Clinicopathologic profile of 470 giant cell tumors of bone from a cancer hospital in western India

Tell-tale of a primary and recurrent giant cell tumour of distal ulna: A report of two cases

INTRODUCTION

Wrist functionality is severely hampered by giant cell tumours (GCT) of the distal ulna, which require careful surgical treatment. A thorough preoperative evaluation and precise tumour grading are essential for developing a treatment plan that maximises functional results while maintaining oncological control.

CASE PRESENTATION

We present 2 cases of distal end ulna giant cell tumour (GCT). The first case involves a primary GCT in a young male, treated with marginal excision and extensor carpi ulnaris tenodesis, with no recurrence over three years. The second case describes a recurrent GCT in a middle-aged male, initially treated with curettage and bone cement in primary stage, followed by a successful marginal excision after recurrence.

DISCUSSION

Distal ulna giant cell tumours (GCTs) are uncommon, violent lesions that have a significant chance of recurring, particularly in Campanacci grade III instances. Stabilisation procedures such as ECU tendon reconstruction address post-resection issues such as discomfort, limited forearm rotation, and grip weakness, although en bloc resection is favoured to minimise recurrence.

CONCLUSION

Both cases highlight the challenges and considerations in managing distal ulna GCTs, emphasizing that en-bloc resection may reduce recurrence rates compared to curettage in grade III Campanacci GCTs.

Giant cell tumor of the cervical spine: A case report

INTRODUCTION

A Giant Cell Tumor (GCT) of the bone is a locally osteolytic tumor made up of mononuclear ovoid stromal cells and multinucleated giant cells. It commonly affects long bones like the distal femur and proximal tibia, but can also develop in the cervical spine during the third and fourth decades of life.

PRESENTATION OF CASE

A 20-year-old female presented to the clinic with a complaint of neck pain persisting for one month. Clinical examination revealed bilateral radiculopathy in the upper limb, which was also associated with pain in the left shoulder and elbow. Imaging revealed a destructive lesion in the 7th cervical vertebra (C7). A biopsy was done which indicated a giant cell tumor (GCT). A C7 corpectomy was performed, which included the removal of the C7 vertebral body and application of a cage. At the two-year follow-up, the patient remained asymptomatic, and radiographs showed no signs of recurrence.

DISCUSSION

A Giant Cell Tumor (GCT) occurring above the sacrum, especially in the cervical spine, is extremely rare. Symptoms of GCT are often nonspecific and can include neck pain, numbness, and weakness in the upper limbs, which are sometimes mistaken for myalgia or disc disease. The main treatment goal for GCT is "en bloc" resection while preserving the joint, though this can be challenging, particularly in spinal cases.

CONCLUSION

It is crucial to acknowledge that GCT can appear in uncommon sites and age groups. Surgeons must have a high level of awareness and perform an adequate preoperative workup, before definitive treatment. The patient should undergo regular follow-ups to detect any recurrence or metastasis at an early stage.

Interferons as Neoadjuvant Chemotherapy for Giant Cell Tumor: A Hospital-Based Prospective Pilot Study

Introduction Neoadjuvant chemotherapy is now considered an effective way to treat Campanacci grade 2 and 3 giant cell tumors (GCTs). Assessment of these drugs is essential clinically, radiologically, and pathologically. This study analyzes the early results of angiogenesis inhibitors (interferons) in the aggressive GCT of bone.

Methodology A prospective pilot study was conducted from January 2021 to July 2022 including eight biopsy-proven GCT patients subjected to interferon therapy. Radiological assessment was done with changes on plain radiograph, computerized tomography scan, and magnetic resonance imaging. Histopathological examination was done by changes in the biopsy and resected segment.

Results Out of the eight patients included in the study, 26% (n = 3) were males and 62% (n = 5) were females, with mean age of the patients being 24.6 ± 8.48 years (range: 22–38). There was significant reduction of the size of swelling (p-value: 0.049), significant reduction in Visual Analog Scale score (p-value: 0.011), significant decrease in swelling size on radiograph (p-value: 0.012), significant marginal sclerosis (p-value: 0.001), significant neocortex formation on radiographs (p-value: 0.001), significant result in and osteoid formation (p-value: 0.001) on histology. Whereas Campanacci grade on plain radiographs, number of viable cells, and number of viable stromal cell were not statistically different in comparison with pretherapy and posttherapy status.

Conclusion Interferon therapy in a GCT has potential beneficiary effect in terms of clinical, radiological, and pathological outcomes. It might prove to be an effective alternative to standard neoadjuvant chemotherapy in the management of aggressive GCT of bones.

Level of Evidence III.

Immunohistochemical expression of H3.3 G34W in 100 giant cell tumors of bone and its diagnostic mimics, including its value in resolving uncommon diagnostic scenarios: A single institutional study at a tertiary cancer referral center, India

BACKGROUND

There can be a diagnostic challenge in differentiating giant cell tumor of bone (GCTB) from its mimics. Lately, histone H 3 F 3 A (Histone 3.3 ) G34W has been identified as a promising immunohistochemical marker.

AIMS

This study was aimed at evaluating H3.3 G34W immunostaining in 100 GCTBs, including its value in resolving diagnostic dilemmas.

MATERIALS AND METHODS

Immunohistochemical staining for H3.3 G34W was graded in terms of staining intensity (1+ to 3+) and the percentage of tumor cells showing crisp nuclear staining.

RESULTS

One hundred GCTBs occurred in 58 males and 42 females (M: F ratio = 1.3), of 7-66 years age (average = 31.3, median = 28), commonly in distal femur (26), followed by proximal tibia (17), distal radius (12), proximal humerus (7), metacarpals (7), sacrum (6), proximal fibula (6), and relatively unusual sites (19), including a single multicentric case. Out of 92 GCTBs, wherein H3.3 G34W immunostaining worked, 81 (88.1%) showed positive staining in the mononuclear cells, including tumors with fibrous histiocytoma-like areas, sparing osteoclast-like giant cells, with 3+ staining intensity in 65/81 (80%) tumors. All 7/7 (100%) malignant GCTBs showed positive staining, including the pleomorphic/sarcomatous cells. All 7/7 (100%) metastatic GCTBs showed positive immunostaining. Seven out of 10 post-denosumab treated GCTBs showed positive H3.3 G34W immunostaining in the residual mononuclear cells. None of the other 37 "giant cell-rich" lesions displayed H3.3 G34W immunostaining. Four of 9 GCTBs tested for H3.3 G34W mutation showed positive results.

CONCLUSIONS

The diagnostic sensitivity and specificity of H3.3 G34W for GCTB were 88.1% and 100%, respectively. This constitutes one of the first reports from our country, further validating the diagnostic value of H3.3 G34W in differentiating GCTB, including metastatic and malignant forms from its mimics, including small biopsy samples. Its value in various diagnostic dilemmas is presented and utility in identifying residual tumor cells in post-denosumab treated GCTBs is worth exploring.

Treatment of Clival Giant Cell Tumor: A Case Report and Literature Review

Giant cell tumors (GCTs) are locally aggressive primary bone tumors of osteoclast-like cells. Most GCTs occur within the long bones, and primary GCTs involving the clivus are extremely rare. We present the case of an 18-year-old boy with binocular horizontal diplopia with an insidious onset who was found to have a hypointense enhancing mass involving the clivus and left side dorsum sellae on magnetic resonance images. The tumor was completely resected via an endoscopic endonasal transclival approach, and histopathologic examination via immunohistochemistry indicated a GCT. The patient's left abducens nerve palsy improved slightly after surgery. Because of the rarity of GCTs, there is no consensus about the definitive treatment protocol. However, we suggest that gross total resection is the treatment of choice, and denosumab plays a critical role in patients with subtotal resection.

Revisiting En Bloc Resection Versus Piecemeal Resection for the Treatment of Giant Cell Tumor of the Spine

OBJECTIVE

Surgery for spinal giant cell tumors (GCTs) is challenging because these tumors often exhibit a poor clinical course owing to their locally aggressive features. This study aimed to investigate the prognostic factors of GCT recurrence in the spine by focusing on surgical factors.

METHODS

We retrospectively reviewed patients who underwent surgery for spinal GCTs between January 2005 and December 2016. Using the Kaplan-Meier method, surgical variables were evaluated for disease-free survival (DFS). Since tumor violation may occur at the pedicle during en bloc resection of the spine, it was further analyzed as a separate variable. Multivariate Cox proportional hazard regression analysis was performed for other clinical and radiographic variables. A total of 28 patients (male:female = 8:20) were included. The mean follow-up period was 90.5 months (range, 15-184 months).

RESULTS

Among the 28 patients, gross total resection (GTR) was the most important factor for DFS (P = 0.001). Any form of tumor violation was also correlated with DFS (P = 0.049); however, use of en bloc resection technique did not show a significant DFS gain compared to piecemeal resection (P = 0.218). In the patient group that achieved GTR, the mode of resection was not a significant factor for DFS (P = 0.959). In the multivariate analysis, the extent of resection was the only significant variable that affected DFS (P = 0.016).

CONCLUSIONS

Conflicting results on tumor violation from univariate and multivariate analyses suggest that GTR without tumor violation should be the treatment goal for spinal GCTs. However, when tumor violation is unavoidable, it would be important to prioritize GTR over adhering to en bloc resection.

Case Report: Unresectable pulmonary metastases of a giant cell tumor of bone treated with denosumab: a case report and review of literature

Giant cell tumors of bone (GCTB) sometimes metastasize to distant organs. In this case report, we present pulmonary metastases of GCTB mimicking malignancies. A 49-year-old man underwent two surgical treatments for a GCTB of the right proximal radius. At the time of the second surgery, no lesions were observed on chest radiography. Three years after surgery, the patient presented with cough and dyspnea, and chest radiography and computed tomography (CT) revealed multiple lung nodules. Positron emission tomography/CT revealed a high accumulation of 18F-fluoro-2-deoxy-D-glucose (18F-FDG) in multiple lesions. Based on the rapid growth and accumulation of 18F-FDG, a metastatic malignant tumor was suspected. CT-guided needle biopsy was performed, and the histology showed proliferation of spindle cells and multinuclear giant cells without malignant changes. Denosumab was administered because multiple lung lesions were unresectable. One month after denosumab treatment, CT showed marked shrinkage of the lesions, and the symptoms significantly improved. Eighteen months after the initial treatment with denosumab, the patient had no symptoms or tumor growth. Although its long-term efficacy and safety remain unclear, denosumab may be a treatment option for patients with unresectable pulmonary GCTB.

Wide resection for giant-cell tumor of the distal radius: which reconstruction? A systematic review of the literature and pooled analysis of 176 cases

Giant-cell tumor (GCT) is often more aggressive when located in the distal radius, and wide resection is then the gold-standard. No single reconstruction protocol is recommended, and the technique depends upon the surgeon's preferences. The aim of the present review was to determine the recurrence rate of GTC of the distal radius after intralesional treatment, to assess the results, advantages and complications of the various surgical techniques, and to draw up a decision-tree for surgical indications. The review of literature was performed in the main healthcare databases, searching for studies that reported results of wide resection and reconstruction of distal radius GCT. Local recurrence rates, metastasis rates, reconstruction techniques and respective results and complications were evaluated and analyzed. Sixteen studies were selected, for a total population of 226 patients; 6.0% and 0.9% experienced local recurrence and lung metastasis, respectively. Arthroplasty with non-vascularized or vascularized ipsilateral fibula were the most common techniques and were associated with the highest satisfaction rates: 86.4% and 88.0%, respectively. Arthroplasty with allograft presented a MusculoSkeletal Tumor Society (MSTS) score of 79.2% and arthroplasty with custom-made prosthesis presented an MSTS score of 81.8%. Arthrodesis was performed in 46 cases, with an MSTS score of 82.7%. Arthroplasty techniques are the most common in literature; they are used in patients who wish to conserve joint motion. Reconstruction with non-vascularized fibula seems to provide the best results, with lower morbidity. Arthrodesis is usually reserved for heavy manual workers or in case of arthroplasty failure.

A Retrospective Audit of Demography and Different Surgical Modalities Adopted for Giant Cell Tumor of Bone in Eastern India

Background and objective

There is scarce data on demography and different surgical treatment modalities for giant cell tumor of bone (GCTB) from eastern India. In light of this, the present study aimed to examine the demographic characteristics, different surgical treatment modalities, and recurrence rate of GCTB at a tertiary care institute in Bihar.

Materials and methods

A retrospective audit of 52 GCTB patients who were treated at the center from January 2016 to December 2020 was conducted. The minimum follow-up period was one year. GCTB patients underwent surgical procedures ranging from extended intralesional curettage with bone graft or bone cement with or without fixation to wide local excision to resection with or without reconstruction or amputation depending on the stage and site of the tumors.

Results

The mean age of patients was 31.86 years (range: 13-67 years). The distal femur (20 patients, 38.46%) and proximal tibia (11 patients, 21.15%) were the most common sites of the tumor. Sixty-eight confirmed cases (male: 32, female: 36) of GCTB were operated on, with a male-to-female ratio of 1:1.125. Sixteen patients (four males and 12 females) were lost to follow-up. So, the final study consisted of 52 patients with a median age of 28 years (first quartile: 24 years, third quartile: 38 years). The majority of patients (32 patients, 61.53%) were in the third and fourth decades of life.

Conclusion

Based on this retrospective audit, it is concluded that the knee region is the most common site of GCTB. Surgery is the mainstay of management. Most of the patients came under Campanacci Grade 3 with low compliance with follow-up and adherence to the treatment. Hence, educational programs, the establishment of early detection centers, and timely referral to expert treatment are necessary.

Outcome of Reoperation for Local Recurrence Following En Bloc Resection for Bone Giant Cell Tumor of the Extremity

En bloc resection is typically performed to treat giant cell tumors of bone (GCTB), particularly when curettage can be challenging owing to extensive bone cortex destruction with soft tissue extension. Few reports have addressed the clinical outcomes after reoperation for local recurrence in patients with GCTB who underwent en bloc resection. In this multicenter retrospective study, we investigated local recurrence, distant metastasis, malignant transformation, mortality, and limb function in patients treated for local recurrence following en bloc resection for GCTB. Among 205 patients who underwent en bloc resection for GCTB of the extremities between 1980 and 2021, we included 29 with local recurrence. En bloc resection was performed for large tumors with soft tissue extension, pathological fractures with joint invasion, complex fractures, and dispensable bones, such as the proximal fibula and distal ulna. Local re-recurrence, distant metastasis, malignant transformation, and mortality rates were 41.4% (12/29), 34.5% (10/29), 6.9% (2/29), and 6.9% (2/29), respectively. The median Musculoskeletal Tumor Society score was 26 (interquartile range, 23–28). The median follow-up period after surgery for local recurrence was 70.1 months (interquartile range, 40.5–123.8 months). Local recurrence following en bloc resection for GCTB could indicate an aggressive GCTB, necessitating careful follow-up.

Secondary Malignancy in Giant Cell Tumor: A Single-Center Study

Giant cell tumor of bone (GCTB) undergoes a sarcomatous transformation. Secondary malignancy in giant cell tumor (MGCT) is associated with radiotherapy and has a dismal prognosis. We reviewed medical records to investigate the clinicopathological characteristics and prognosis of MGCT patients. The enrollment criterion was high-grade spindle-cell sarcoma, which developed at the site of prior GCTB treatment. Twelve patients were analyzed: six females and six males. The median age was 42.5 years. Benign recurrence occurred in five GCTB patients not treated with radiotherapy. No pulmonary implants were observed. The median latency to the malignant transformation was 63 months. Nine patients were AJCC stage IIB, and three were stage IVA. The median follow-up period after malignant transformation was 62.5 months. Five patients developed local recurrence, and six had distant metastasis. Five-year overall recurrence and metastasis-free survival rates were 61.9%, 66.7%, and 58.3%, respectively. Initial metastasis was a predictive factor for overall survival. Benign local recurrence of GCTB was also a negative factor for metastasis-free survival of MGCT patients. Differences in overall survival according to benign recurrence also showed a tendency toward significance. In our series, secondary MGCT did not occur after radiotherapy. The prognosis was better than previous findings. Benign recurrence of GCTB could reflect the prognosis of MGCT.

Diagnosis and Treatment of Lumbar Giant Cell Tumor of the Spine: Update on Current Management Strategies

(1) Background: Giant Cell Tumor of the spine remains a difficult tumor to treat. Recent advances in adjuvant therapy such as denosumab and innovations in surgical technique in the last 5 years have given providers new options for treatment after a successful diagnosis of the tumor. (2) Methods: Articles published between 1927 and 2021 were selected from PubMed and Scopus searches using key words “Giant Cell Tumor” AND “Lumbar Spine” AND “Treatment”. Relevant articles were reviewed and selected by the authors. (3) Results: A total of 191 articles were discovered. Complete en bloc spondylectomy remains the most definitive treatment option; however, this surgery is challenging and carries a high rate of complication. New adjuvant therapies including denosumab offer a viable alternative to surgery. (4) En bloc spondylectomy remains the gold standard treatment for Giant Cell Tumor of the spine with the lowest published recurrence rate. The use of (neo)adjuvant denosumab improves recurrence rates. More data are needed to determine if denosumab alone is a viable standalone definitive treatment.

Metastasectomy Versus Non-Metastasectomy for Giant Cell Tumor of Bone Lung Metastases

Approximately 2% to 9% of giant cell tumor of bone (GCTB) metastasizes systemically, mainly to the lungs. The biological behaviors and clinical courses of lung metastases are difficult to predict, and their treatment recommendations vary, including metastasectomy and non-metastasectomy with chemotherapy (denosumab, interferon-alfa, bisphosphonates), with radiation therapy, or with observation alone. However, it is unclear whether metastasectomy for GCTB lung metastases decreases the mortality rate of these patients. Therefore, the authors performed this systematic review to compare metastasectomy and non-metastasectomy for GCTB patients with operable lung metastasis. Of the 919 relevant studies, 16 studies (138 patients) were included for analysis; 61.6% of patients had metastasectomy and 38.4% had non-metastasectomy. Analysis showed that mortality rates were similar for the patients who had metastasectomy compared with those who did not; the proportion of patients who died of disease was 7.1% in the metastasectomy group and 17.0% in the non-metastasectomy group, with an overall pooled odds ratio of 0.64 (P=.36). Therefore, physicians should reconsider the potential risks and benefits of metastasectomy for patients with GCTB and lung metastasis, because metastasectomy does not reduce the mortality rate in these patients. [Orthopedics. 2021;44(6):e707-e712.].

The roles of metastasis-related proteins in the development of giant cell tumor of bone, osteosarcoma and Ewing's sarcoma

BACKGROUND:

Giant cell tumor of bone (GC), osteosarcoma (OS) and Ewing’s sarcoma (ES) are three different types of bone cancer with common and specific pathology features.

OBJECTIVE:

The purpose of the study was to examine the relationship and differences of the three bone tumors using clinical samples.

METHODS:

Through screening the profiles of clinical samples from GC, OS and ES patients using a humanoncology array, we found 26, 25 and 15 tumorigenesis factors significantly increased in GS, OS and ES tissues compared to normal individuals. eNOS, endostatin, HIF-1α, IL-6, CCL2/MCP-1, CCL8/MCP-2, CCL7/MCP-3, Tie and VEGF directly or indirectly involve in the metastasis Therefore, expression levels of the 6 factors were further determined by Western blot.

RESULTS:

The results showed levels of MCP1, MCP2, MCP3 or IL-6 in the GS, OS and ES significantly increased, and the expression levels of angiogenesis and anti-angiogenesis factors containing eNOS, endostatin, HIF-1α, Tie or VEGF were enhanced.

CONCLUSIONS:

Our results suggest that eNOS, endostatin, HIF-1α, IL-6, CCL2/MCP-1, CCL8/MCP-2, CCL7/MCP-3, Tie and VEGF may play important roles in tumorigenesis, reveal the expression differences of tumor-associated cytokines and angiogenesis related factors, and provide clinical evidence for studying the mechanisms on the metastasis in GC, OS and ES.

Current Concepts in the Treatment of Giant Cell Tumors of Bone

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.

Risk factors and oncological outcomes of pulmonary metastasis in patients with giant cell tumor of bone

BACKGROUND

Giant cell tumor (GCT) of bone has a rare potential for metastatic spread. This study aimed at evaluating the incidence of chest metastases in GCT and their oncological outcome and identifying possible risk factors.

METHODS

Medical records of 466 (313 de novo and 153 recurrent) patients with primary GCT of bone were retrospectively reviewed. Fifteen (3.2%) patients developed chest metastasis. Time from diagnosis of the primary bone lesion to the diagnosis of metastasis, treatment modalities of metastasis, and the course of treatment were revised. The functional outcome was evaluated using the Musculoskeletal Tumor Society (MSTS) scoring system, and postoperative complications were recorded.

RESULTS

This study included 7 males and 8 females with a mean age of 27.3 ± 7.9 years. The most common site of the primary tumor was the distal femur. All fifteen patients were recurrent cases. The mean follow-up period was 67.7 ± 33.2 months. Chest metastasis was diagnosed after a mean time of 28.1 ± 28.9 months from the initial diagnosis of the bone lesion. One patient died of disease (DOD) 18 months after the surgical intervention. The incidence of chest metastasis in recurrent cases was 9.8%, while de novo cases did not develop chest metastasis, P < 0.001. Previous curettage was associated with a higher incidence of chest metastasis (14.6%) compared to previous resection (4.2%), P = 0.03.

CONCLUSIONS

Chest metastasis following GCT of bone is rare. Risk factors include recurrent cases, especially following previous curettage. Patients have a good prognosis and a low mortality rate.

LEVEL OF EVIDENCE

Level IV, retrospective.

Surgical management of rare benign tumors of the sternum

Primary benign tumors of the sternum are an exceedingly rare entity. Surgical techniques regarding intervention for these lesions are not clearly defined in the literature given their scarcity. Operative techniques include en-bloc resection of the tumor, and this has proven to be successful in preventing local recurrence despite benign nature of the lesion. Given the often extensive defect created by the excision, reconstruction is frequently necessary; depending on the size of the defect, either autologous bone grafting or the use of synthetic materials may be indicated. This study serves to present two cases of rare primary benign tumors of the sternum, giant cell tumors and osteoma spongiosum and to summarize the available literature. We present a review of the literature of 17sternal giant cell tumor cases reported so far including our patient and unique case of osteoma spongiosum of the sternum, that discusses their surgical management, as well as reconstructive techniques that provided an excellent clinical result and a lack of recurrence on long term follow-up.

Osteoclasts in Tumor Biology: Metastasis and Epithelial-Mesenchymal-Myeloid Transition

Osteoclast is a specialized cell that originates from monocytic lineage, communicates closely with osteoblasts under physiological conditions, participates in bone modeling and re-modeling, contributes to calcium homeostasis and osteoimmunity. In pathological conditions, it is involved in many tumors such as giant cell bone tumor (osteoclastoma), aneurysmal bone cyst, osteosarcoma, and metastatic cancers, and it usually causes local spread and progression of the tumor, working against the host. Since osteoclasts play an active role in primary bone tumors and bone metastases, the use of anti-osteoclastic agents significantly reduces the mortality and morbidity rates of patients by preventing the progression and local spread of tumors. Osteoclasts also accompany undifferentiated carcinomas of many organs, especially pancreas, thyroid, bladder and ovary. Undifferentiated carcinomas rich in osteoclasts have osteoclastoma-like histology. In these organs, osteoclastoma-like histology may accompany epithelial carcinomas, and de novo, benign and borderline tumors. Mature and immature myeloid cells, including osteoclasts, play an active role in the tumor progression in primary and metastatic tumor microenvironment, in epithelial-mesenchymal transition (EMT), mesenchymal-epithelial-transition (MET), and cancer stem cell formation. Additionally, they are the most suitable candidates for cancer cells in cell fusion due to their evolutionary fusion capabilities. Myeloid features and markers (CD163, CD33, CD68 etc.) can be seen in metastatic cancer cells. Consequently, they provide metastatic cancer cells with motility, margination, transmigration, chemotaxis, phagocytosis, angiogenesis, matrix degradation, and resistance to chemotherapy. For these reasons, we think that the concept of Epithelial-Mesencyhmal-Myeloid-Transition (EMMT) will be more accurate than EMT for cancer cells with myeloid properties.

Pulmonary metastasis of giant cell tumour: a retrospective study of three hundred and ten cases

BACKGROUND

Giant cell tumour (GCT) is an invasive benign bone tumour, and the incidence of pulmonary metastasis is rare. We are aiming to analyze risk factors of pulmonary metastasis and clinical prognosis for giant cell tumour patients with pulmonary metastasis.

METHOD

We performed a retrospective study of 310 patients with GCT between December 2004 and December 2016. Risk factors of pulmonary metastasis were analyzed by univariate and multivariate logistic regression analysis. Then, the influence of risk factors of overall LR (local recurrence), recurrent tumor at presentation, LR after our therapy, and with soft tissue mass on the pulmonary metastasis-free survival rates was analyzed.

RESULTS

The mean follow-up of the present cohort was 45.6 ± 35.3 months (median, 36.6 months; range, 6.1-193.4 months). Eighteen (5.8%) of 310 patients developed pulmonary metastasis. The average interval from surgery of primary tumour to detection of pulmonary metastasis was 15 months. Multivariate logistic regression analysis showed overall local recurrence was the independent risk factor of developing pulmonary metastasis. Among 18 patients with pulmonary metastasis, sixteen cases had history of local recurrence (88.9%, 16/18), including eleven (68.8%, 11/16) with local recurrence at presentation before receiving our therapy and seven (43.8%, 7/16) with local recurrence after receiving treatment in our hospital. Time to local recurrence had obvious difference between patients with and without pulmonary metastasis. Patients with pulmonary metastasis were prone to recur earlier. Furthermore, overall local recurrence, local recurrence after our therapy, recurrent tumor at presentation, and tumour with a soft tissue mass showed statistical differences in the pulmonary metastasis-free survival rates.

CONCLUSIONS

Giant cell tumour patients with soft tissue mass and overall local recurrence are prone to develop pulmonary metastasis. Although giant cell tumour is a benign tumor, more attention should be paid to the problem of pulmonary metastatic lesions, and chest CT scan should be recommended during follow-up.

Limb Salvage Surgery in Fungating Giant Cell Tumors: A Report of Three Cases

Introduction:

The WHO defines giant cell tumor as a benign locally aggressive neoplasm with metastasizing capacity and aggressive behavior. Very rarely, these tumors are seen fungating, mostly when neglected. But when they do, the treatment option commonly conferred is amputation of the limb which is disabling and traumatizing.

Case Report:

We report three cases of fungating limb masses (proximal tibia, distal fibula, and distal radius) diagnosed with giant cell tumor histologically, undergoing limb saving surgeries with various reconstruction techniques to endorse a good quality of life and functioning limb.

Conclusion:

Our study is one of the earliest to report medium-term follow-up after such limb salvage procedure. We recommend that salvage procedures should be considered in giant cell tumors even in the presence of fungation if there is no neurovascular encasement.

Dosing interval adjustment of denosumab for the treatment of giant cell tumor of the sphenoid bone: A case report

Background:

In the treatment of giant cell tumor of bone (GCTB), the efficacy and safety of denosumab, a receptor activator nuclear factor κ-B ligand inhibitor, has previously been demonstrated, especially for unresectable tumors. One of the current issues in denosumab treatment for unresectable GCTB is whether it can be discontinued, or whether the dosage or the dosing interval can safely be adjusted, if discontinuation is not possible, to avoid the occurrence of side effects.

Case Description:

A 15-year-old boy with diplopia was referred to our hospital after a space-occupying lesion in the sphenoid bone was found on head CT. Partial removal of the tumor was performed through an endoscopic endonasal approach, and pathological diagnosis was confirmed as GCTB. Thereafter, the patient received 120 mg subcutaneous injections of denosumab every 28 days for the first 2 years. Since bone formation was induced and sustained along with tumor reduction, the dosing interval was gradually extended, with 4 monthly dosing for the next 1 year, followed by 6 monthly dosing for the succeeding 2 years. With the extension of the dosing interval, the ossified tumor has regrown slightly, but within an acceptable range.

Conclusion:

Discontinuation of denosumab treatment for unresectable GCTB was not thought to be possible for the current case due to the nature of the drug, as reported in the literature. Extending the dosing interval up to 6 monthly, as could be done safely in the current case, can be considered a useful and appropriate measure.

Clinical and Radiological Profile of Ten Interesting Though Rare Presentations of Giant Cell Tumor of Bone

Giant cell tumor (GCT) is a benign but locally aggressive lesion of the bone. They are common in skeletally matured individuals with female preponderance. Unusual presentations can occur rarely. This study aims to find out the clinical and radiological profile of ten rare presentations of GCT. We have conducted a retrospective analysis of medical records of ten interesting presentations of giant cell tumor of bone. There was a patient with soft-tissue recurrence after excision. In five cases, the GCT occurred at rare sites and a case to discuss the radiological dilemma in the diagnosis. One case of pathological fracture, another case of seeding of tumor cells in the graft donor site, and a case of pulmonary metastasis were included. There were seven females, two males, and a boy. Out of ten patients, all except two cases were primarily treated at our institution. Clinical profiles of soft-tissue recurrence, rare sites of occurrence, diagnostic dilemma, pathological fracture, seeding at donor site, and metastasis were analyzed and presented. GCT, even though it is a benign lesion, can have a variety of clinical presentations and complications.

Incidence, Management, and Outcomes of Spinal Giant Cell Tumor of Bone in Adult Patients: A National Cancer Database Analysis

OBJECTIVE

Giant cell tumors (GCTs) constitute 5% of all primary bone tumors with spinal GCTs (SGCTs) accounting for 2%-15% of all GCTs. The standard of care for SGCT has been maximal surgical resection. However, many adjuvant therapies have been used owing to the difficulty in achieving gross total resection combined with the high local recurrence rate. The purpose of the present study was to analyze the incidence, management, and outcomes of SGCT.

METHODS

Patients with diagnosis codes specific for SGCT were queried from the National Cancer Database from 2004 to 2016. The outcomes were investigated using Cox univariate and multivariate regression analyses, and survival curves were generated for comparative visualization.

RESULTS

The search criteria identified 92 patients in the NCDB dataset from 2004 to 2016 with a diagnosis of SGCT. Of the 92 patients, 64.1% had undergone surgical intervention, 24.8% had received radiotherapy, and 15.2% had received immunotherapy. Univariate analysis revealed that age ≥55 years and tumor location in the sacrum/coccyx were associated with worsened overall survival (OS) and that surgical resection was associated with improved OS. On multivariate analysis, age 55-64 years was associated with worsened OS, and radical surgical resection was associated with improved OS. The survival analysis revealed improved OS with surgery but not with radiotherapy, chemotherapy, or immunotherapy.

CONCLUSION

SGCT is a rare primary bone tumor of the vertebral column. The standard of care has been surgical resection with the goal of gross total resection; however, adjuvant therapies have often been used. Our study found that surgical resection significantly improved OS and that immunotherapy neared significance in improving OS.

Successful Treatment with Denosumab of a Giant Cell Tumor of Bone in the Iliac Bone of an 84-Year-Old Man

We report a case of GCTB in an 84-year-old Japanese man who had a tumor in his left iliac bone and was treated safely with denosumab. The patient noticed a painful mass, with gradual enlargement, in his left low back next to the iliac region. Magnetic resonance imaging revealed that the tumor measured 94 × 66 × 90 mm and was located in the left iliac bone. Histologically, the tumor was composed of proliferative oval-shaped mononuclear cells, admixed with large number of osteoclast-like giant cells. Immunohistochemically, a strong positivity for histone 3.3 G34W mutant protein was observed in the nuclei of the mononuclear cells, confirming the diagnosis of GCTB. Because it was considered as unresectable tumor, the patient was treated with denosumab without any side effects.

Atraumatic groin pain secondary to an aneurysmal bone cyst: A case report and literature review

BACKGROUND

Bone lesions can present the multi-displinary team with a challenge by way of diagnosis as some lesions share many radiological and histological characteristics. Giant cell tumours of the bone (GCTB) are relatively common, benign bone tumours. Aneurysmal bone cysts (ABC) are less common benign osteolytic lesions that are histologically similar to GCTBs but produce blood filled cavities. Both GCTBs and ABCs are locally aggressive and are typically found on meta-epiphyseal regions of long bones with pelvic tumours being less common.

CASE SUMMARY

A 17-year old female presented with atraumatic right groin pain and was initially diagnosed with a GCTB on the right superior pubic ramus of the pelvis. The patient was treated successfully with a wide excision, curettage and bone graft and underwent open reduction and internal fixation of the right hemi-pelvis. Following further intra-operative histological investigations, the lesion was diagnosed as an ABC.

CONCLUSION

This patient has had an uncomplicated post-operative course, has returned to comfortable weight bearing and will be reviewed for minimum 5 yr in the out-patient setting to monitor for reoccurrence.

Histone H3.3 mutation in giant cell tumor of bone: an update in pathology

Giant cell tumor of bone (GCTB) is a locally aggressive bone tumor that frequently shows local recurrence and occasionally shows malignant transformation to high-grade sarcoma. Histologically, conventional GCTB is composed mainly of three types of cells: mononuclear neoplastic cells with an osteoblastic precursor phenotype, mononuclear histiocytic cells, and osteoclast-like multinucleated giant cells. These cells interact with each other via the RANKL-RANK axis and other mechanisms for tumor formation. The vast majority of GCTBs were recently revealed to harbor H3F3A p.G34W mutation, and a minor subset have H3F3A p.G34L, p.G34M, p.G34R, or p.G34V mutation. H3.3 G34W mutant-specific immunohistochemistry is a highly sensitive and specific surrogate marker for H3F3A p.G34W mutation in GCTB and thus useful for differential diagnoses of histological mimics. H3.3 mutant-specific immunohistochemistry has also contributed to the understanding of the bone-forming ability of neoplastic cells of GCTB and the remarkable new bone formation after treatment with denosumab, an inhibitor of RANKL. In primary and secondary malignant GCTBs, the H3F3A gene allele can be preserved or lost with malignant transformation.

Increased Risk of Lung Metastases in Patients with Giant Cell Bone Tumors: A Systematic Review

Giant cell tumors of the bone are rare, usually benign, tumors consisting of large, multinucleated bone cells. Remarkably, these tumors are characterized by aggressive growth. They tend to recur frequently and, in rare cases, metastasize to the lungs. Previous studies tried to identify risk factors for lung metastasis by giant cell bone tumors. Those studies reported different results due to a small number of patients. Therefore, a particularly high risk associated with this type of bone tumor prompted this systematic review and meta-analysis to identify risk factors for the development of lung metastases. The risk factors for lung metastasis by giant cell bone tumors searched for in this study were gender, age, lung metastasis and recurrence period, follow-up time, primary or recurrent tumor, Campanacci grading, tumor localization, disease course, treatment of primary and recurrent tumors, and pulmonary metastases treated by surgery, radiation, and chemotherapy. This meta-analysis identified the features outlined above by comparing the groups of patients with giant cell bone tumors and lung metastases with the control group consisting of patients without lung metastases. The search for suitable studies revealed 63 publications with a total of 4,295 patients with giant cell bone tumors. Of these, 247 (5.8%; 95% confidence interval (95%CI) 5.1-6.5%) patients had lung metastases. Further, the risk factors for lung metastases were the following: recurrence (p < 0.0001), lung metastasis time (p < 0.0001), Campanacci grade II (p = 0.028) and grade III (p = 0.006), localization in the lower limbs (p = 0.0007), curettage (p = 0.0005), and local irradiation of the primary tumor (p = 0.008). All studies showed a high-risk bias due to the absence of blinding of the participants, personnel, and outcome assessment. Special attention should be paid to tumor recurrence in the long follow-up time, since more advanced giant cell bone tumors, particularly in lower extremities, tend to reoccur and metastasize to the lung. Surgical treatment and local irradiation should be performed thoughtfully, with extended follow-up periods.

Prognosis of metastatic giant cell tumor of bone in the pre-denosumab era. A systematic review and a meta-analysis

Background

Data on long-term prognosis of metastatic GCT (mGCT) is scant. The frequency of spontaneous regressions (SRs) is unknown. We aimed to estimate the prognosis of mGCT.

Methods

We searched electronic scientific literature databases and generic Internet from January 1980 to August 2017. After identifying eligible studies we performed descriptive analyses and meta-analyses to estimate overall survival (OS), disease specific survival (DSS) and frequency of SRs in the years before the widespread use of denosumab. We performed pre-specified subgroup analyses of studies published before and after 2000 and of those with more and less than 10 years of follow-up.

Results

After retrieving and combining data from 26 relevant retrospective case-series totaling 242 patients with a median follow-up of 6.9 years, the estimated pooled OS was 86.9% (95% CI 78.0-94.2). Pooled DSS was 88.0% (95% CI 79.7-94.7). SRs were observed in 4.5% of patients. In the subgroup of studies published after 2000 mGCT was the only cause of death of affected subjects. In case-series with a follow-up longer than 10 years pooled DSS was 69.7% (95% CI 25.5-99.8).

Conclusions

To our knowledge this is the first study to derive estimated pooled OS and DSS of mGCT based on a large dataset. SRs were not exceptional phenomena. In a long run the disease could impact in a significant way on the life expectancy of affected subjects.

Safety and efficacy of denosumab in the treatment of pulmonary metastatic giant cell tumor of bone

Background

Giant cell tumor (GCT) of bone is an intermittent and locally aggressive tumor with increasing pulmonary metastatic potential. In this study, we evaluated the interim clinical outcome of denosumab in patients with pulmonary metastatic GCT.

Materials and methods

We retrospectively reviewed seven patients with pulmonary metastatic GCT who received denosumab treatment after local tumor surgery during January 2014 and July 2016. Denosumab treatment for all patients lasted for at least 12 months. Serial chest computerized tomography scan was used to monitor the drug response and RECIST 1.1 standard was used to evaluate the therapeutic efficacy.

Results

All patients experienced chest pain relief in the first month of treatment. Three patients showed partial response. Four patients got stable disease after denosumab treatment. Adverse events included one patient with hypocalcemia and two patients with fever. No treatment-related deaths were reported. No patient with metastatic disease progression was found during an average of 28.6 months follow-up period.

Conclusion

We presented a promising interim clinical outcome using denosumab to treat patients with pulmonary metastatic GCT. Denosumab might be considered as the first-line treatment for patients with inoperable metastatic pulmonary GCT. However, Phase II clinical study with larger number of patients and longer follow-up period is needed to detect the further efficacy and safety of this drug for lung metastatic GCT.

A rare case of giant cell tumour (GCT) of bone with lung metastases

A case of 16-year-old girl with giant cell tumour of right fibula is presented to us with bilateral lung metastases. In view of widespread bilateral lung metastatic lesions, the patient was given multimodality treatment. Chemotherapy followed by radiotherapy to the local site as well as lung bath has been given and has shown good response.

Salleh MS, Yahaya S, Syahrul Fitri ZM. The Values of Receptor Activator Nuclear Kappa-B Ligand Expression in Stage III Giant Cell Tumor of the Bone

BACKGROUND

Giant cell tumor (GCT) of bone is a benign locally aggressive primary bone tumor which is risky for local recurrences and pulmonary metastasis. Till date, there are still many uncertainties in predicting the aggressiveness of GCT. We aim to investigate whether receptor activator nuclear kappa-B ligand (RANKL) expression may determine the prognosis of the lesion.

MATERIALS AND METHODS

We examined RANKL expression in 39 patients (21 males, 18 females) by immunohistochemistry. Four patients (10%) were presented with tumor recurrence, eight patients (20%) were complicated with lung metastasis, and two patients (5%) were presented with both recurrence and lung metastasis. Positive RANKL expression was assessed according to a scoring system evaluating the percentage of the immunostained epithelial area and the staining intensity. The cumulative score was calculated to determine the final score value. Data were analyzed using PASW version 18.0 and independent t-test between nonrecurrence/recurrence groups, and nonlung metastasis/lung metastasis groups. Significance was set at P < 0.05.

RESULTS

Thirty-two patients (82%) scored 3 in RANKL-staining percentage from whole stromal cell population (>75%), 6 patients scored 2, and 1 patient scored 1. Nine patients (23%) scored 3 in RANKL-staining intensity (most intense), 19 patients (48%) scored 2, and 11 patients (29%) scored 1. Twenty six patients (67%) had strong RANKL expression (total score of 5-6), 12 patients (31%) showed moderate score (3-4) whereas only 1 patient (2%) showed weak RANKL expression. Together, the mean value of RANKL-staining percentage was 2.79, intensity 1.95 and the total score 4.77. The mean RANKL-staining percentage between recurrence and nonrecurrence groups was statistically significant (P = 0.009). There was no significant difference in the mean staining intensity and total score between nonrecurrence and recurrence groups, and staining percentage staining intensity and a total cumulative score of RANKL expression between lung metastasis and nonlung metastasis groups.

CONCLUSION

RANKL expression is generally high in Stage III GCT and is a reliable prognostic marker in predicting the risk of local recurrence however not in lung metastasis.

Diagnostic utility of histone H3.3 G34W, G34R, and G34V mutant-specific antibodies for giant cell tumors of bone

Giant cell tumors of bone (GCTBs) are characterized by mononuclear stromal cells and osteoclast-like giant cells; up to 95% have H3F3A gene mutation. The RANKL inhibitor denosumab, when used for the treatment of GCTB, leads to histological changes such as new bone formation and giant cell depletion. Here we assessed the diagnostic utility of immunohistochemical staining with the antibodies against histone H3.3 G34W, G34R and G34V mutant proteins for GCTB and other histologically similar bone and joint lesions. H3.3 G34W, G34R and G34V expressions were detected in mononuclear stromal cells in 47/51 (92%), 1/51 (2%) and 3/51 (6%) cases of primary GCTBs, respectively, in a mutually exclusive manner. All recurrent/metastatic GCTBs (n=14), post-denosumab GCTBs (n=8) and secondary malignant GCTBs (n=2) were positive for H3.3 G34W. The immunohistochemical results were essentially correlated with the H3F3A genotype determined by mutation analysis. In post-denosumab GCTBs, H3.3 G34W expression was seen in immature bone-forming cells. H3.3 G34W, G34R and G34V were negative in 121/122 cases of non-GCTB, including chondroblastoma, osteosarcoma, primary aneurysmal bone cyst and other giant cell-rich lesions. The exception was a single case of undifferentiated high-grade pleomorphic sarcoma that was positive for H3.3 G34W, suggesting the possibility of sarcomatous overgrowth of primary malignant GCTB. Therefore, H3.3 G34W/R/V mutant-specific antibodies are useful surrogate markers for the H3F3A genotype and helpful for the diagnosis of GCTB and its variants. The expression of H3.3 G34W mutant protein in post-denosumab GCTB suggests that neoplastic stromal cells may play a role in new bone formation.

MiR-127 and miR-376a act as tumor suppressors by in vivo targeting of COA1 and PDIA6 in giant cell tumor of bone

Giant cell tumors of bone (GCTB) are generally benign bone tumors associated with expansive osteolytic defects, a high rate of recurrence and potential malignant transformation. We recently observed silencing of miR-127-3p and miR-376a-3p in GCTB and identified COA1 and PDIA6 as their target genes. Here, we investigate the impact of these microRNAs and their target genes on tumor engraftment and progression of giant cell tumor stromal cells (GCTSC) in vivo by xenotransplantation on the chorioallantoic membrane of chicken eggs. Prior to transplantation, the neoplastic GCTSCs were transfected with miRNA mimics or siRNAs directed against their target genes. Restoration of miR-127-3p and miR-376a-3p reduced the tumor take rate to 17% and 47% compared to 95% in the controls. The tumor volumes were significantly reduced to 29% by both miRNAs. Silencing of COA1 and PDIA6 significantly decreased the tumor volumes to 37.7% and 42.7%, while the tumor take rates remained stable. Our results indicate that re-expression of miR-127-3p and miR-376a-3p induces a strong tumor suppressor effect in GCTSC, which is partially mediated via COA1 and PDIA6.

Epidemiological and Clinical Features of Primary Giant Cell Tumors of the Distal Radium: A Multicenter Retrospective Study in China

Giant cell tumors of the distal radius are challenging for surgeons because they are associated with high recurrence rates and poor functional outcomes. Between June 2005 and October 2015, patients with primary giant cell tumors of the distal radius were recruited from seven orthopedic centers in China. The patients’ clinical features and demographic characteristics were obtained from medical records and reviewed retrospectively. Overall, 48 cases of giant cell tumors of the distal radius were assessed in this study. These patients were more likely to be between 20 and 40 years of age, to have a Campanacci grade of III, and to undergo a surgical style of resection. The prevalence of pathological fractures was 12.5% overall (20.0% in men and 4.3% in women). The prevalence of local recurrence was 30.0% overall (38.1% in men and 21.1% in women) during the average follow-up period of 62.5 months, with a pulmonary metastasis rate of 5.0%. Giant cell tumors of the distal radius were predominant in men and were more likely to recur locally than around the knee. These findings suggest that it is crucial to evaluate the optimal surgical approach for balancing local recurrence control and functional outcomes to reduce the disease burden.

Epidemiological characteristics of primary spinal osseous tumors in Eastern China

BACKGROUND

Primary spinal osseous tumors are rare, yet they represent a difficult treatment paradigm because of the complexities of tumor resection and significant resistance to chemotherapy and radiation therapy. The geographic distribution of primary spinal osseous tumors throughout the world appears to be quite variable, with a very low incidence reported in Asian countries.

METHODS

Data on 1209 cases of primary spinal osseous malignant and benign tumor cases diagnosed during the 20-year period of 1995 through 2015 in eastern China were analyzed.

RESULTS

In 780 cases (64.5%), the lesion was benign and in 429 (35.5%) was malignant. The commonest primary malignant tumors were chordoma (9.8% of all cases) followed by plasma cell myeloma (8.5% of all cases). The most common benign tumor was hemangioma (28.1% of all cases) followed by giant cell tumor of bone (15.7% of all cases) and osteoblastoma (4.4% of all cases). The benign tumors affected men in 33.8% of cases and women in 30.7% of cases, the malignant tumors affected men in 23.7% of cases and women in 11.8%. The mean age (mean ± SD) in the benign group was 34.7 ± 19.8 years and in the malignant group was 47.4 ± 16.5 years. Related symptoms were pain (54.4%), radiculopathy (12.9%), cord compression (9.2%), mass (5.7%), pathological fracture (4.7%), deformity (2.1%), and weight loss (1.9%). The anatomical locations included almost every vertebra of the spine. The thoracic spine (38.1%) was the most common location of the tumors, followed by the cervical spine (27.4%) and lumbar spine (18.4%).

CONCLUSIONS

Compared with other similar series reported in the literature from the other countries, our results obtained in a developing country were different in some degree. This large series of primary spinal osseous tumors may reflect fairly well their real incidence and provide a sufficiently detailed perspective on epidemiologic studies of primary spinal osseous tumors in eastern China.

Characterization of MicroRNA Expression Profiles in Patients with Giant Cell Tumor

OBJECTIVE

Giant cell tumors of bone (GCTs) are bone destructive neoplasms, the bone resorption being mediated by osteoclasts. Given that microRNAs are crucially involved in tumorigenesis and the modulation of cell fate and behavior, they are promising candidates for regulation of osteoclastogenesis. However, no reliable miRNAs profile for GCT is available. Our study aimed to evaluate osteoclastogenesis-related miRNA expression in GCTs of Chinese patients.

METHODS

From January 2013 to December 2014, 11 patients with GCTs were treated in our department and grouped into a GCT group. A control group comprising four patients with benign tumors of the iliac bone was established. The diagnoses were initially established by imaging examinations and intraoperative frozen sections and later confirmed by standard histologic examination. The GCT group (five male and six female patients) were aged from 17 to 61 years (mean, 32.9 years; SD, 12.8 years). Six patients with GCT underwent intralesional curettage surgery and the other five wide resection. According to Campanacci grading, four patients had Grade I tumors, three Grade II, and three Grade III. The average age of the control group was 28.75 years (SD, 14.24 years); all of them were diagnosed as having benign tumors and underwent iliac grafting. The morphology of the excised tissue was evaluated by examining standardized hematoxylin and eosin (HE) stained paraffin-embedded samples. In all, three osteoclastogenesis-related RNAs and 20 microRNAs (miRNAs) were extracted from the patients. The strength of expression was assessed by quantitative reverse transcription polymerase chain reaction (PCR ) and the results assessed by a Student's t test.

RESULTS

Examination of HE stained sections revealed that the higher the Campanacci grade, the more numerous and bigger the osteoclasts (P < 0.05). PCR results indicated large amounts of osteoclast-related mRNA (cathepsin K, tartrate-resistant acid phosphatase and matrix metalloproteinase9) in GCTs (P < 0.05). Expression of six miRNAs was significantly weaker in the GCT than the control group (P < 0.05). The expression of has-mir-16-5p and has-let-7a-5p was correlated with Campanacci grade in the GCT patients (P = 0.009 and 0.034, respectively). The expression of these two miRNAs may indicate severity of bone destruction.

CONCLUSION

Overall, the clinical utility of six novel miRNA markers for GCTs was demonstrated. Of these, strength of expression of hsa-mir-16-5p and hsa-let-7a-5p may indicate the grade of bone resorption.

Chemotherapy for Bone Sarcoma in Adults

The largest studies of chemotherapy for bone sarcomas are in the pediatric population. Although increasing age is often found to be an adverse prognostic factor in these clinical trials, few studies are aimed at assessing regimens specifically in the adult population. Osteosarcoma and Ewing sarcoma have peak incidences in the pediatric and young adult population but also occur in adults. Chondrosarcoma and giant cell tumor of bone are generally found in adults. In this review, we describe the current status of our knowledge about treating adults with cancers of bone origin. We also describe our experience treating patients in the adult Sarcoma Medical Oncology group at The University of Texas MD Anderson Cancer Center.

Recurrence Rates and Risk Factors for Primary Giant Cell Tumors around the Knee: A Multicentre Retrospective Study in China

Giant cell tumors of the bone (GCTBs) are commonly diagnosed in Asian populations, usually around the knee. Herein, we aimed to determine the clinical characteristics, local recurrence rates, and relevant risk factors of primary GCTB around the knee. Univariate and multivariate survival analyses were used to identify the risk factors for local recurrence. Four hundred ten patients with primary GCTB around the knee, treated between March 2000 and June 2014, were recruited from 7 institutions in China. The overall local recurrence rate was 23.4%, but was higher in patients aged 20–39 years (28.5%; P = 0.039). The local recurrence rate was the highest in patients treated with intralesional curettage (53.4%), and the lowest in those treated with resection (4.9%). We found a higher risk of tumor recurrence in the proximal fibula compared to the distal femur (hazard ratio: 28.52, 95% confidence interval: 5.88–138.39; P < 0.0001), and in patients treated with curettage compared to those treated with resection (hazard ratio: 12.07, 95% confidence interval: 4.99–29.18; P < 0.0001). Thus, the tumor location must be considered when selecting the optimal surgical treatment approach to reduce the risk of local recurrence and preserve joint function, especially in young patients.

Clinicopathological Features of a Series of 27 Cases of Post-Denosumab Treated Giant Cell Tumors of Bones: A Single Institutional Experience at a Tertiary Cancer Referral Centre, India

Giant cell tumor of bone (GCTB) is mostly a benign tumor, but associated with recurrences and metastasis. Lately, denosumab is being utilized in the treatment of certain GCTBs. Twenty-seven tumors, analyzed in the present study, occurred in 16 males and 11 females (M: F = 1.45:1), in the age-range of 16 to 47 years (mean = 29.5, median = 29). Most tumors were identified in the tibia(6) and femur(6), followed by the humerus(3), radius(3), pelvis(3), fibula(3), sacrum(1), metacarpal(1) and metatarsal(1) bones. There were 18(66.6 %) primary and 9(33.3 %) recurrent tumors. Exact tumor size (19 cases) varied from 3.7 to 15 cm (mean = 7.8, median = 6.4). Eight of the 19 tumors (42.1 %) had size more than or equal to 8 cm. On histopathologic examination of post-denosumab treated specimens, more than half cases (15)(55.5 %) revealed complete absence of osteoclast-like giant cells (OCLGs) and 12 cases revealed residual OCLGCs. In addition, there was replacement by fibro-osseous tissue, including reactive woven bone or osteoid in most cases, followed by variable amount of spindle cells, hyalinisation, fibrosis and chronic inflammatory cells, including lymphocytes, macrophages and plasma cells. Post-treatment follow-up (25 cases, 92.5 %), over 7-27 months duration (median = 18), revealed 20 cases continuously disease-free. Five patients developed recurrences at 9, 12, 13, 14 and 18 months, respectively. Out of these, who underwent repeat surgical intervention, 4 patients are alive with no evidence of disease and a single patient, planned for a second surgery, is alive-with-disease. Denosumab was mostly offered to patients with large sized, borderline salvageable tumors, in order to decrease the morbidity of index surgical procedure, that led to disappearance of OCLGCs in most cases. Post-denosumab treated GCT cases appear as low grade osteosarcomas on histopathologic examination, but lack the clinical behaviour of an osteosarcoma, therefore may be considered as pseudo malignant bony lesions.

Giant Cell Tumors of the Bone With Pulmonary Metastasis

Giant cell tumors of the bone are benign but locally aggressive, and they rarely metastasize to the lungs. The purpose of this study was to retrospectively review the clinical presentation, long-term outcomes, and treatment of pulmonary metastasis of these tumors. Between 1991 and 2004, a total of 168 patients with giant cell tumors of the bone were treated at the authors' institution, 7 of whom developed lung metastasis. Four of the 7 patients were men, and mean age of these patients at initial surgery was 40 years (range, 19-56 years). All patients underwent wide excision and reconstruction or curettage and bone grafting for the bony lesions. Lung metastases were detected at a mean of 44 months after the treatment of bone lesions. Five patients had multiple metastases, and 2 had solitary pulmonary metastases. Six of these patients underwent delayed treatment, locally aggressive, or multiple recurrent and surgical procedures. All of the aforementioned procedures had similar risk factors to those previously reported in the literature. One patient had multiple giant cell tumors of the bone. At last follow-up, 2 patients had died due to complications from the pulmonary metastases or chemotherapy. One patient underwent a metastasectomy 4 years after treatment due to the progression of pulmonary metastasis. The remaining 4 patients were alive and healthy after chemotherapy or conservative treatment. Therefore, early detection, adequate treatment of the primary bone lesion, conservative treatment of lung metastases, and regular long-term follow-up are recommended.

Sex Differences in the Recurrence Rate and Risk Factors for Primary Giant Cell Tumors Around the Knee in China

Although giant cell tumor of bone (GCTB) is more common in women in Western countries, it tends to be more common in men in Asian countries. We aimed to determine the sex differences in clinical characteristics, local recurrence rate, and relevant risk factors for local recurrence in primary GCTB around the knee. Between March 2000 and June 2014, patients with primary GCTB around the knee were recruited from 7 institutions in China, and 410 patients were included. The age at diagnosis was younger in women than in men (34.0 vs 37.2 years). The local recurrence rates were 23.4% overall, 25.8% in men, and 20.7% in women. Lower local recurrence rates were observed with en-bloc marginal resection in both men (6.9%) and women (3.1%). With tumors located in the distal femur, the local recurrence rate was higher for men than for women (29.1% vs 14.3%, P = 0.025). Local recurrence was significantly associated with the tumor location and surgical operation in men and only surgical operation in women. These findings suggest that more aggressive operations should be considered in men with GCTB in the proximal fibula.

Segmental excision versus intralesional curettage with adjuvant therapy for giant cell tumour of bone

PURPOSE

To review the functional outcome and local recurrence rate of 29 patients who underwent segmental excision or intralesional curettage with adjuvant therapy for giant cell tumour (GCT) of bone.

METHODS

Records of 17 men and 12 women (mean age, 30.17 years) who underwent segmental excision (n=18) or intralesional curettage followed by adjuvant therapy (n=11) for GCT of the femur (n=13), tibia (n=8), radius (n=6), or ulna (n=2) were reviewed. Nine of the patients had recurrent GCT of bone and had undergone segmental excision (n=6) or intralesional curettage (n=3) elsewhere. Functional outcome was evaluated using the Musculoskeletal Tumour Society (MSTS) scoring system.

RESULTS

The mean follow-up period was 6.4 (range, 3-13.5) years. 14 patients were followed up for 3 to 5 years, 12 for 5 to 10 years, and 3 for >10 years. Of 20 patients with primary GCT of bone, 12 underwent segmental excision and had no recurrence, and 8 underwent intralesional curettage, 2 of whom developed local recurrence. Of the remaining 9 patients with recurrent GCT of bone, there was one re-recurrence in each surgical option. Local recurrence was not associated with Campanacci grading or type of surgery. One of 18 patients with segmental excision and 3 of 11 patients with intralesional curettage had local recurrence (5.6% vs. 27.3%, p=0.139). The MSTS score was excellent in 7, good in 6, moderate in 2, fair in 2, and poor in one patient after segmental excision, whereas the score was excellent in 9 and good in 2 patients after intralesional curettage (p=0.206). The proportion of yielding an excellent outcome was higher after intralesional curettage (38.9% vs. 81.8%, p=0.0289). Nonetheless, the mean MSTS score of the 2 groups was comparable (74.17% vs. 86.36%, p=0.054).

CONCLUSION

Local recurrence of GCT was not associated with the surgical option. Nonetheless, intralesional curettage resulted in better functional outcome.

The epidemiological and clinical features of primary giant cell tumor around the knee: A report from the multicenter retrospective study in china

Objectives

We aimed to determine the demographic characteristics of giant cell tumor around the knee in China.

Methods

Between March 2000 and June 2014, patients with primary giant cell tumor around the knee were recruited from 6 institutions located in different regions of China, and were reviewed retrospectively the clinical features according to gender and age.

Results

334 qualified patients were included in this study. The sex ratio was 1.14:1 (178/156), with mean ages of 36.9 years in men and 33.1 years in women, constituting a significant difference (P=0.007). The prevalence of pathological fracture was 32.9% overall (28.7% in men and 37.8% in women). The prevalence of simple fracture was significantly higher in women (26.3%) than in men (15.2%), P=0.042. Tumor location and staging did not differ significantly according to sex (P>0.05). However, comparing with >40 years old, those patients aged ≤40 were more likely to have a right knee tumor (56.7% vs. 44.7%, P=0.042), less likely to have Enneking stage 3 disease (18.6% vs. 35.0%, P=0.005), and less likely to have both soft-tissue extension and a mass (18.6% vs. 34.0%, P=0.009).

Conclusions

Giant cell tumor around the knee was more common in men than in women, although female patients were younger on average. Further, cases among patients ≤40 years old were observed to be milder than cases among older patients. The results suggest that efficient treatment and preservation of function should both be valued for young patients with giant cell tumor around the knee.

•

This is the first report of primary GCT around the knee in China.

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Women are youngerand have a a higher rate of simple pathological fracture than men.

•

Young patients are more likely to have tumor at right knee and to be mild.

Giant cell tumor of bone: current treatment options

OPINION STATEMENT

Giant cell tumor of bone (GCTB) comprises up to 20 % of benign bone tumors in the US. GCTB are typically locally aggressive, but metastasize to the lung in ~5 % of cases. Malignant transformation occurs in a small percentage of cases, usually following radiation therapy. Historically, GCTB have been treated primarily with surgery. When the morbidity of surgery would be excessive, radiation therapy may achieve local control. In most cases the primary driver of the malignant cell appears to be a mutation in H3F3A leading to a substitution of Gly34 to either Trp or Leu in Histone H3.3. This change presumably alters the methylation of the protein, and thus, its effect on gene expression. The malignant stromal cells of GCTB secrete RANKL, which recruits osteoclast precursors to the tumor and stimulates their differentiation to osteoclasts. The elucidation of the biology of GCTB led to trials of the anti-RANKL monoclonal antibody denosumab in this disease, with a clear demonstration of beneficial clinical effect. Surgery remains the primary treatment of localized GCTB. When surgery is not possible or would be associated with excessive morbidity, denosumab is a good treatment option. The optimal length of treatment and schedule of denosumab is unknown, but recurrences after apparent complete responses have been observed after stopping denosumab, and long-term follow-up of denosumab treatment may reveal unrecognized effects. The role of denosumab in the preoperative or adjuvant setting will require clinical trials. In some cases local radiation therapy may be useful, although long term effects should be considered.

Risk factors for pulmonary metastases from giant cell tumor of bone

BACKGROUND

Giant cell tumor (GCT) of bone is a rare, benign, aggressive bone tumor with an unusual capacity to metastasize to the lung. It was the goal of this study to identify patient and treatment-specific variables associated with the development of pulmonary metastases of GCT of bone.

METHODS

From 1980 to 2009, 291 patients with benign GCT of bone were treated at our institution, and 167 were followed for at least two years. Eleven (6.6%) of these 167 patients developed biopsy-confirmed pulmonary metastasis. All patients were evaluated relative to nine patient, disease, and treatment-specific variables.

RESULTS

We identified four properties of benign GCT of bone associated with an increased risk of metastasis on univariate analysis: age at diagnosis, axial location of the primary GCT, primary Enneking stage-3 disease, and local recurrence. Multivariate analysis showed local recurrence to be an independent risk factor for pulmonary metastasis (adjusted odds ratio, 7.42).

CONCLUSIONS

There is an increased risk of pulmonary metastasis of GCT of bone in patients who are younger, present with Enneking stage-3 disease, develop local recurrence, and/or present with axial disease. The mode of treatment was not found to be associated with the development of pulmonary metastasis.

Enrichment of c-Met+ tumorigenic stromal cells of giant cell tumor of bone and targeting by cabozantinib

Giant cell tumor of bone (GCTB) is a very rare tumor entity, which is little examined owing to the lack of established cell lines and mouse models and the restriction of available primary cell lines. The stromal cells of GCTB have been made responsible for the aggressive growth and metastasis, emphasizing the presence of a cancer stem cell population. To identify and target such tumor-initiating cells, stromal cells were isolated from eight freshly resected GCTB tissues. Tumorigenic properties were examined by colony and spheroid formation, differentiation, migration, MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay, immunohistochemistry, antibody protein array, Alu in situ hybridization, FACS analysis and xenotransplantation into fertilized chicken eggs and mice. A sub-population of the neoplastic stromal cells formed spheroids and colonies, differentiated to osteoblasts, migrated to wounded regions and expressed the metastasis marker CXC-chemokine receptor type 4, indicating self-renewal, invasion and differentiation potential. Compared with adherent-growing cells, markers for pluripotency, stemness and cancer progression, including the CSC surface marker c-Met, were enhanced in spheroidal cells. This c-Met-enriched sub-population formed xenograft tumors in fertilized chicken eggs and mice. Cabozantinib, an inhibitor of c-Met in phase II trials, eliminated CSC features with a higher therapeutic effect than standard chemotherapy. This study identifies a c-Met⁺ tumorigenic sub-population within stromal GCTB cells and suggests the c-Met inhibitor cabozantinib as a new therapeutic option for targeted elimination of unresectable or recurrent GCTB.