of bisphosphonates as adjuvant therapy may lower the incidence of postoperative recurrence outcomes, but no appreciable difference was identified after extensive resection. According to the observed relationship, using bisphosphonates is advised to lower the likelihood of postoperative recurrence that can happen in patients with giant cell tumors of the bone.
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Global Prevalence and Risk of Local Recurrence following Cryosurgery of Giant Cell Tumour of Bone: A Meta-Analysis. Cancers (Basel) 2022; 14:cancers14143338. [PMID: 35884399 PMCID: PMC9318769 DOI: 10.3390/cancers14143338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/03/2022] [Accepted: 07/06/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Giant cell tumours are benign but locally aggressive and can potentially metastasise to the lungs. Reducing the risk of local recurrence while maintaining limb function and minimising adverse consequences is the best therapeutic strategy in treating giant cell tumours. Based on our observation through this meta-analysis, cryosurgery is one of the viable treatment options that can provide good oncologic and functional outcomes with minimal complication rates. Abstract The challenge in the surgical treatment of giant cell tumours of bone is the relatively high recurrence rate after curettage alone. The use of a local adjuvant following curettage, on the other hand, has lowered the rate of recurrence. This systematic review and meta-analysis aimed to investigate the prevalence and risk of local recurrence of giant cell tumours of the bone after cryosurgery and the subsequent complications. Web of Science, Scopus, ScienceDirect, PubMed, and Google Scholar were searched to identify articles published until 13 October 2021. A random-effects model was used to examine the pooled prevalence and risk ratio (RR) of local recurrence in patients with giant cell tumours after cryosurgery with 95% confidence intervals (CIs). This study was registered with PROSPERO (CRD42020211620). A total of 1376 articles were identified, of which 38 studies (n = 1373, 46.2% male) were included in the meta-analysis. Following cryosurgery, the pooled prevalence of local recurrence in giant cell tumours was estimated as 13.5% [95% CI: 9.3–17.8, I2 = 63%], where European subjects exhibited the highest prevalence (24.2%). Compared to other local adjuvants. The RR of local recurrence following cryosurgery was 0.85 (95% CI: 0.63–1.17, I2 = 15%), which was not statistically significant compared to other local adjuvants. We found 3.9% fracture, 4.0% infection, 2.1% nerve injury, and 1.5% skin necrosis as the common complications. Based on the sensitivity analyses, this study is robust and reliable. This meta-analysis estimated a low prevalence of local recurrence of giant cell tumours with low complications following cryosurgery. Thus, it can be one of the adjuvant options for treating giant cell tumours.
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Tsukamoto S, Ali N, Mavrogenis AF, Honoki K, Tanaka Y, Spinnato P, Donati DM, Errani C. Intralesional nerve-sparing surgery versus non-surgical treatment for giant cell tumor of the sacrum. BMC Musculoskelet Disord 2021; 22:1023. [PMID: 34872538 PMCID: PMC8650241 DOI: 10.1186/s12891-021-04907-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 11/24/2021] [Indexed: 11/30/2022] Open
Abstract
Background There is no standard treatment for giant cell tumors of the sacrum. We compared the outcomes and complications in patients with sacral giant cell tumors who underwent intralesional nerve-sparing surgery with or without (neo-) adjuvant therapies versus those who underwent non-surgical treatment (denosumab therapy and/or embolization). Methods We retrospectively investigated 15 cases of sacral giant cell tumors treated at two institutions between 2005 and 2020. Nine patients underwent intralesional nerve-sparing surgery with or without (neo-) adjuvant therapies, and six patients received non-surgical treatment. The mean follow-up period was 85 months for the surgical group (range, 25–154 months) and 59 months (range, 17–94 months) for the non-surgical group. Results The local recurrence rate was 44% in the surgical group, and the tumor progression rate was 0% in the non-surgical group. There were two surgery-related complications (infection and bladder laceration) and three denosumab-related complications (apical granuloma of the tooth, stress fracture of the sacroiliac joint, and osteonecrosis of the jaw). In the surgical group, the mean modified Biagini score (bowel, bladder, and motor function) was 0.9; in the non-surgical group, it was 0.5. None of the 11 female patients became pregnant or delivered a baby after developing a sacral giant cell tumor. Conclusions The cure rate of intralesional nerve-sparing surgery is over 50%. Non-surgical treatment has a similar risk of complications to intralesional nerve-sparing surgery and has better functional outcomes than intralesional nerve-sparing surgery, but patients must remain on therapy over time. Based on our results, the decision on the choice of treatment for sacral giant cell tumors could be discussed between the surgeon and the patient based on the tumor size and location.
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Affiliation(s)
- Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijo-cho, Kashihara-city, Nara, 634-8521, Japan.
| | - Nikolin Ali
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 41 Ventouri Street, 15562 Holargos, Athens, Greece
| | - Kanya Honoki
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijo-cho, Kashihara-city, Nara, 634-8521, Japan
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijo-cho, Kashihara-city, Nara, 634-8521, Japan
| | - Paolo Spinnato
- Radiology Unit, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Davide Maria Donati
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Costantino Errani
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
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Facchini G, Parmeggiani A, Peta G, Martella C, Gasbarrini A, Evangelisti G, Miceli M, Rossi G. The role of percutaneous transarterial embolization in the management of spinal bone tumors: a literature review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:2839-2851. [PMID: 34415449 DOI: 10.1007/s00586-021-06963-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/07/2021] [Accepted: 08/10/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Spinal bone tumors include a heterogeneous broad of primary or metastatic lesions that may present as incidental findings or manifest with painful symptoms and pathological fractures. Optimal management of spine bone lesions is often difficult and treatment algorithms are usually solidly based on surgery. We aimed to evaluate the contribution of trans-arterial embolization in this field, with particular attention to the procedure efficacy, technical difficulties and complications. METHODS We present a literature review on the role of trans-arterial embolization in the management of spinal bone tumors, both primary and metastatic, evaluating its contribution as preoperative treatment, palliative procedure and standalone curative strategy. RESULTS Trans-arterial embolization provides an important contribution to reducing surgery hemorrhagic risks, offering a better visualization of the operating field, and possibly increasing tumor susceptibility to chemotherapy or radiation therapy. Nonetheless, it plays an important part in pain palliation, with the unquestionable advantage of being easily repeatable in case of necessity. Its curative role as a standalone therapy is still subject of debate, and at the present time, satisfactory results have been recorded only in the treatment of aneurysmal bone cysts. CONCLUSION Percutaneous trans-arterial embolization has established as a highly useful minimally invasive procedure in the management of spinal bone lesions, particularly as adjuvant preoperative therapy and palliative treatment.
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Affiliation(s)
- Giancarlo Facchini
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
| | - Anna Parmeggiani
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy. .,Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Giuliano Peta
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
| | - Claudia Martella
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Gasbarrini
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Gisberto Evangelisti
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Miceli
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
| | - Giuseppe Rossi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
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Errani C, Mavrogenis AF, Tsukamoto S. What's new in musculoskeletal oncology. BMC Musculoskelet Disord 2021; 22:704. [PMID: 34404379 PMCID: PMC8369444 DOI: 10.1186/s12891-021-04590-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 08/05/2021] [Indexed: 12/26/2022] Open
Abstract
We reviewed the recent literature related to primary musculoskeletal tumors and metastatic bone tumors. With regard to primary bone tumors, computer navigation systems and three-dimensional-printed prostheses seem to be new treatment options, especially in challenging anatomical locations, such as the sacrum and pelvis. Regarding the treatment of giant cell tumor of bone, recent studies have suggested that denosumab administration is related to a higher local recurrence rate following curettage, but a lower local recurrence rate following en bloc resection. In addition, there was no difference in the local recurrence rate at five years after surgery between short-term and long-term denosumab therapy. With regard to soft tissue tumors, percutaneous cryoablation appears to be a new treatment option for extra-abdominal desmoid tumors, with encouraging results. Regarding soft tissue sarcomas, a negative surgical margin of < 1 mm is sufficient to control local recurrence. Pexidartinib seems to be a promising systemic therapy for the treatment of tenosynovial giant cell tumors for which surgery is not expected to improve the function of the affected limb. Finally, the life expectancy of patients is the most important factor in determining the optimal surgical procedure for patients with impending or pathological fractures of the long bone due to metastatic bone tumors. Elevated C-reactive protein level was found to be an independent poor prognostic factor at 1 year after surgery for long bone metastases.
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Affiliation(s)
- Costantino Errani
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy.
| | - Andreas F Mavrogenis
- First Department of Orthopedics, School of Medicine, National and Kapodistrian University of Athens, 41 Ventouri Street Holargos, 15562, Athens, Greece
| | - Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijo-cho, Nara, 634-8521, Kashihara-city, Japan
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Current Concepts in the Treatment of Giant Cell Tumors of Bone. Cancers (Basel) 2021; 13:cancers13153647. [PMID: 34359548 PMCID: PMC8344974 DOI: 10.3390/cancers13153647] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 02/02/2023] Open
Abstract
Simple Summary According to the 2020 World Health Organization classification, a giant cell tumor of bone is an intermediate malignant bone tumor. Denosumab treatment before curettage should be avoided due to the increased risk of local recurrence. Administration of denosumab before en bloc resection of the giant cell tumors of the pelvis and spine facilitates en bloc resection. Nerve-sparing surgery after embolization is a possible treatment for giant cell tumors of the sacrum. Denosumab therapy with or without embolization is indicated for inoperable giant cell tumors of the pelvis, spine, and sacrum. A wait-and-see approach is recommended for lung metastases at first, then denosumab should be administered to the growing lesions. Radiotherapy is not recommended owing to the risk of malignant transformation. Local recurrence after 2 years or more should be indicative of malignant transformation. This review summarizes the treatment approaches for non-malignant and malignant giant cell tumors of bone. Abstract The 2020 World Health Organization classification defined giant cell tumors of bone (GCTBs) as intermediate malignant tumors. Since the mutated H3F3A was found to be a specific marker for GCTB, it has become very useful in diagnosing GCTB. Curettage is the most common treatment for GCTBs. Preoperative administration of denosumab makes curettage difficult and increases the risk of local recurrence. Curettage is recommended to achieve good functional outcomes, even for local recurrence. For pathological fractures, joints should be preserved as much as possible and curettage should be attempted. Preoperative administration of denosumab for pelvic and spinal GCTBs reduces extraosseous lesions, hardens the tumor, and facilitates en bloc resection. Nerve-sparing surgery after embolization is a possible treatment for sacral GCTBS. Denosumab therapy with or without embolization is indicated for inoperable pelvic, spinal, and sacral GCTBs. It is recommended to first observe lung metastases, then administer denosumab for growing lesions. Radiotherapy is associated with a risk of malignant transformation and should be limited to cases where surgery is impossible and denosumab, zoledronic acid, or embolization is not available. Local recurrence after 2 years or more should be indicative of malignant transformation. This review summarizes the treatment approaches for non-malignant and malignant GCTBs.
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Langevelde KV, Vucht NV, Tsukamoto S, Mavrogenis AF, Errani C. Radiological Assessment of Giant Cell Tumour of Bone in the Sacrum: From Diagnosis to Treatment Response Evaluation. Curr Med Imaging 2021; 18:162-169. [PMID: 33845749 DOI: 10.2174/1573405617666210406121006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 11/22/2022]
Abstract
Giant cell tumour of bone (GCTB) typically occurs in young adults from 20-40 years old. Although the majority of lesions are located in the epi-metaphyses of the long bones, approximately one third of tumours is located in the axial skeleton, of which only 4% in the sacrum. Sacral tumours tend to be large at the time of presentation, and they present with aggressive features such as marked cortical destruction and an associated soft tissue component. The 2020 World Health Organisation classification of Soft Tissue and Bone Tumours describes GCTB as neoplasm which is locally aggressive and rarely metastasizing. The tumour contains three different cell types: neoplastic mononuclear stromal cells, macrophages and osteoclast-like giant cells. Two tumour subtypes were defined: conventional GCTB and malignant GCTB. Only 1-4% of GCTB is malignant. In this review article, we will discuss imaging findings at the time of diagnosis to guide the musculoskeletal radiologist in reporting these tumours. In addition, imaging for response evaluation after various treatment options will be addressed, such as surgery, radiotherapy, embolization and denosumab. Specific findings will be presented per imaging modality and illustrated by cases from our tertiary sarcoma referral center. Common postoperative and post radiotherapy findings in GCTB of the sacrum on MRI will be discussed.
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Affiliation(s)
| | - Niels Van Vucht
- Department of Radiology, University College London Hospitals, London. United Kingdom
| | - Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University, Nara. Japan
| | - Andreas F Mavrogenis
- Division of Orthopaedics and Traumatology, National and Kapodistrian University of Athens, Athens. Greece
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Rajgor HD, James S, Botchu R, Grainger M, Czyz M. Should Denosumab or Radical Surgery Be Recommended for a Spinal Giant Cell Tumour in a Fertile Female? Cureus 2020; 12:e11526. [PMID: 33354470 PMCID: PMC7746321 DOI: 10.7759/cureus.11526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Giant cell tumour (GCT) of the spine is a benign aggressive tumour with high recurrence rates. Patients can be asymptomatic due to the slow growth rate and present with localized pain or neurological dysfunction. Current management strategies include intralesional curettage, total en-bloc resection (TER) and denosumab therapy. Treatment strategies can be particularly challenging in women of childbearing age who wish to conceive, as the risks of tumour recurrence need to be balanced against the fetal complications associated with adjuvant denosumab therapy. This case report discusses the management options and controversies for women of childbearing age with GCT of the thoracic spine. Clinicians need to be aware of the complications associated with TER and denosumab treatment when managing GCTs of the spine in young females.
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Affiliation(s)
| | - Steven James
- Radiology, Royal Orthopaedic Hospital, Birmingham, GBR
| | - Rajesh Botchu
- Radiology, Royal Orthopaedic Hospital, Birmingham, GBR
| | - Melvin Grainger
- Neurosurgery, University Hospitals Birmingham, Birmingham, GBR
| | - Marcin Czyz
- Neurosurgery, University Hospitals Birmingham, Birmingham, GBR
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13
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Singh SK, Kumar A, Nigam J. Sacral Giant Cell Tumor-Induced Cauda Equina Syndrome: Case Report with Successful Management. J Neurosci Rural Pract 2020; 12:398-401. [PMID: 33927530 PMCID: PMC8064861 DOI: 10.1055/s-0040-1718856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Sacral giant cell tumor (GCT) is a rare entity. It often presents late after massive enlargement of tumor. Here we are reporting a case of sacral GCT treated successfully at our institute. A 30-year-old male patient presented with paraplegia, significant sensory disturbance below L2 level, along with severe vesicorectal dysfunction. On imaging, giant mass was seen filling the sacrum with homogenous enhancement and flow voids from L5 level to S4 level. The patient underwent surgical exploration with L4–5 decompressive laminectomy, near-total resection of tumor, and lumboiliac fixation. The patient recovered symptomatically in postoperative period. Sacral GCT is a rare but treatable lesion. Its presentation as sudden cauda equina syndrome is rare, but final management should be aggressive with en bloc resection and fixation.
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Affiliation(s)
- Saraj K Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Avinash Kumar
- Department of Orthopedics, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Jitendra Nigam
- Department of Pathology, All India Institute of Medical Sciences, Patna, Bihar, India
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14
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Puri A, Gupta SM, Gulia A, Shetty N, Laskar S. Giant cell tumors of the sacrum: is non-operative treatment effective? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:2881-2886. [PMID: 33106943 DOI: 10.1007/s00586-020-06650-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 10/20/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Giant cell tumors of sacrum in which surgery could endanger important neural components were treated with short term denosumab, angioembolisation and radiotherapy in different combinations to provide a non-operative function preserving treatment option. METHODS Between April 2013 and April 2017, 13 sacral GCTs [proximal extent of disease-S1 (10), S2 (2) and S3 (1)] were treated. Age ranged from 20 to 50 years. One patient had loss of bladder control at presentation. Treatment protocol included short term denosumab, angioembolisation and radiotherapy in different combinations. Patients were evaluated every 10-12 weeks. If disease ceased to progress no further treatment was advised. In case of progress, patient was advised additional denosumab and/or angioembolisation and/or radiotherapy till disease stopped progressing. RESULTS 10 patients have non-progressive disease and are asymptomatic, 2 have non-progressive disease with occasional pain, 1 patient died. Follow-up duration (since final non-progression of disease) ranged from 15 to 54 months (mean 31 months). Total number of angio embolisation sessions ranged from 0 to 12 (mean = 4), total number of denosumab doses ranged from 5 to 16 (mean = 9). Five patients did not receive any radiotherapy, 5 received 50.4 Gy and one patient each received 50.4 + 30 + 12 Gy, 50.4 + 30 Gy and 50.4 + 12 Gy. The patient with loss of bladder control at presentation recovered. There were no other long-term complications. CONCLUSION This study offers a non-surgical management option that provides good mid-term local control while preserving neurological function in these complex lesions.
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Affiliation(s)
- Ajay Puri
- Orthopaedic Oncology unit of Surgical Oncology, Tata Memorial Centre, HBNI, Mumbai, India.
| | - Srinath M Gupta
- Orthopaedic Oncology unit of Surgical Oncology, Tata Memorial Centre, HBNI, Mumbai, India
| | - Ashish Gulia
- Orthopaedic Oncology unit of Surgical Oncology, Tata Memorial Centre, HBNI, Mumbai, India
| | - Nitin Shetty
- Interventional Radiology, Tata Memorial Centre, HBNI, Mumbai, India
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15
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Abstract
Giant cell tumor of the sacrum is a rare primary tumor in a challenging anatomical location without clear consensus on treatment. We present a case of giant cell tumor of the sacrum and subsequent treatment with preoperative embolization, L5 to S4 laminectomy, partial sacrectomy, intraoperative thermal ablation, and L4 to pelvis stabilization and fusion.
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Affiliation(s)
- James Rizkalla
- Department of Orthopaedic Surgery, Baylor University Medical Center, Dallas, Texas
| | - Brendan Holderread
- Department of Orthopaedic Surgery, Baylor University Medical Center, Dallas, Texas
| | - Jonathan Liu
- Department of Orthopaedic Surgery, Baylor University Medical Center, Dallas, Texas
| | - Al Mollabashy
- Department of Orthopaedic Surgery, Baylor University Medical Center, Dallas, Texas
| | - Ishaq Y Syed
- Department of Orthopaedic Surgery, Baylor University Medical Center, Dallas, Texas
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16
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Lim CY, Liu X, He F, Liang H, Yang Y, Ji T, Yang R, Guo W. Retrospective cohort study of 68 sacral giant cell tumours treated with nerve-sparing surgery and evaluation on therapeutic benefits of denosumab therapy. Bone Joint J 2020; 102-B:177-185. [PMID: 32009426 DOI: 10.1302/0301-620x.102b2.bjj-2019-0813.r1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS To investigate the benefits of denosumab in combination with nerve-sparing surgery for treatment of sacral giant cell tumours (GCTs). METHODS This is a retrospective cohort study of patients with GCT who presented between January 2011 and July 2017. Intralesional curettage was performed and patients treated from 2015 to 2017 also received denosumab therapy. The patients were divided into three groups: Cohort 1: control group (n = 36); cohort 2: adjuvant denosumab group (n = 9); and cohort 3: neo- and adjuvant-denosumab group (n = 17). RESULTS There were 68 patients within the study period. Six patients were lost to follow-up. The mean follow-up was 47.7 months (SD 23.2). Preoperative denosumab was found to reduce intraoperative haemorrhage and was associated with shorter operating time for tumour volume > 200 cm3. A total of 17 patients (27.4%) developed local recurrence. The locoregional control rate was 77.8% (7/9) and 87.5% (14/16) respectively for cohorts 2 and 3, in comparison to 66.7% (24/36) of the control group. The recurrence-free survival (RFS) rate was significantly higher for adjuvant denosumab group versus those without adjuvant denosumab during the first two years: 100% vs 83.8% at one year and 95.0% vs 70.3% at two years. No significant difference was found for the three-year RFS rate. CONCLUSION Preoperative denosumab therapy was found to reduce intraoperative haemorrhage and was associated with shorter operating times. Adjuvant denosumab was useful to prevent early recurrence during the first two years after surgery. Cite this article: Bone Joint J 2020;102-B(2):177-185.
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Affiliation(s)
- Chiao Yee Lim
- Department of Orthopaedic Surgery, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia.,Orthopaedic oncology fellow, Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Xingyu Liu
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Fangzhou He
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Haijie Liang
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Yi Yang
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Tao Ji
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Rongli Yang
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Wei Guo
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
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17
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Deslivia MF, Savio SD, Dharmapradita MW, Wiratnaya IGE. Efficacy of Minimally Invasive Surgery on Giant Cell Tumour of the Bone: A Systematic Review. Open Access Maced J Med Sci 2019; 7:3721-3725. [PMID: 32010405 PMCID: PMC6986520 DOI: 10.3889/oamjms.2019.731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 09/23/2019] [Accepted: 09/24/2019] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND: Although major reconstructive surgeries in the form of excision and reconstruction have been the mainstay treatment for Giant Cell Tumour (GCT) of the bone, its recurrence rate remains high and poses various morbidities such as implant failure or skin breakdown. Minimal invasive surgery (MIS) techniques, which has gained popularity mostly in other fields in orthopaedic surgery, are being introduced as an alternative to limit the surgical complications while achieving the best possible outcome. Until now, there has been no literature summarising the evidence of MIS outcome in treating GCT of the bone. AIM: The purpose of this systematic review was to investigate the efficacy of this relatively new treatment. METHODS: We comprehensively searched PubMed, EMBASE, and Cochrane Library to search for studies about MIS for GCT of the bone treatment up to March 1, 2019. The selection of appropriate studies was performed by two independent investigators based on PRISMA guideline. Given the limited number of studies, there was no restriction in terms of patient’s demographics, the specific minimally invasive surgical method, and publication status. RESULTS: We found 120 articles from the database. After evaluating full text, 5 articles (16 patients) were found to be eligible. The minimally invasive methods were curettage, cryosurgery, and argon beam coagulator. The visualisation methods include a computer-assisted navigation system, endoscope, otoscope, CT, and MRI. Location of tumours includes axial and long bones. The follow-up period ranges from 7 to 126 months. The functional and oncological outcome was found to be satisfying with no recurrence or complications. CONCLUSION: In conclusion, MIS is a familiar method in orthopaedic surgery with potential expansion in tumour field. The current evidence shows that this approach for GCT results in good functional outcome, with low risk of recurrence.
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Affiliation(s)
- Maria Florencia Deslivia
- Orthopaedics and Traumatology Department, Faculty of Medicine Udayana University, Sanglah General Hospital, Denpasar, Indonesia
| | - Sherly Desnita Savio
- Orthopaedics and Traumatology Department, Faculty of Medicine Udayana University, Sanglah General Hospital, Denpasar, Indonesia
| | - Made Wahyu Dharmapradita
- Orthopaedics and Traumatology Department, Faculty of Medicine Udayana University, Sanglah General Hospital, Denpasar, Indonesia
| | - I Gede Eka Wiratnaya
- Orthopaedics and Traumatology Department, Faculty of Medicine Udayana University, Sanglah General Hospital, Denpasar, Indonesia
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Sertbaş İ, Karatay M, Hacisalihoğlu UP. Cervical spine giant cell bone tumor: a case report. World J Surg Oncol 2019; 17:82. [PMID: 31078142 PMCID: PMC6511659 DOI: 10.1186/s12957-019-1625-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 05/02/2019] [Indexed: 12/17/2022] Open
Abstract
Background Giant cell tumors (GCTs) of the bone are locally aggressive primary bone tumors with a benign character. Spinal involvement is rare and they are quite rare in the cervical spine. Case presentation A 31-year-old male patient presented with neck pain. Cervical CT revealed a lytic lesion extending posteriorly and causing the collapse of the C4 vertebra corpus. The patient underwent excision of the tumor extending from the anterior to the posterior with a single-stage anterior intervention followed by the placement of an anterior cage and plate-screw system for fusion. The pathology was reported as GCT. Conclusions The posteriorly located lesion was widely curetted through an anterior approach in a single session.
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Affiliation(s)
- İdris Sertbaş
- Department of Neurosurgery, Yeni Yüzyıl University Medical Faculty, Merkez Mahallesi,Çukurçeşme Caddesi No:51, Gaziosmanpaşa, İstanbul, Turkey.
| | - Mete Karatay
- Department of Neurosurgery, Yeni Yüzyıl University Medical Faculty, Merkez Mahallesi,Çukurçeşme Caddesi No:51, Gaziosmanpaşa, İstanbul, Turkey
| | - Uguray Payam Hacisalihoğlu
- Department of Pathology, Yeni Yüzyıl University Medical Faculty, Merkez Mahallesi, Çukurçeşme Caddesi No:51, Gaziosmanpaşa, İstanbul, Turkey
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19
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Shi M, Chen L, Wang Y, Wang W, Zhang Y, Yan S. Effect of bisphosphonates on local recurrence of giant cell tumor of bone: a meta-analysis. Cancer Manag Res 2019; 11:669-680. [PMID: 30666162 PMCID: PMC6331072 DOI: 10.2147/cmar.s187316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Giant cell tumor of bone (GCTB) is a locally aggressive tumor, and its postoperative recurrence remains a problem. The present meta-analysis aimed to analyze the effect of bisphosphonates (BPs) on local recurrence of GCTB. Methods Seven case-control studies were included by computerized searches of bibliographic databases (PubMed, AMED, EMBASE, the Cochrane library, ISI Web of Science, and China National Knowledge Infrastructure). The pooled adjusted ORs were calculated to evaluate the local recurrence of GCTB. Results The BP group presented significantly lower total local recurrence rate than the control group in GCTB (P<0.01). Subgroup analysis shows BP group presented significantly lower local recurrence than the control group in GCTB with different tumor grades (P<0.05). In patients who underwent intralesional curettage, a significantly lower local recurrence rate was found in the BP group compared with the control group (P<0.01), but no significance was found for patients who underwent wide resection (P=0.16). None of the included studies described severe adverse effects related to BPs. Conclusion The results confirmed the effect of BPs on reducing the local recurrence of GCTB, and the effect is not influenced by the tumor grades. BPs are benefit for the patients who underwent intralesional curettage but not recommended for those who underwent wide resection.
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Affiliation(s)
- Mingmin Shi
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China,
| | - Lei Chen
- Department of Endocrinology and Metabolism, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Yangxin Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China,
| | - Wei Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China,
| | - Yujie Zhang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China,
| | - Shigui Yan
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China,
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20
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Kamath N, Agarwal J, Gulia A. Axial giant cell tumor - current standard of practice. J Clin Orthop Trauma 2019; 10:1027-1032. [PMID: 31736609 PMCID: PMC6844211 DOI: 10.1016/j.jcot.2019.09.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 09/28/2019] [Accepted: 09/29/2019] [Indexed: 01/21/2023] Open
Abstract
Giant cell tumors of bone are relatively rare in the axial skeleton, accounting for approximately 6.7% of all cases. Due to their anatomical complexity, difficult access and proximity to vital neurovascular structures, management of these tumors poses a huge challenge on the treating surgeon. Several data series reported on axial GCTB involve short series of limited cases with varied methods used in their local control due to which, proper guidelines are unavailable for the management of such difficult cases. Though the present data support the use of denosumab for effective management of these lesions but there is varied consensus on dosage and duration of treatment. This review article summarizes the basic features and treatment modalities related to axial GCTB stressing on multidisciplinary approach to achieve optimum outcomes.
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Affiliation(s)
| | | | - Ashish Gulia
- Corresponding author. Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, India.
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21
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Pannu CD, Kandhwal P, Raghavan V, Khan SA, Rastogi S, Jayaswal A. Role of Bisphosphonates as Adjuvants of Surgery in Giant Cell Tumor of Spine. Int J Spine Surg 2018; 12:695-702. [PMID: 30619673 DOI: 10.14444/5087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background The role of bisphosphonates is well established in giant cell tumor of bone (GCTB) of extremities, but its role in spine GCTB is still not established. Our main purpose was to evaluate the role of bisphosphonates in spinal GCTB with the help of radiologic assessment. Methods A retrospective analysis of all spine GCTB patients who underwent an operation from July 2005 to January 2014 was done. Patients of spine GCTB in whom bisphosphonates were given constituted the study group. This group was compared to patients in whom bisphosphonates were not given. Preoperative and postoperative radiographs and CT scans were studied. A thorough evaluation of the presence of sclerosis was done on them. Bisphosphonates were considered to be effective if either sclerosis or new bone formation was present. Results A total of 13 cases of spine GCT underwent operation from July 2005 to January 2014. All patients of GCTB spine who underwent an operation after 2008 at our institute were given bisphosphonates postoperatively. Of 13 cases, bisphosphonates were given postoperatively in 6 patients: 5 patients were female and 1 patient was male. Of these 6 patients, 3 patients had sacrum GCTB and 1 patient each had T9, T11, and L5 vertebrae GCTB. Average follow-up period was 39.33 months (minimum follow-up was 18 months and maximum follow-up was 72 months). Postoperative sclerosis was present in all 6 patients. No recurrence of the tumor was present in the bisphosphonate group, but 2 patients had a recurrence in the group that did not receive bisphosphonates. Conclusions Bisphosphonates are effective and safe adjuvant therapy along with appropriate surgical intervention in spinal GCTBs and may have a role in decreasing the recurrence of this tumor.
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Affiliation(s)
- Chaitanya Dev Pannu
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Kandhwal
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Raghavan
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Shah Alam Khan
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Shishir Rastogi
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Jayaswal
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
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22
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He SH, Xu W, Sun ZW, Liu WB, Liu YJ, Wei HF, Xiao JR. Selective Arterial Embolization for the Treatment of Sacral and Pelvic Giant Cell Tumor: A Systematic Review. Orthop Surg 2018. [PMID: 28644557 DOI: 10.1111/os.12336] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Giant cell tumor of the bone (GCTB) is a locally aggressive tumor with a certain distant metastatic rate. For sacral GCT (SGCT) and pelvic GCT (PGCT), surgery has its limitations, especially for unresectable or recurrent tumors. Selective arterial embolization (SAE) is reported to be an option for treatment in several cases, but there are few systematic reviews on the effects of SAE on SGCT and/or PGCT. Medline and Embase databases were searched for eligible English articles. Inclusion and exclusion criteria were conducted before searching. All the clinical factors were measured by SPSS software, with P-values ≤0.05 considered statistically significant. A total of 9 articles were retrieved, including 44 patients receiving SAE ranging from 1 to 10 times. During the mean follow-up period of 85.8 months, the radiographic response rate was 81.8%, with a local control and overall survival rate of 75% and 81.8%, respectively. No bowel, bladder, or sexual dysfunction was observed. Three patients developed distant metastases and finally died. Patients with primary tumors tended to have better prognosis than those with recurrence (P = 0.039). The favorable outcomes of SAE suggest that it may be an alternative treatment for SGCT and PGCT patients for whom surgery is not appropriate.
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Affiliation(s)
- Shao-Hui He
- Department of Orthopaedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wei Xu
- Department of Orthopaedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Zheng-Wang Sun
- Department of Orthopaedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wei-Bo Liu
- Department of Orthopaedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Spine Surgery, Central Hospital of Qingdao, Qingdao, China
| | - Yu-Jie Liu
- Department of Orthopaedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Hai-Feng Wei
- Department of Orthopaedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jian-Ru Xiao
- Department of Orthopaedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
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Jamshidi K, Bagherifard A, Mirzaei A, Bahrabadi M. Giant Cell Tumor of the Sacrum: Series of 19 Patients and Review of the Literature. THE ARCHIVES OF BONE AND JOINT SURGERY 2017; 5:443-450. [PMID: 29299501 PMCID: PMC5736895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 04/12/2017] [Indexed: 06/07/2023]
Abstract
There are still some debates regarding the best treatment of Giant Cell Tumor (GCT) of the sacrum. Since GCT of this location is rare, therapeutic strategies are mainly based on the treatment of GCT in other anatomic locations. The objective of this study was to evaluate the oncologic and clinical results of surgical management of sacral GCT with and without local adjuvant therapy. Medical records of 19 patients diagnosed with GCT of the sacrum, were retrospectively reviewed. Sixteen patients were treated by intralesional curettage and three patients with marginal resection. Musculoskeletal tumor society (MSTS) score was used for the evaluation of functional outcome. Prolonged pain was the most common complication after treatment. Mean Pre and post-operative pain based on visual analogue scale (VAS) was 6.1 ± 1.99 and 3.05 ± 1.64, respectively. Postoperative neurologic deficit appeared in six patients. In addition, infection occurred in five patients. One case of spinopelvic instability was also observed after surgery. At average follow up of 158.5 ± 95.9 months (25 to 316 months), recurrence was seen in eight (42.7%) out of seventeen patients treated by intralesional curettage. The size of the tumor significantly correlated with the tumor recurrence (r=0.654, P=0.001). Mean MSTS score was 74.7 ± 16.78. Those patients, in whom sacral nerve roots remained intact before and after surgery, had better functional outcome. Preservation of sacral nerve roots is associated with better functional outcome and less pain. Although an acceptable surgical outcome was observed in our cohort, the problem of local recurrence still warrants further investigations for better local control of the tumor.
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Affiliation(s)
- Khodamorad Jamshidi
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Abolfazl Bagherifard
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Mirzaei
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mehrdad Bahrabadi
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
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24
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En Bloc Resection Versus Intralesional Surgery in the Treatment of Giant Cell Tumor of the Spine. Spine (Phila Pa 1976) 2017; 42:1383-1390. [PMID: 28146024 DOI: 10.1097/brs.0000000000002094] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Multicenter, ambispective observational study. OBJECTIVE The aim of this study was to quantify local recurrence (LR) and mortality rates after surgical treatment of spinal giant cell tumor and to determine whether en bloc resection with wide/marginal margins is associated with improved prognosis compared to an intralesional procedure. SUMMARY OF BACKGROUND DATA Giant cell tumor (GCT) of the spine is a rare primary bone tumor known for its local aggressiveness. Optimal surgical treatment remains to be determined. METHODS The AOSpine Knowledge Forum Tumor developed a comprehensive multicenter database including demographics, presentation, diagnosis, treatment, mortality, and recurrence rate data for GCT of the spine. Patients were analyzed based on surgical margins, including Enneking appropriateness. RESULTS Between 1991 and 2011, 82 patients underwent surgery for spinal GCT. According to the Enneking classification, 59 (74%) tumors were classified as S3-aggressive and 21 (26%) as S2-active. The surgical margins were wide/marginal in 27 (36%) patients and intralesional in 48 (64%) patients. Thirty-nine of 77 (51%) underwent Enneking appropriate (EA) treatment and 38 (49%) underwent Enneking inappropriate (EI) treatment. Eighteen (22%) patients experienced LR. LR occurred in 11 (29%) EI-treated patients and six (15%) EA-treated patients (P = 0.151). There was a significant difference between wide/marginal margins and intralesional margins for LR (P = 0.029). Seven (9%) patients died. LR is strongly associated with death (Relative Risk 8.9, P < 0.001). Six (16%) EI-treated patients and one (3%) EA-treated patients died (P = 0.056). With regards to surgical margins, all patients who died underwent intralesional resection (P = 0.096). CONCLUSION En bloc resection with wide/marginal margins should be performed when technically feasible because it is associated with decreased LR. Intralesional resection is associated with increased LR, and mortality correlates with LR. LEVEL OF EVIDENCE 3.
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25
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Mavrogenis AF, Igoumenou VG, Megaloikonomos PD, Panagopoulos GN, Papagelopoulos PJ, Soucacos PN. Giant cell tumor of bone revisited. SICOT J 2017; 3:54. [PMID: 28905737 PMCID: PMC5598212 DOI: 10.1051/sicotj/2017041] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 07/17/2017] [Indexed: 01/15/2023] Open
Abstract
Giant cell tumor (GCT) of bone is a locally aggressive benign neoplasm that is associated with a large biological spectrum ranging from latent benign to highly recurrent and occasionally metastatic malignant bone tumor. It accounts for 4–10% of all bone tumors and typically affects the meta-epiphyseal region of long bones of young adults. The most common site involved is the distal femur, followed by the distal radius, sacrum, and proximal humerus. Clinical symptoms are nonspecific and may include local pain, swelling, and limited range of motion of the adjacent joint. Radiographs and contrast-enhanced magnetic resonance imaging (MRI) are the imaging modalities of choice for diagnosis. Surgical treatment with curettage is the optimal treatment for local tumor control. A favorable clinical outcome is expected when the tumor is excised to tumor-free margins, however, for periarticular lesions this is usually accompanied with a suboptimal functional outcome. Local adjuvants have been used for improved curettage, in addition to systematic agents such as denosumab, bisphosphonates, or interferon alpha. This article aims to discuss the clinicopathological features, diagnosis, and treatments for GCT of bone.
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Affiliation(s)
- Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, 41 Ventouri Street, 15562 Holargos, Athens, Greece
| | - Vasileios G Igoumenou
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, 41 Ventouri Street, 15562 Holargos, Athens, Greece
| | - Panayiotis D Megaloikonomos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, 41 Ventouri Street, 15562 Holargos, Athens, Greece
| | - Georgios N Panagopoulos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, 41 Ventouri Street, 15562 Holargos, Athens, Greece
| | - Panayiotis J Papagelopoulos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, 41 Ventouri Street, 15562 Holargos, Athens, Greece
| | - Panayotis N Soucacos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, 41 Ventouri Street, 15562 Holargos, Athens, Greece
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26
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Ji T, Yang Y, Wang Y, Sun K, Guo W. Combining of serial embolization and denosumab for large sacropelvic giant cell tumor: Case report of 3 cases. Medicine (Baltimore) 2017; 96:e7799. [PMID: 28816971 PMCID: PMC5571708 DOI: 10.1097/md.0000000000007799] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Both serial arterial embolization (SAE) and denosumab have been proved to be effective in treatment for giant cell tumor (GCT). There is potential synergic effect of combining two methods. The purpose of current study is to justify a new treatment strategy of combination of SAE and denosumab as neoadjuvant or stand-alone treatment for large sacropelvic giant cell tumor. PATIENT CONCERNS Pelvic and sacral GCTs tend to be very large size and vascular. The concerns of surgical treatment were invasiveness of extensive surgery, intraoperative hemorrhage, nerve function jeopardized and local recurrence. However, SAE alone may not be adequate for complete removal of the tumor. DIAGNOSES All the three cases were proved to be GCT by core-needle biopsy. Post-treatment pathological change was confirmed by further biopsy. INTERVENTIONS The patient in Case 1 diagnosed of large recurrent sacral GCT received 6 times of endovascular embolizations with 2-month interval and started on denosumab simultaneously after first session of embolization. The second case was a 22-year-old female presented with a massive iliosacral tumor. SAE was performed for 3 sessions and the denosumab was started simultaneously. The patients was on treatment for half year. Both patients experienced a dramatic decrease in symptoms and concomitant improvement in function after the first embolization and weekly injection of denosumab. Tumor removal was performed on patient in case 2. The last case was a pelvic GCT and the patient received SAE and denosumab for half year. The tumor was then removed with purpose of complete cure. OUTCOMES The first patient was still on denosumab with stable tumor. The other two patients were both free of recurrence after surgical removal of the tumors. No denosumab was used postoperatively. LESSONS We reported the first three cases treated by combination of SAE and denosumab in the literature and aim to raise an alternative method for large GCT at challenging anatomical locations, for which surgery would carry significant risk. SAE and denosumab can synergically promote sclerosis and result in significant decrease in pain. It is reasonable to consider using SAE combined with denosumab neoadjuvantly to reduce the extensiveness and morbidity of surgery, however further investigation is warranted.
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Affiliation(s)
- Tao Ji
- Musculoskeletal Tumor Center
| | - Yi Yang
- Musculoskeletal Tumor Center
| | | | - Kunkun Sun
- Department of Pathology, People's Hospital, Peking University, Beijing, China
| | - Wei Guo
- Musculoskeletal Tumor Center
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Xu W, Wang Y, Wang J, Yang X, Liu W, Zhou W, Liu T, Xiao J. Long-term administration of bisphosphonate to reduce local recurrence of sacral giant cell tumor after nerve-sparing surgery. J Neurosurg Spine 2017; 26:716-721. [PMID: 28338455 DOI: 10.3171/2016.10.spine151197] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to investigate the effect of long-term bisphosphonate treatment on reducing local recurrence of sacral giant cell tumors (GCTs) after nerve-sparing surgery. METHODS Thirty-five consecutive patients with sacral GCTs who received treatment in Shanghai Changzheng Hospital between January 2000 and December 2010 were included in this study. Between January 2007 and December 2010, 19 patients received bisphosphonates following nerve-sparing surgery. Before January 2007, 16 patients received nerve-sparing surgery alone, and these cases were included as the control group. The difference in clinical data between the groups was compared by Student's t-test and 2-tailed chi-square or Fisher's exact test. The postoperative recurrence-free survival (RFS) and overall survival (OS) rates were estimated by the Kaplan-Meier method and compared between the groups by log-rank test. A p value < 0.05 was considered statistically significant. RESULTS All of the patients had relatively good nerve function. The clinical data were homogeneous between the groups. The local recurrence rate was 10.53% (2 of 19) in the bisphosphonate treatment group and 43.75% (7 of 16) in the control group. The log-rank test showed that the 3-year RFS and 3-year OS in the bisphosphonate treatment group were significantly higher than those in the control group (RFS 89.5% vs 56.3%, p = 0.04; OS 100% vs 81.3%, p = 0.05). CONCLUSIONS The long-term use of bisphosphonates after nerve-sparing surgery is a viable option for the treatment of sacral GCTs. This approach could reduce local recurrences while preserving nerve function.
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Affiliation(s)
- Wei Xu
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai
| | - Yu Wang
- Department of Spine Surgery, First Affiliated Hospital of Wenzhou Medical University, Zhejiang; and
| | - Jing Wang
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai
| | - Xinghai Yang
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai
| | - Weibo Liu
- Department of Spine Surgery, Qingdao Central Hospital, Qingdao, Shandong, China
| | - Wang Zhou
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai
| | - Tielong Liu
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai
| | - Jianru Xiao
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai
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Benign Tumors of the Spine: Has New Chemotherapy and Interventional Radiology Changed the Treatment Paradigm? Spine (Phila Pa 1976) 2016; 41 Suppl 20:S178-S185. [PMID: 27488295 DOI: 10.1097/brs.0000000000001818] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Clinically based systematic review. OBJECTIVE To determine the role of (A) medical treatment and (B) interventional radiology as either adjuvant or stand-alone treatment in primary benign bone tumors of the spine. METHODS A multidisciplinary panel of spine surgeons, radiation oncologists, and medical oncologists elaborated specific focused questions regarding aneurysmal bone cyst, giant cell tumor, and osteoid osteoma. Denosumab, bisphosphonate, interferon, bone marrow aspirate, doxycycline, thermal ablation, and selective arterial embolization were identified as areas of interest for the article. A systematic review was performed through MEDLINE and EMBASE. Recommendations based on the literature review and clinical expertise were issued using the GRADE system. RESULTS The overall quality of the literature is very low with few multicenter prospective studies. For giant cell tumor, combination with Denosumab identified 14 pertinent articles with four multicenter prospective studies. Nine studies were found on bisphosphonates and six for selective arterial embolization. The search on aneurysmal bone cyst and selective arterial embolization revealed 12 articles. Combination with Denosumab, Doxycycline, and bone marrow aspirate identified four, two, and three relevant articles respectively. Eleven focused articles were selected on the role of thermal ablation in osteoid osteoma. CONCLUSION Alternative and adjuvant therapy for primary benign bone tumors have emerged. Their ability to complement or replace surgery is now being scrutinized and they may impact significantly the algorithm of treatment of these tumors. Most of the data are still emerging and further research is desirable. Close collaboration between the different specialists managing these pathologies is crucial. LEVEL OF EVIDENCE N/A.
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Gaston CL, Grimer RJ, Parry M, Stacchiotti S, Dei Tos AP, Gelderblom H, Ferrari S, Baldi GG, Jones RL, Chawla S, Casali P, LeCesne A, Blay JY, Dijkstra SPD, Thomas DM, Rutkowski P. Current status and unanswered questions on the use of Denosumab in giant cell tumor of bone. Clin Sarcoma Res 2016; 6:15. [PMID: 27651889 PMCID: PMC5022265 DOI: 10.1186/s13569-016-0056-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 08/09/2016] [Indexed: 01/07/2023] Open
Abstract
Denosumab is a monoclonal antibody to RANK ligand approved for use in giant cell tumour (GCT) of bone. Due to its efficacy, Denosumab is recommended as the first option in inoperable or metastatic GCT. Denosumab has also been used pre-operatively to downstage tumours with large soft tissue extension to allow for less morbid surgery. The role of Denosumab for conventional limb GCT of bone is yet to be defined. Further studies are required to determine whether local recurrence rates will be decreased with the adjuvant use of Denosumab along with surgery. The long term use and toxicity of this agent is unknown as is the proportion of patients with primary or secondary resistance. It is advised that complicated cases of GCT requiring Denosumab treatment should be referred and followed up at expert centres. Collaborative studies involving further clinical trials and rigorous data collection are strongly recommended to identify the optimum use of this drug.
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Affiliation(s)
- Czar Louie Gaston
- Oncology Service, Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Birmingham, B31 2AP UK
| | - Robert J Grimer
- Oncology Service, Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Birmingham, B31 2AP UK
| | - Michael Parry
- Oncology Service, Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Birmingham, B31 2AP UK
| | - Silvia Stacchiotti
- Department of Cancer Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | | | | | | | - Giacomo G Baldi
- Department of Cancer Medicine, S. Stefano Civil Hospital, Prato, Italy
| | - Robin L Jones
- University of Washington/Fred Hutchinson Cancer Research Center, Seattle, WA USA ; Royal Marsden Hospital, London, UK
| | - Sant Chawla
- Sarcoma Oncology Center, Santa Monica, CA USA
| | - Paolo Casali
- Department of Cancer Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | | | | | | | | | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Center and Institute of Oncology, Warsaw, Poland
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Gulia A, Puri A, Byregowda S, Rekhi B, Laskar S, Shetty N. Inferior Vena Caval Tumor Thrombus in Giant Cell Tumor of Sacrum - An Unusual Complication Treated with Multimodality Management. J Orthop Case Rep 2016; 5:54-6. [PMID: 27299100 PMCID: PMC4845458 DOI: 10.13107/jocr.2250-0685.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Giant cell tumor is the most common benign lesion encountered. It accounts for 5 % of all skeletal tumors. It mainly affects the epiphysis of long bones and rarely axial bones. In axial bones, sacrum is the most common site to be affected. CASE REPORT A 23 year old female with giant cell tumor of sacrum was treated initially with conservative treatment (serial angioembolisation and bisphosphonates). Later intralesional curettage was done as the patient started developing bladder and bowel disturbances after two sessions of angioembolisation. Six months later patient again presented with pain at the primary lesion site and bilateral limb swelling. Imaging revealed recurrence of the disease and tumor thrombus extending into the inferior vena cava up to the subhepatic region. CONCLUSION Treatment of sacral GCT (Giant Cell Tumor) poses a unique challenge to the treating surgeon because of the close proximity of vital neurovascular structures, viscera and associated complications related to the disease. Tumor thrombi are a very rare phenomenon associated with giant cell tumors of the bone. High index of suspicion and multimodality approach is the key in treating such challenging tumors and their complications.
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Affiliation(s)
- Ashish Gulia
- Department of surgical oncology, Tata Memorial Centre, Mumbai, India
| | - Ajay Puri
- Department of surgical oncology, Tata Memorial Centre, Mumbai, India
| | - Suman Byregowda
- Department of surgical oncology, Tata Memorial Centre, Mumbai, India
| | - Bharat Rekhi
- Department of Pathology, Tata Memorial Centre, Mumbai, India
| | - Siddhartha Laskar
- Department of Raditaion Oncology, Tata Memorial Centre, Mumbai, India
| | - Nitin Shetty
- Department of Intervention Radiology, Tata Memorial Centre, Mumbai, India
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Tumor de células gigantes de raquis lumbar. Caso clínico y revisión de la literatura. Neurocirugia (Astur) 2015; 26:251-5. [DOI: 10.1016/j.neucir.2014.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 11/05/2014] [Accepted: 11/06/2014] [Indexed: 11/18/2022]
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Modified kraske procedure with mid-sacrectomy and coccygectomy for en bloc excision of sacral giant cell tumors. Case Rep Surg 2014; 2014:834537. [PMID: 25386379 PMCID: PMC4216674 DOI: 10.1155/2014/834537] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 10/05/2014] [Indexed: 12/13/2022] Open
Abstract
Sacral giant cell tumors are rare neoplasms, histologically benign but potentially very aggressive due to the difficulty in achieving a complete resection, their high recurrence rate, and metastization capability. Although many treatment options have been proposed, en bloc excision with tumor-free margins seems to be the most effective, being associated with long term tumor control, improved outcome, and potential cure. An exemplifying case of a 29-year-old female with progressive complaints of pain and paresthesias in the sacral and perianal regions, constipation, and weight loss for 6 months is presented. The surgical technique for en bloc excision of a large sacral giant cell tumor through a modified Kraske procedure with mid-sacrectomy and coccygectomy is described. Complete resection with wide tumor-free margins was achieved. At 5 years of follow-up the patient is neurologically intact, without evidence of local recurrence on imaging studies. A multidisciplinary surgical procedure is mandatory to completely remove sacral tumors. In the particular case of giant cell tumors, it allows minimizing local recurrence preserving neurovascular function, through a single dorsal and definitive approach.
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van der Heijden L, Dijkstra PDS, van de Sande MAJ, Kroep JR, Nout RA, van Rijswijk CSP, Bovée JVMG, Hogendoorn PCW, Gelderblom H. The clinical approach toward giant cell tumor of bone. Oncologist 2014; 19:550-61. [PMID: 24718514 DOI: 10.1634/theoncologist.2013-0432] [Citation(s) in RCA: 161] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
We provide an overview of imaging, histopathology, genetics, and multidisciplinary treatment of giant cell tumor of bone (GCTB), an intermediate, locally aggressive but rarely metastasizing tumor. Overexpression of receptor activator of nuclear factor κB ligand (RANKL) by mononuclear neoplastic stromal cells promotes recruitment of numerous reactive multinucleated giant cells. Conventional radiographs show a typical eccentric lytic lesion, mostly located in the meta-epiphyseal area of long bones. GCTB may also arise in the axial skeleton and very occasionally in the small bones of hands and feet. Magnetic resonance imaging is necessary to evaluate the extent of GCTB within bone and surrounding soft tissues to plan a surgical approach. Curettage with local adjuvants is the preferred treatment. Recurrence rates after curettage with phenol and polymethylmethacrylate (PMMA; 8%-27%) or cryosurgery and PMMA (0%-20%) are comparable. Resection is indicated when joint salvage is not feasible (e.g., intra-articular fracture with soft tissue component). Denosumab (RANKL inhibitor) blocks and bisphosphonates inhibit GCTB-derived osteoclast resorption. With bisphosphonates, stabilization of local and metastatic disease has been reported, although level of evidence was low. Denosumab has been studied to a larger extent and seems to be effective in facilitating intralesional surgery after therapy. Denosumab was recently registered for unresectable disease. Moderate-dose radiotherapy (40-55 Gy) is restricted to rare cases in which surgery would lead to unacceptable morbidity and RANKL inhibitors are contraindicated or unavailable.
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Affiliation(s)
- Lizz van der Heijden
- Departments of Orthopedic Surgery, Clinical Oncology, Radiology, and Pathology, Leiden University Medical Center, Leiden, The Netherlands
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van der Heijden L, van de Sande MAJ, van der Geest ICM, Schreuder HWB, van Royen BJ, Jutte PC, Bramer JAM, Öner FC, van Noort-Suijdendorp AP, Kroon HM, Dijkstra PDS. Giant cell tumors of the sacrum--a nationwide study on midterm results in 26 patients after intralesional excision. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:1949-62. [PMID: 24614982 DOI: 10.1007/s00586-014-3263-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 02/20/2014] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Evaluation of recurrences, complications and function at mid-term follow-up after curettage for sacral giant cell tumor (GCT). METHODS We retrospectively studied all 26 patients treated for sacral GCT in the Netherlands (from 1990 to 2010). Median follow-up was 98 (6-229) months. All patients underwent intralesional excision, 21 with local adjuvants, 5 radiotherapy, 3 IFN-α, 1 bisphosphonates. Functional outcome was assessed using Musculoskeletal Tumor Society (MSTS) score. Statistics were performed with Kaplan-Meier, Cox regression, log rank and Mann-Whitney U. RESULTS Recurrence rate was 14/26 after median 13 (3-139) months and was highest after isolated curettage (4/5). Soft tissue masses >10 cm increased recurrence risk (HR = 3.3, 95 % CI = 0.81-13, p = 0.09). Complications were reported in 12/26 patients. MSTS was superior in patients without complications (27 vs. 21; p = 0.024). CONCLUSION Recurrence rate for sacral GCT was highest after isolated curettage, indicating that (local) adjuvant treatment is desired to obtain immediate local control. Complications were common and impaired function.
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Affiliation(s)
- L van der Heijden
- Department of Orthopedic Surgery, Leiden University Medical Center (LUMC), Postzone J11-70, PO Box 9600, 2300 RC, Leiden, The Netherlands,
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Federman N, Brien EW, Narasimhan V, Dry SM, Sodhi M, Chawla SP. Giant cell tumor of bone in childhood: clinical aspects and novel therapeutic targets. Paediatr Drugs 2014; 16:21-8. [PMID: 24114694 DOI: 10.1007/s40272-013-0051-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Giant cell tumor of bone (GCTB) is a rare primary bone tumor that primarily affects young adults, but can be seen in children. The primary modality of treatment is surgical resection; however, this is not always possible given the location and extent of the neoplasm. Recent developments in the understanding of the underlying molecular pathogenesis of disease have pointed to interactions between the stromal component producing receptor activator of nuclear factor-kappaB (RANK) and RANK-ligand (RANKL) causing the formation of osteoclast-like giant cells that drive bone destruction. The development of a monoclonal humanized antibody to RANKL, denosumab, has been shown to reduce skeletal-related events from osteoporosis and from bony metastases from solid tumors. Recent phase II clinical trials with denosumab in skeletally mature adolescents over age 12 years and adults with GCTB, have shown both safety and efficacy, leading to its accelerated US FDA approval on 13 June 2013. In children who are skeletally immature, safety and efficacy has not been established, and there has been only published anecdotal use.
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Affiliation(s)
- Noah Federman
- Department of Pediatrics, Hematology/Oncology, Mattel Children's Hospital at University of California, Los Angeles, USA,
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Nakanishi K, Osuga K, Hori S, Hamada K, Hashimoto N, Araki N, Yoshikawa H, Tomiyama N. Transarterial embolization (TAE) of sacral giant cell Tumor (GCT) using spherical parmanent embolic material superabsorbant polymer microsphere (SAP-MS). SPRINGERPLUS 2013; 2:666. [PMID: 24353982 PMCID: PMC3866374 DOI: 10.1186/2193-1801-2-666] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 12/06/2013] [Indexed: 11/10/2022]
Abstract
Purpose We retrospectively evaluated our experience of transcatheter arterial embolization (TAE) of the sacral GCT with use of a spherical permanent embolic agent, superabsorbant polymer microsphere (SAP-MS) as an alternative treatment modality. Materials and methods From 1997 to 2011, four patients with sacral GCT were treated with TAE. In all cases, SAP-MS was used as an embolic material. The effects of TAE were evaluated for improvement of patients’ symptoms, radiographic change such as vascularity of tumor, size of tumor and occurrence of reossification. Results Of the four patients, three responded favorably to TAE with improvement in pain and neurologic symptoms with long-term follow up. Diminished vascularity, stabilization of tumor size and reossification were shown radiographically. One patient died because of tumor growth 26 months after the initial TAE. Conclusion In sacral GCT, TAE using SAP-MS might be useful for symptom improvement, reossification of the lesion and stabilization of tumor size.
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Affiliation(s)
- Katsuyuki Nakanishi
- Department of Diagnostic Radiology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3, Nakamichi, Higashinari-ku Osaka, 537-8511 Japan
| | - Keigo Osuga
- Department of Diagnostic and Interventional Radiology Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shinichi Hori
- Gate Tower Institute for Image Guided Therapy, Osaka, Japan
| | - Kenichiro Hamada
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Nobuyuki Hashimoto
- Department of Orthopedic Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Nobuhito Araki
- Department of Orthopedic Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Hideki Yoshikawa
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Noriyuki Tomiyama
- Department of Diagnostic and Interventional Radiology Osaka University Graduate School of Medicine, Osaka, Japan
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Long-term outcome of giant cell tumor of bone involving sacroiliac joint treated with selective arterial embolization and curettage: a case report and literature review. World J Surg Oncol 2013; 11:72. [PMID: 23497322 PMCID: PMC3615942 DOI: 10.1186/1477-7819-11-72] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 02/23/2013] [Indexed: 11/30/2022] Open
Abstract
Background Giant cell tumor of the sacrum, especially involving the sacroiliac joint, is rare, but is particularly challenging to treat. The long term outcome of a patient was studied with giant cell tumor involving the sacroiliac joint treated with selective arterial embolization and curretage. Method One patient with giant cell tumor involving the sacroiliac joint was treated with selective arterial embolization and curettage in our hospital in October 2002. The curettage and bone grafting was done after two times of selective arterial embolization;1600 ml of blood were transfused and no complications developed during the operation. Results At the final follow-up of 9 years after the operation, no local recurrence and metastasis developed and she retained normal activity in daily life. Conclusion We think it is an optimal treatment for giant cell tumor involving the sacroiliac joint, with repeated selective arterial embolization and curettage, which has the advantage of less injury, less blood loss and fewer complications.
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Shen CC, Li H, Shi ZL, Tao HM, Yang ZM. Current treatment of sacral giant cell tumour of bone: a review. J Int Med Res 2012; 40:415-25. [PMID: 22613402 DOI: 10.1177/147323001204000203] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Sacral giant cell tumour of bone has an insidious onset and slow growth rate, making early diagnosis difficult. The tumour has a high recurrence rate and is often fatal. Magnetic resonance imaging and computed tomography (CT), including CT-guided fine-needle biopsy, are useful for early diagnosis. Although therapy for sacral giant cell tumour often involves surgical resection and reconstruction challenges, improvements in various treatment modalities, including arterial embolization and radiotherapy, have widened the effective treatment options. The current surgical and adjuvant treatment modalities available for the management of sacral giant cell tumour are systematically reviewed and a suggested treatment algorithm is provided. En bloc excision remains the surgical procedure of choice, with functional reconstruction important in cases where the lesion is high in the sacrum. The use of adjuvant radiotherapy and chemotherapy remains controversial and should be studied further. Determination of the optimum treatment for sacral giant cell tumour will require randomized controlled trials. Early diagnosis, complete surgical resection with tumour-free margins and comprehensive treatment are important for local tumour control and improved outcome.
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Affiliation(s)
- C C Shen
- Department of Orthopaedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Laugharne E, Stirling A, Grimer R. Giant cell tumour with a lipoma of the sacrum. J Surg Case Rep 2012; 2012:10. [PMID: 24960735 PMCID: PMC3649558 DOI: 10.1093/jscr/2012.7.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We report the case of a 58-year old female who presented with insidious low back pain radiating to the buttock and thigh. Magnetic resonance imaging revealed a heterogenous high-signal (on T2-weighting) in the midline of the sacrum. Within this mass was a distinct area of low-signal intensity. Computed tomography revealed a lytic lesion within the sacrum. Biopsy confirmed the presence of a lipoma that contained within it a giant cell tumour. The patient proceeded to have surgical excision and bone graft augmentation.
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Affiliation(s)
| | - A Stirling
- Royal Orthopaedic Hospital, Birmingham, UK
| | - R Grimer
- Royal Orthopaedic Hospital, Birmingham, UK
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Surgical strategy for the management of sacral giant cell tumors: a 32-case series. Spine J 2012; 12:484-91. [PMID: 22801004 DOI: 10.1016/j.spinee.2012.06.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Revised: 04/28/2012] [Accepted: 06/21/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Surgical treatment of sacral giant cell tumors (GCTs) is associated with a high rate of complications, and there is controversy over which type of surgical treatment is optimal. PURPOSE To develop an optimal treatment strategy for sacral GCTs. STUDY DESIGN/SETTING Retrospective/academic medical center. PATIENT SAMPLE A total of 32 patients (18 women and 14 men) with sacral GCT who underwent surgery between August 1996 and August 2008. OUTCOME MEASURES Local recurrence rate, surgical margins, blood loss, sacral nerve root preservation, and complications. METHODS The medical charts of 32 patients were reviewed. RESULTS Patients underwent either wide resection (n=2), marginal resection (n=11), marginal resection plus curettage (n=12), or curettage alone (n=7). The curettage group and the wide resection group had the highest and lowest amounts of blood loss (4,500 vs. 1,300 mL, respectively). During follow-up (median, 42 months), 12 patients (37.5%) had local recurrence, including five of seven in the curettage group. The recurrence rate was significantly lower in the marginal excision group compared with that in the curettage group (18.2% vs. 71.4%, respectively; p=.049). Five patients had bladder dysfunction, and two patients had bowel dysfunction. Four patients who underwent marginal resection had lower limb dysfunction. Overall survival was 93.6%, and 2-year recurrence-free survival was 84.4%. CONCLUSIONS Choosing an optimal surgical margin in the treatment of sacral GCTs is of great importance for local recurrence control and sacral nerve root preservation. Curettage alone should not be used to treat sacral GCT.
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Giant cell tumors of the axial skeleton. Sarcoma 2012; 2012:410973. [PMID: 22448122 PMCID: PMC3289906 DOI: 10.1155/2012/410973] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Revised: 10/27/2011] [Accepted: 11/01/2011] [Indexed: 11/18/2022] Open
Abstract
Background. We report on 19 cases of giant cell tumor of bone (GCT) affecting the spine or sacrum and evaluate the outcome of different treatment modalities. Methods. Nineteen patients with GCT of the spine (n = 6) or sacrum (n = 13) have been included in this study. The mean followup was 51.6 months. Ten sacral GCT were treated by intralesional procedures of which 4 also received embolization, and 3 with irradiation only. All spinal GCT were surgically treated. Results. Two (15.4%) patients with sacral and 4 (66.7%) with spinal tumors had a local recurrence, two of the letter developed pulmonary metastases. One local recurrence of the spine was successfully treated by serial arterial embolization, a procedure previously described only for sacral tumors. At last followup, 9 patients had no evidence of disease, 8 had stable disease, 1 had progressive disease, 1 died due to disease. Six patients had neurological deficits. Conclusions. GCT of the axial skeleton have a high local recurrence rate. Neurological deficits are common. En-bloc spondylectomy combined with embolization is the treatment of choice. In case of inoperability, serial arterial embolization seems to be an alternative not only for sacral but also for spinal tumors.
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Chaudhary P, Khadim H, Gajra A, Damron T, Shah C. Bisphosphonate therapy is effective in the treatment of sacral giant cell tumor. ACTA ACUST UNITED AC 2011; 34:702-4. [PMID: 22156450 DOI: 10.1159/000334549] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Sacral giant cell tumors are particularly challenging to treat as they are often quite extensive and surround the sacral nerve roots, making surgical extirpation very difficult without high morbidity and frequent local recurrence. CASE REPORT We report on a 33-year old male patient with sacral giant cell tumor treated with intravenous bisphosphonate therapy after early failure of embolization procedures. At 3 years follow-up, the patient had no pain, no neurological deficits, and no local recurrence. CONCLUSION To our knowledge, this is one of the first reported cases of bisphosphonate therapy after failed embolization for control of a difficult giant cell tumor.
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Affiliation(s)
- Preeti Chaudhary
- Department of Internal Medicine, SUNY Upstate Medical Center, Syracuse, NY, USA
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Martin C, McCarthy EF. Giant cell tumor of the sacrum and spine: series of 23 cases and a review of the literature. THE IOWA ORTHOPAEDIC JOURNAL 2010; 30:69-75. [PMID: 21045974 PMCID: PMC2958273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Although there have been a few large case series of giant cell tumor (GCT) in the spine and sacrum, the treatment of these lesions remains controversial. We are reporting 23 additional cases of giant cell tumor in the spine and sacrum gathered from our institution and the personal consultation files of the senior author. Ten lesions occurred in the sacrum with an average age of 31 years (range of 13-49) and 13 occurred in the mobile spine with an average age of 39.1 years (range of 13-64). Most patients presented with pain or neurologic deficit at the site of tumor involvement, and symptoms were usually present for many months prior to diagnosis. Six of the sacral GCT patients were treated with pre-operative arterial embolization and intralesional surgical resection, and two developed a recurrence. Two of the sacral GCT patients had an en bloc resection and neither developed a recurrence. One sacral GCT patient was treated only with serial arterial embolization with good disease control. One sacral GCT patient did not receive any treatment. Eleven spinal GCT patients were treated with en bloc surgical resection and two developed a recurrence, the other two spinal GCT patients were treated with intralesional surgical resection and both developed a recurrence. Giant cell tumors of the spine and sacrum should be managed with en bloc resections whenever possible as this provides the greatest chance for cure. When the risk of post-operative neurologic deficit after en bloc excision is high, as in most of our sacral lesions, conservative therapy involving arterial embolization and intralesional resection offers the best results.
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