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

Japanese orthopaedic association (JOA) clinical practice guideline on the management of primary malignant bone tumors - Secondary publication

BACKGROUND

In Japan, there are currently no general guidelines for the treatment of primary malignant bone tumors. Therefore, the Japanese Orthopaedic Association established a committee to develop guidelines for the appropriate diagnosis and treatment of primary malignant bone tumors for medical professionals in clinical practice.

METHODS

The guidelines were developed in accordance with "Minds Clinical Practice Guideline Development Handbook 2014″ and "Minds Clinical Practice Guideline Development Manual 2017". The Japanese Orthopaedic Association's Bone and Soft Tissue Tumor Committee established guideline development and systematic review committees, drawing members from orthopedic specialists leading the diagnosis and treatment of bone and soft tissue tumors. Pediatricians, radiologists, and diagnostic pathologists were added to both committees because of the importance of multidisciplinary treatment. Based on the diagnosis and treatment algorithm for primary malignant bone tumors, important decision-making points were selected, and clinical questions (CQ) were determined. The strength of recommendation was rated on two levels and the strength of evidence was rated on four levels. The recommendations published were selected based on agreement by 70% or more of the voters.

RESULTS

The guideline development committee examined the important clinical issues in the clinical algorithm and selected 22 CQs. The systematic review committee reviewed the evidence concerning each CQ and a clinical value judgment was added by experts. Eventually, 25 questions were published and the text of each recommendation was determined.

CONCLUSION

Since primary malignant bone tumors are rare, there is a dearth of strong evidence based on randomized controlled trials, and recommendations cannot be applied to all the patients. In clinical practice, appropriate treatment of patients with primary malignant bone tumors should be based on the histopathological diagnosis and degree of progression of each case, using these guidelines as a reference.

Establishment and characterization of NCC-GCTB10-C1: a novel cell line derived from a patient with recurrent giant cell tumor of bone

Giant cell tumor of bone (GCTB) is a rare osteolytic tumor composed of mononuclear stromal cells, macrophages, and osteoclast-like giant cells. While generally benign, GCTB has a high risk of local recurrence and can occasionally undergo malignant transformation or metastasis, posing significant clinical challenges. The primary treatment is complete surgical resection; however, effective management strategies for recurrent or advanced GCTB remain elusive, underscoring the need for further preclinical research. This study reports the establishment of a novel cell line, NCC-GCTB10-C1, derived from a recurrent GCTB lesion. NCC-GCTB10-C1 retains the characteristic H3-3A G34W mutation, which is central to the tumor's pathogenesis, and demonstrates significant growth potential, spheroid formation capability, and invasive properties. Extensive drug screening of NCC-GCTB10-C1, along with nine previously established GCTB cell lines, revealed a distinct drug response profile, with the cell line showing resistance to many previously effective agents. However, doxorubicin, foretinib, and ceritinib were identified as promising therapeutic candidates due to their low IC50 values in NCC-GCTB10-C1. The establishment of NCC-GCTB10-C1 offers a critical resource for further research into GCTB, especially in the context of recurrent disease, and holds potential for the development of more effective treatment strategies.

RANKL, OPG, and RUNX2 expression and epigenetic modifications in giant cell tumour of bone in 32 patients

Aims

The present study investigated receptor activator of nuclear factor kappa-Β ligand (RANKL), osteoprotegerin (OPG), and Runt-related transcription factor 2 (RUNX2) gene expressions in giant cell tumour of bone (GCTB) patients in relationship with tumour recurrence. We also aimed to investigate the influence of CpG methylation on the transcriptional levels of RANKL and OPG.

Methods

A total of 32 GCTB tissue samples were analyzed, and the expression of RANKL, OPG, and RUNX2 was evaluated by quantitative polymerase chain reaction (qPCR). The methylation status of RANKL and OPG was also evaluated by quantitative methylation-specific polymerase chain reaction (qMSP).

Results

We found that RANKL and RUNX2 gene expression was upregulated more in recurrent than in non-recurrent GCTB tissues, while OPG gene expression was downregulated more in recurrent than in non-recurrent GCTB tissues. Additionally, we proved that changes in DNA methylation contribute to upregulating the expression of RANKL and downregulating the expression of OPG, which are critical for bone homeostasis and GCTB development.

Conclusion

Our results suggest that the overexpression of RANKL/RUNX2 and the lower expression of OPG are associated with recurrence in GCTB patients.

A new joint reconstruction technique in the treatment of giant cell tumors around the knee: Structural allograft and unicompartmental arthroplasty

OBJECTIVE

The long-term prognosis of patients who underwent unicompartmental knee arthroplasty (UKA) with a structural allograft or hemiarticular allograft transplantation to treat giant cell tumors (GCTs) around the knee and the prosthesis survival rate were analyzed.

METHODS

We retrospectively reviewed 73 patients who were diagnosed with GCTs around the knee and underwent surgery to restore joint function from 2000 to 2015. Patients were divided into two groups according to the surgical procedure used for functional knee reconstruction: hemiarticular allograft transplantation or structural allograft and UKA. The Knee Society Score (KSS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) were used to analyze postoperative knee function between the two groups. The Kellgren-Lawrence (K-L) classification system was used to evaluate the progression of osteoarthritis. The incidence of complications and the prosthesis survival rate were also investigated.

RESULTS

Patients who underwent UKA to treat GCT demonstrated significantly improved knee function. The rate of an excellent or good KSS was significantly different between the two groups (p = 0.041 at the 1-year follow-up, p = 0.033 at the last follow-up). The proportion of severe cases according to WOMAC in the two groups was also different (p = 0.030 at the 1-year follow-up, p = 0.021 at the last follow-up). According to the K-L grade of unaffected compartments, UKA better prevented the progression of osteoarthritis (p = 0.034).

CONCLUSIONS

Patients with GCTs around the knee could benefit from UKA. In addition to providing better knee function and range of motion, UKA could also slow the progression of osteoarthritis in the knee joint. This new surgical method could meet the needs of patients wishing to preserve joint integrity and favorable joint function.

Giant cell tumor of bone in the pediatric population: a retrospective study highlighting cases of metaphyseal only location and increased local recurrence rates in skeletally immature patients

OBJECTIVE

To describe the presentation of giant cell tumors (GCT) of the bone in the pediatric population to (1) improve the differential diagnosis of pediatric bone tumors and (2) identify the origin of GCT. Understanding the origin of bone tumors assists in establishing appropriate diagnoses and recommending treatment options. This is particularly important in children, where evaluating the need for invasive procedures is balanced with the desire to avoid overtreatment. GCT have historically been considered epiphyseal lesions with potential metaphyseal extension. Therefore, GCT may be inappropriately excluded from the differential diagnosis of metaphyseal lesions in the skeletally immature.

MATERIALS AND METHODS

We identified 14 patients from 1981 to 2021 at a single institution who had histologic confirmation of GCT and were less than 18 years old at diagnosis. Patient characteristics, tumor location, surgical treatment, and local recurrence rates were collected.

RESULTS AND CONCLUSIONS

Ten (71%) patients were female. Eleven (78.6%) were epiphysiometaphyseal (1 epiphyseal, 4 metaphyseal, 6 epiphysiometaphyseal). Five patients had an open adjacent physis, of which three (60%) had tumors confined solely to the metaphysis. Of the five patients with open physis, four (80%) developed local recurrence while only one patient (11%) with a closed physis had local recurrence (p value = 0.0023). Our results illustrate that for the skeletally immature, GCT can (and in our results more commonly did) occur in the metaphyseal location. These findings suggest that GCT should be included in the differential diagnosis of primary metaphyseal-only lesions in the skeletally immature.

The expression changes of PD-L1 and immune response mediators are related to the severity of primary bone tumors

The expression pattern, diagnostic value, and association of PD-L1, IFN-γ and TGF-β with bone tumor type, severity, and relapse are determined in this study. 300 human samples from patients with osteosarcoma, Ewing sarcoma, and GCT were enrolled. The PD-L1 gene and protein expression were assessed by qRT-PCR and immunohistochemistry, respectively. ELISA and flow cytometry was used to detect cytokines and CD4/CD8 T cell percentages, respectively. A considerable increase in PD-L1 level was detected in bone tumor tissues at both gene and protein levels that was considerable in osteosarcoma and Ewing sarcoma. A positive correlation was detected regarding the PD-L1 and tumor metastasis and recurrence in osteosarcoma and Ewing sarcoma. The increased IFN-γ level was detected in patients with metastatic, and recurrent osteosarcoma tumors that were in accordance with the level of TGF-β in these samples. The simultaneous elevation of IFN-γ and TGF-β was detected in Ewing sarcoma and GCT, also the CD4 + /CD8 + ratio was decreased significantly in patients with osteosarcoma compared to GCT tumors. The elevated levels of PD-L1, TGF- β, and IFN-γ were associated with bone tumor severity that can provide insights into the possible role of this axis in promoting immune system escape, suppression, and tumor invasion.

Epidemiology of bone tumors in Lebanon: a retrospective study from 2000 to 2022 at a tertiary center

Aim

Bone tumors are rare and have an uneven geographic distribution.

Methods

730 patients diagnosed with bone tumors were included in this retrospective analysis.

Results

With a 64% rate of malignancy, the most common tumors were metastasis (40%) mostly in the axial skeleton, Osteosarcoma (9%) mostly in the femur, Osteochondroma (8%) mostly in the femur, giant cell tumors (7%) mostly in the knee, and Ewing's sarcoma (6%) mostly in the axial skeleton.

Conclusion

Even though a some of the tumors have a predilection for certain localizations in the human body, they may differ in the middle-eastern population. One must also pay attention to the higher rates of malignancies as compared with other cohorts.

"A New Clinical and Radiological Classification of Grading GCT and Its Impact on the Management"

Background

The management of the GCT continues to be controversial. The most accepted treatment reported is extended curettage with various adjuvants. However, the rate of recurrence has been very high (10-66%). For better understanding of the lesion and its management, it has become necessary to revise the existing grading system.

Materials and Methods

The recommendation of the proposed grading is based on 480 cases of GCT along with the analysis of other major reports published. Out of these, 279 were grade-II and 109 grade-III which were subjected to en bloc excision and reconstruction with non-vascularized fibular graft. Depending on the site, the grafts were stabilized with a suitable plate or extra long Kirschner wires.

Results

The observations made in 480 cases over a period of 5 decades revealed that for Campanacci grade-II and grade-III lesions, en bloc excision and suitable reconstruction resulted in minimum recurrence rate of 1.2%. The fibular reconstruction after excision has proved advantageous to our patients as it provides a stable joint in the form of an arthrodesis of the neighboring joint.

Conclusion

GCT of bone has been a challenging lesion. Extended curettage has been recommended as the choice of treatment but the reported rate of recurrence has been high. En bloc excision and suitable reconstruction with fibular strut graft have resulted in 1.2% recurrence. It is, therefore, suggested the existing grading system should be revised mainly for grade-II and grade-III lesions which can bring down the high rate of recurrence in this unpredictable tumor.

Level of Evidence

Level-IV.

Giant cell tumors of the distal ulna: long-term recurrence rate and functional outcomes of en bloc resection versus curettage in a multicenter study

OBJECTIVE

The wrist is the second most commonly involved location for GCTB, while distal ulna is a relatively rare location and limited evidence exists on which surgical approaches and reconstruction techniques are optimal. We carried out a multicenter retrospective study to evaluate the recurrence rate of distal ulna GCTB and the long-term functional outcomes of different surgery options.

METHODS

All 28 patients received surgical treatment for distal ulna GCTB in one of three tertiary bone tumor centers between May 2007 and January 2021 with a minimum two-year follow-up. Surgical options included intralesional curettage or en bloc resection (one of 3 types). Functional outcomes were assessed by the MSTS score, the QuickDASH instrument, MWS, and MHQ according to the latest treatment.

RESULTS

Overall recurrence rate was 14.2%. The curettage group (N = 7) had a significantly higher recurrence rate compared to en bloc resection (N = 21) (42.9% vs 4.8%) (mean follow-up: 88.8 mo). Seven patients received the Darrach procedure, 5 received the original Sauvé-Kapandji procedure, and 9 received the modified Sauvé-Kapandji procedure with extensor carpi ulnaris (ECU) tenodesis. Of the 4 patients having a recurrence, 1 received the Darrach EBR, 2 received the modified Sauvé-Kapandji procedure, and 1 received resection for soft tissue recurrence. Only MWS and esthetics in the MHQ scores were different (curettage, Darrach, Sauvé-Kapandji, and Sauvé-Kapandji with ECU tenodesis [MWS: 96.5 ± 1.3 vs 91.5 ± 4.7 vs 90.8 ± 2.8 vs 91.5 ± 3.6; esthetics in MHQ: 98.5 ± 3.1 vs 89.9 ± 4.7 vs 93.8 ± 4.4 vs 92.6 ± 3.8], respectively).

CONCLUSIONS

En bloc resection for distal ulna GCTB had a significantly lower recurrence rate compared with curettage and achieved favorable functional outcome scores. Given the higher recurrence rate after curettage, patients should be well informed of the potential benefits and risks of selecting the distal radioulnar joint-preserving procedure. Moreover, reconstructions after tumor resection of the ulna head do not appear to be necessary.

Proximal Tibia Tumour Location and Curettage Are Major Risk Factors of Local Recurrence in Giant Cell Tumour of Bone

Giant cell tumour of bone (GCTB) is one of the most common local aggressive tumourous lesions with a wide variety of biological behaviour. However, there are no clear indicative criteria when choosing the type of procedure and the complication rates remain high, especially in terms of local recurrence. The purpose of the study was to (1) identify the main risk factors for local recurrence, (2) evaluate the recurrence-free survival in dependence on neoadjuvant denosumab use and the type of procedure, and (3) compare the functional outcomes after curettage and en bloc resection. The group included 102 patients with GCTB treated between 2006 and 2020. The mean age of patients was 34.4 years (15-79). The follow-up period was 8.32 years (2-16) on average. Local recurrence occurred in 14 patients (29.8%) who underwent curettage and in 5 patients (10.6%) after en bloc resection. Curettage was shown to be a factor in increasing recurrence rates (OR = 3.64 [95% CI: 1.19-11.15]; p = 0.023). Tibial location was an independent risk factor for local recurrence regardless of the type of surgery (OR = 3.22 [95% CI: 1.09-9.48]; p = 0.026). The recurrence-free survival rate of patients treated with resection and denosumab was higher compared to other treatments at five years postoperatively (p = 0.0307). Functional ability and pain as reported by patients at the latest follow-up were superior after curettage compared to resection for upper and lower extremity (mean difference: -4.00 [95% CI: -6.81 to -1.18]; p < 0.001 and mean difference: -5.36 [95% CI: -3.74 to -6.97]; p < 0.001, respectively). Proximal tibia tumour location and curettage were shown to be major risk factors for local recurrence in GCTB regardless of neoadjuvant denosumab treatment. The recurrence-free survival rate of patients treated with resection and denosumab was higher compared to other treatments. The functional outcome of patients after curettage was better compared to en bloc resection.

Giant Cell Tumor of the Distal Fibula Managed by an Autologous Proximal Fibula Graft

A giant cell tumor of the bone is among the most common bone tumors encountered by orthopedic surgeons. These benign and aggressive tumors are most commonly present around the knee joint; however, rare cases may involve the distal fibula. An 18-year-old man presented with a painless swelling of the lateral aspect of the left ankle. Clinical examination, radiologic evaluation, and biopsy confirmed the diagnosis of a giant cell tumor of the distal fibula. The patient was treated with resection of the distal fibula followed by reconstruction using an ipsilateral proximal fibula graft. The post-operative recovery was uneventful, and the patient was doing well on the last visit, one month after the intervention.

Treatment of Recurrent Giant Cell Tumor of Bones: A Systematic Review

The giant cell tumor of bones (GCTB) is a benign bone tumor with high postoperative recurrence potential. No specific treatment protocol has been developed to date in case of tumor recurrence, and the kind of re-operative surgery depends upon the surgeon's preferences. The aim of this systematic review is to determine the second recurrence rate and the respective functional results of the available treatment options applied to recurrent GCTB. Medline/PubMed and Scopus were searched to identify articles published until March 2023. Twelve studies fulfilled the inclusion criteria, comprising 458 patients suffering from recurrent GCTB. The overall incidence of second recurrence was 20.5%, at a mean interval of 28.8 months after the first surgery, and it was more evident after intralesional curettage (IC) surgery than en-bloc resection (EBR) (p = 0.012). In the IC group of patients, the second recurrence rate was lower and the functional outcome was greater when polymethylmethacrylate cement (PMMAc) was used as an adjuvant instead of bone grafting (p < 0.001 for both parameters). Reconstruction of the created bone defect after EBR with a structural allograft provided a better outcome than prosthesis (p = 0.028). According to this systematic review, EBR (first choice) and IC with PMMAc (second choice) are the best treatment options for recurrent GCTB.

Single-Centre Experience Regarding the Use of Fibular Graft for Reconstruction after Resection of Grade III GCT of Distal Radius

Background: A giant cell tumour (GCT) is a locally invasive benign tumour of bone in young adults. Treatment includes surgical resection as first-line or denosumab pharmacotherapy in inoperable patients. However, surgical resection of distal radius GCT has produced debatable functional outcomes. Here we study the use of fibular grafts for reconstruction of surgically resected GCT of the distal radius. Methods: A total of 11 patients having Grade III GCT of the distal radius were recruited for a retrospective single-centred study. Five underwent arthrodesis with fibular shaft graft and six received arthroplasty with the proximal fibula. Functional outcomes at 6 weeks, 6 and 12 months were measured by Mayo wrist score (MWS) (>51% = good) and Revised Musculoskeletal tumor society (MSTS) score (>15 = good). Results: At 6 weeks, mean MSTS score and MWS were 23.64 and 58.64% respectively, and the length of the fibular graft was a predictor for both MSTS score (p = 0.014) and MWS (p = 0.006). At 6 months, the mean MSTS and MWS were 26.36 and 76.82%, respectively. At 6 months, the surgical procedure was a predictor in MSTS score (p = 0.02) while MWS was predicted by length of graft (p = 0.02). At 12 months, MSTS score was 28.73, and MWS remained 91.82%. Length of the fibular graft was an insignificant predictor, but a significant risk factor was surgical procedure for MWS (p = 0.04) at 12 months. No variable was found significant for MSTS score. Conclusions: Resection along with reconstruction of Grade III GCT of the radius with fibular graft was found an optimal treatment option. Also, use of the fibular head grafts and shorter length grafts are predictors for better outcomes after surgery. Level of Evidence: Level IV (Therapeutic).

Giant Cell Tumor of the Proximal Fibula With Common Peroneal Nerve Neuropraxia

Giant cell tumor (GCT) is among the commonest benign tumors and represents 5% of bone neoplasms. It is more common in young adults aged between 20 and 40 years. The distal femur is one of the most common sites, with the proximal tibia and distal radius the next frequently involved site, respectively. Previous research indicates that the tumor is an uncommon occurrence at this given age and location. Surgical management is the primary treatment for GCT universally. Extended curettage with the use of an argon beam cauterizer, a power burr, bone cement, hydrogen peroxide, phenol, liquid nitrogen, and zinc chloride are some of the treatment modalities for GCT. Opting for appropriate surgical treatments plays a crucial role to reduce the rate of recurrence and improve functional and oncological outcomes. In this case study, a 55-year-old male was diagnosed with GCT of the head of the right fibula with foot drop. The patient was managed with wide excision of the tumor and anchoring of lateral collateral ligament and biceps femoris to medial tibia condyle followed by postoperative galvanic stimulation for common peroneal nerve neuropraxia and guarded weight-bearing mobilization with bracing for knee joint. After 12 months of follow-up, there is no evidence of recurrence with a stable knee joint and dorsiflexion of the right ankle up to the neutral position.

Effect of bisphosphonates on bone giant cell tumor recurrence: a meta-analysis

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.

[Application of LARS ligament combined with three-dimensional printed prosthesis in reconstruction of radial hemicarpal joint after tumor resection]

OBJECTIVE

To investigate the effectiveness of LARS ligament and three-dimensional (3D) printed prosthesis on the combined reconstruction of radial hemicarpal joint after distal radius tumor resection.

METHODS

The clinical data of 12 patients with combined reconstruction of radial hemicarpal joint with LARS ligament and 3D printed prosthesis after distal radius tumor resection between September 2017 and March 2021 were retrospectively analyzed. There were 7 males and 5 females with an average age of 41.8 years (range, 19-63 years). There were 8 cases on the left side and 4 cases on the right side, and 10 cases of giant cell tumor of bone and 2 cases of osteosarcoma. The disease duration ranged from 1 to 20 months, with an average of 8.1 months. The osteotomy length, operation time, and intraoperative blood loss were recorded, and the wrist function was evaluated by Mayo wrist score and Musculoskeletal Tumor Society (MSTS) score before and after operation. The grip strength of the affected limb was expressed by the percentage of grip strength of the healthy upper limb, and the range of motion (ROM) of the wrist joint was measured, including extension, flexion, radial deviation, and ulnar deviation; the bone ingrowth and osseointegration at the bone-prosthesis interface of the wrist joint were observed by radiographic follow-up; the possible wrist complications were recorded.

RESULTS

All 12 patients successfully completed the operation. The osteotomy length was 5.0-10.5 cm (mean, 6.8 cm), and the operation time was 180-250 minutes (mean, 213.8 minutes). The intraoperative blood loss was 30-150 mL (mean, 61.7 mL). All patients were followed up 11-52 months (mean, 30.8 months). Radiographic follow-up showed that bone ingrowth and osseointegration at the bone-prosthesis interface were observed in all patients, and biological fixation was gradually achieved. During the follow-up, the stability, motor function, and ROM of the wrist joint were good. There was no complication such as arthritis, subluxation, prosthesis loosening, and infection, and no tumor recurrence and metastasis. At last follow-up, the Mayo score was 82.1±5.4, and MSTS score was 27.5±1.5, which were significantly improved when compared with those before operation (48.8±13.5, 16.4±1.4; t=-10.761, P<0.001; t=-26.600, P<0.001). The grip strength of the affected side was 59%-88% of that of the healthy side, with an average of 70.5%. The ROM of wrist joint were 55°-80° (mean, 65.42°) in extension, 35°-60° (mean, 44.58°) in flexion, 10°-25° (mean, 17.92°) in radial deviation, 10°-25° (mean, 18.33°) in ulnar deviation.

CONCLUSION

The combined application of LARS ligament and 3D printed prosthesis is an effective way to reconstruct bone and joint defects after distal radius tumor resection. It can improve the function of wrist joint, reduce the incidence of complications, and improve the stability of wrist joint.

En Bloc Resection of Giant Cell Tumor following Neoadjuvant Denosumab: A Case Report and Review of the Literature

Introduction

The RANK ligand inhibitor denosumab has been used to treat cases of unresectable giant cell tumors of bone (GCTB) or preoperatively to facilitate intralesional curettage. However, there are no clear guidelines for use of denosumab prior to en bloc resection.

Case Presentation

In this study, a 26-year-old patient presented with atraumatic lateral knee pain. X-rays demonstrated a destructive lesion within the proximal fibula, and biopsy confirmed the diagnosis of GCTB.

Management and Outcomes

The patient received 3 months of neoadjuvant denosumab with complete resolution of his pain and cortical rim formation surrounding the tumor. The tumor was removed en bloc with negative margins. At 6-month follow-up, the patient had returned to his functional baseline with no evidence of tumor recurrence.

Conclusion

Neoadjuvant denosumab can mitigate symptoms related to GCTB and promotes cortical bone formation, facilitating en bloc resection and permitting acceptable functional outcomes in select cases.

Aneurysmal bone cyst secondary to giant cell tumor of the extremities: a case series of 30 patients

The purpose was to investigate the clinical features, diagnosis, treatment, and prognosis of aneurysmal bone cyst (ABC) secondary to giant cell tumors (GCT) of the extremities. Data from patients with ABC secondary to GCT of the extremities were obtained from the medical records. Clinical features, imaging findings, pathologic diagnosis, surgical methods, and prognosis were analyzed. The median age of the patients was 33 years (range 15 to 52 years) and 83.3 percent were between 20 to 40 years. The lesions were mainly located in the proximal tibia and distal femur, accounting for 63.3% (19/30). 21 patients were treated with curettage, and 9 with tumor resection. The recurrence rates of the curettage group and resection group were 52.4% and 11.1% respectively. However, the average postoperative (Musculoskeletal Tumor Society) MSTS score were 28.6±1.2 post-curettage, and 25.0±0.5 post-resection, with a significant difference between the 2 groups (P<0.01). In these relapsed patients, 10 underwent a second curettage, while 2 cases underwent a resection and there was no postoperative re-recurrence in both groups. A comprehensive analysis should be performed when making the diagnosis of ABC secondary to GCT. Although the recurrence rate is higher, curettage is still the optimal method for satisfactory joint function. If recurrence occurs after the first curettage, a second curettage should be performed.

Computerised tomography features of giant cell tumour of the knee are associated with local recurrence after extended curettage

Background

Extended curettage has increasingly become the preferred treatment for giant cell tumour of bone (GCTB), but the high recurrence rate after curettage poses a major challenge for orthopaedic surgeons. Computed tomography (CT) is valuable in the evaluation of GCTB. Our aim was to identify specific features of GCTB around the knee in pre-operative CT images that might have prognostic value for local recurrence.

Methods

We retrospectively analyzed data from 124 patients with primary GCTB around the knee who underwent extended curettage from 2010 through 2019. We collected demographic, clinical, and therapeutic data along with several CT-derived tumour characteristics. CT-derived tumor characteristics included tumour size, the distance between the tumour edge and articular surface (DTA), and destruction of posterior cortical bone (DPC). Akaike information criterion (AIC) was used to select which variables to enter into multivariate logistic regression models and to determine significant factors affecting recurrence.

Results

The total recurrence rate was 21.0% (26/124), and the average follow-up time was 69.5 ± 31.2 months (24–127 months). Age, DTA (< 2 mm), and DPC were significantly related to recurrence, as determined by multivariate logistic regression. The C-index of the final model was 0.79 (95% CI: 0.71 to 0.88), representing a good model for predicting recurrence.

Conclusion

Identifying certain features of GCTB around the knee on CT has prognostic value for patients treated with extended curettage. A three-factor model predicts tumour recurrence well after extended curettage.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00264-021-05260-6.

The use of denosumab in the setting of acute pathological fracture through giant cell tumour of bone

Background

Denosumab (Xgeva^TM) is a fully human antibody to RANK-Ligand, an important signal mediator in the pathogenesis of giant cell tumour of bone (GCTB). The use of denosumab in the treatment of GCTB has changed the way in which these tumours are managed over the past years.

Case presentation

Described is the case of an acute fracture through a GCTB of the distal radius of a fit and well 32-year-old, non-smoking, female patient following a simple fall onto her outstretched, dominant hand. The aim was to enable joint sparing management for the patient, as opposed to an acute fusion procedure of the carpus. The patient underwent percutaneous k-wire fixation with application of plaster and immediate commencement with denosumab to halt the activity of the GCTB. Bone healing was rapid; plaster and k-wires were removed after 6 weeks. At 6 months denosumab, was ceased and an open curettage and grafting procedure of the tumour bed was undertaken (using MIIG X3, Wright Medical, aqueous calcium sulphate as graft material).

Conclusions

The use of denosumab in the acute setting of pathological fracture through giant cell tumour of bone allowing joint salvage has not been previously described. The treatment was well tolerated and functional outcomes are excellent, with very promising 4-year follow-up.

This novel approach may allow for more joint sparing strategies in the future for other patients in this difficult situation. Further cases will need to be gathered to establish this technique as a suitable treatment pathway.

Significance of EGFR/HER2 Expression and PIK3CA Mutations in Giant Cell Tumour of Bone Development

Giant Cell Tumour of Bone (GCTB) is a rare bone tumour. Locally aggressive and recurrent, it might evolve into pulmonary metastases. Our present work is aimed at investigating the involvement of the epidermal growth factor receptor (ErbB) family and its downstream effectors in the development and recurrence of GCTB. For this purpose, we used a cohort of 32 GCTB patients and we evaluated the clinicohistological features and the expression of RANKL, EGFR, and HER2. The mutation status of KRAS, PI3KCA, and PTEN gene as potential oncogene involved in GCTB was also evaluated. We found a significant correlation between advanced histological stages, overexpression of EGFR/HER2, and tumour recurrence. Moreover, two mutations were found in the PIK3CA gene: a missense mutation, 1634A>C, detected for the first time in GCTB patients, without influencing the stability of the protein, and a frameshift mutation, c.1658_1659delGTinsC, causing the loss of the protein kinase domain. Altogether, these results suggest that overexpression of HER2/EGFR, Campanacci, and histological stages could be used as a novel prognostic marker for GCTB recurrence.

Comorbidities and Pregnancy Do Not Affect Local Recurrence in Patients With Giant Cell Tumour of Bone

This study evaluates the relationship between pregnancy, comorbid conditions and giant cell tumour of bone. Furthermore, it examines if pregnancy and comorbid conditions affect the outcome following treatment for this tumour. A multi-centre retrospective review was conducted of consecutive patients with a confirmed histological diagnosis of giant cell tumour of bone between June 2012 and May 2017. A total of 195 patients were identified from two centres. Of these, 168 patients were treated with curative intent and had more than six months follow-up. Data were collected on pregnancy status, comorbid conditions, site of disease, surgical management and local recurrence rates. Statistical analysis included the Fisher exact test and Kaplan-Meier survival analysis. There were 72 females of childbearing age, of which 15 (21%) were currently pregnant or had been pregnant within the last six months. The pregnancy rate is higher than the highest reported pregnancy rate over the last 10 years (8.4%; Fisher test, p = 0.033). Women were more likely to have a comorbid condition than men (Fisher test, p < 0.002) and had a higher rate of autoimmune disease than the normal population (p = 0.015). Men were older than women (Wilcoxon test, p = 0.046) and had less risk of local recurrence (logrank test, p = 0.014). Pregnancy or comorbid conditions did not increase the local recurrence rate. Predictors for local recurrence included location in the distal radius (logrank test, p < 0.001), intralesional treatment (logrank test, p = 0.008) and age less than 40 (logrank test, p = 0.043). In conclusion, giant cell tumour of bone is more common in pregnant females and patients with immune disease. Comorbidities and pregnancy do not affect the local recurrence rate. Male patients over 40 years of age have a lower risk of local recurrence, and patients with disease in the distal radius have a high risk of recurrence.

Oncology and functional prognosis are both vital in the surgical treatment of RGCTs around the knee joint

AIMS

To explore and provide reasonable surgical options for recurrent giant cell tumors of bone (RGCTs) around the knee joint and compare the pros and cons of extended curettage (EC) and segmental resection (SR).

MATERIALS AND METHODS

A retrospective analysis was performed of 22 patients (11 male, 11 female; mean age, 34.1 years) with RGCT around the knee joint treated in our hospital between June 2007 and June 2017. Average recurrence time was 14.2 ± 4.7 months. Basic clinical data, including Campanacci grade, lesion location, filler materials, pathological fracture, were recorded. Based on different reoperation methods, patients were divided into the EC and SR groups. Patients were regularly followed up; and recurrence, metastasis, local complications such as osteoarthritis, infection, prosthesis loosening, were recorded. Patient function and surgical efficacy were evaluated using the musculoskeletal tumor society (MSTS) score and Mankin score, respectively.

RESULTS

Postoperative recurrence occurred in one patient in both groups, and no difference in the prognosis of oncology was observed between the groups. In the EC group, seven patients developed postoperative complications, but required no surgical treatment, whereas in the SR group, five patients developed postoperative complications and surgical treatment was performed on two patients. There were significant differences in the functional prognosis and surgical efficacy between the two groups; however, the EC group showed more satisfactory results.

CONCLUSION

The oncological and functional prognosis of patients with RGCT around the knee joint is vital. EC should be considered as the first-line treatment, unless the tumors severely invade the surrounding soft tissues or are accompanied by complex fractures with significant displacement leading to no surgical curettage boundary.

Surgical Treatment Options for Giant Cell Tumors of Bone Around the Knee Joint: Extended Curettage or Segmental Resection?

Aims: This study aimed to compare and evaluate the oncological and functional prognosis of two surgical approaches for giant cell tumor of the bone (GCTB) around the knee joint and provide worthy suggestion for clinical treatment. Patients and Methods: This study included 93 patients, who were divided into the extended curettage (EC) group and segmental resection (SR) group. Relevant preoperative and postoperative data were collected, oncological and functional prognosis were evaluated, and postoperative complications of the two groups were analyzed. Local recurrence was assessed via clinical and radiological tests. Functional prognosis was evaluated using the Musculoskeletal tumor Society (MSTS) scoring system. Results: The EC group had 69 patients; it included 57 primary cases and 12 recurrent cases. The SR group had 24 patients (12 men and 12 women; mean age, 34.9 years), including 15 primary cases and 9 recurrent cases. In this study, six cases (6.5%; EC group, 5 cases; SR group 1 case) recurred within 18 months postoperatively. There was a significant difference in the mean MSTS score between the two groups (p < 0.001). Nononcologic complications occurred frequently in the EC group than in the SR group (28.0 vs. 16.7%), but no complications had serious consequences, and the functional prognosis was not affected. Conclusion: EC and SR for GCTB around the knee joint can achieve satisfactory oncological prognosis, but we should individually select the most suitable surgical method according to Campanacci grade, age, and long-term complications of patients and consider the functional prognosis to ensure excellent oncological prognosis.

Evaluation of Local Recurrence in Giant-Cell Tumor of Bone Treated by Neoadjuvant Denosumab

Background

Giant-cell tumor of bone (GCTB) is a locally aggressive primary benign tumor presenting as an expansile osteolytic lesion affecting the epiphysis of long bones. Denosumab halts the osteolysis by giant cells thereby downstaging the tumor, helping in performing less morbid procedures to remove the tumor. Our aim was to report the incidence of local recurrence (LR) in patients operated following neoadjuvant denosumab, to investigate factors associated with LR following extended curettage for GCTB, and to compare the postoperative functional and oncological outcome of patients operated with and without neoadjuvant denosumab.

Methods

A total of 123 patients with a mean age of 29.6 years undergoing extended curettage for GCTB were retrospectively divided into group 1 receiving neoadjuvant denosumab and group 2 operated without denosumab. The mean follow-up period was 35 months. The perioperative characteristics and outcome were compared between the two groups and the factors for LR of GCTB were analyzed.

Results

The incidence of LR among patients operated after neoadjuvant denosumab therapy was 42.8% and was significantly high compared to that in patients without denosumab (p < 0.001). On multivariate logistic regression analysis, use of denosumab as a neoadjuvant was the only factor independently associated with LR following surgery (p = 0.002). Patients treated with denosumab had a lower LR-free survival rate (log-rank, p = 0.018).

Conclusions

Denosumab was independently associated with increased LR following surgery for GCTB. Denosumab has to be used cautiously in patients in whom the burden of downstaging the disease outweighs the possible chance of LR.

Giant cell tumors combined with secondary aneurysmal bone cysts are more likely to develop postoperative recurrence: A retrospective study of 256 cases

PURPOSE

The epidemiology and clinicopathology of aneurysmal bone cysts (ABCs) secondary to giant cell tumors of bone (GCTBs) have been well documented in the previous literature. However, reports on whether secondary ABCs could affect the postoperative recurrence of GCTBs are rare. This study analyzed the effects of secondary ABCs and other relevant clinical factors on the postoperative recurrence of GCTBs of the extremities.

METHODS

We retrospectively analyzed 256 cases of GCTBs of the extremities that were treated surgically at our institution. Among them, there were 60 patients diagnosed with GCTBs combined with secondary ABCs and 196 patients diagnosed with simple GCTBs. Intralesional curettage and tumor resection were performed in 136 and 120 cases, respectively. Univariate analysis, Kaplan-Meier survival analysis, and multivariate regression analysis were used to assess the factors for postoperative recurrence. The follow-up period was at least 24 months.

RESULTS

The total postoperative recurrence rate was 32%. The recurrence rate in the secondary ABCs group was significantly higher than that in the simple GCTBs group (53.3% vs 25.5%, P < 0.05). Curettage was associated with a higher recurrence rate than tumor resection (42.5% vs 20%, P < 0.05). Kaplan-Meier survival analysis showed that patients with GCTBs combined with secondary ABCs and who were treated by intralesional curettage had a decreased disease-free survival rate. The hazard ratio was 2.18 (95% confidence interval [CI], 1.15-4.13) for the group of GCTB combined with ABCs ( P = 0.01) and 1.97 (95% CI, 1.22-7.50) for the curettage group ( P = 0.01), respectively. Multivariate regression analysis revealed that the presence of secondary ABCs and curettage were independent factors for recurrence of GCTBs.

CONCLUSION

According to the results of this study, the presence of secondary ABCs is a potential risk factor for postoperative relapse of GCTBs.

Malignancy in Giant Cell Tumor of Bone: A Review of the Literature

Background:

Primary and recurrent giant cell tumor of bone is typically benign; however, rarely giant cell tumor of bone can undergo malignant transformation. Malignancy in giant cell tumor of bone may be primary (adjacent to benign giant cell tumor of bone at first diagnosis) or secondary (at the site of previously treated giant cell tumor of bone). Malignant giant cell tumor of bone has a poor prognosis; it is important to distinguish malignant from benign lesions to facilitate appropriate management. The true incidence of malignant giant cell tumor of bone is not known, probably owing to inaccurate diagnosis and inconsistent nomenclature. We have analyzed current data to provide a robust estimate of the incidence of malignancy in giant cell tumor of bone.

Methods:

A literature search was performed to source published reports of primary and secondary cases of malignant giant cell tumor of bone. Studies that reported a denominator were used to estimate the incidence of malignancy.

Results:

We identified 4 large series of patients with malignant giant cell tumor of bone that provided data on 2315 patients with giant cell tumor of bone. Across these studies, the cumulative incidence of malignancy was 4.0%; the cumulative incidence of primary malignancy was 1.6% compared with 2.4% for secondary malignancy. Our analyses confirmed that most malignant giant cell tumor of bone is secondary and occurs following radiation. In addition, data from 8 small series showed that 4.8% of patients with giant cell tumor of bone who received radiation therapy developed secondary malignancy.

Conclusions:

Malignant giant cell tumor of bone is rare, and its identification is hindered by a lack of clear diagnostic criteria. For optimal care of patients with giant cell tumor of bone, we recommend: comprehensive histologic sampling to ensure accurate diagnoses; watchful follow-up, particularly for patients treated with radiation; and timely treatment of local recurrence.

Tumor immunohistochemistry and preoperative magnetic resonance imaging features predict local recurrence of giant cell tumor of bone following intralesional curettage

Giant cell tumor of bone (GCTB) is among the most prevalent types of tumor of the bone in East and Southeast Asia. The high rate of local recurrence following intralesional curettage poses a challenge for the clinical treatment of GCTB. In the present study, the expression of matrix metalloproteinase-9 (MMP-9), vascular endothelial growth factor (VEGF), receptor activator of nuclear factor-κB (RANK) and RANK ligand (RANKL) in GCTB was investigated by immunohistochemical staining. A correlation between expression and preoperative magnetic resonance imaging (MRI) features was identified. The patients were followed up for ≥2 years after intralesional curettage. The rates of local recurrence were compared among different groups. A total of 74 cases of GCTB in the proximal tibia or distal femur were investigated. MRI features were retrospectively examined by correlation analysis. The expression of MMP-9 was demonstrated to be associated with cystic changes and the 'paint brush borders' sign (P<0.05), and positively associated with the expression of RANKL (P<0.05) and VEGF (P<0.05). Cystic changes, the 'paint brush borders' sign and adjacent soft tissue invasion were associated with high rates of local recurrence (P<0.05) and were therefore identified as significant risk factors. Pathologically, the 'paint brush borders' sign was demonstrated to be indicative of local invasion of the bone. These findings may be useful for predicting local recurrence of GCTB, and may provide important insight into the preoperative MRI features and molecular expression patterns of GCTB tumors.

Residual bone fragments in tibiofibular joint and postoperative local recurrence: an analysis of 21 cases of proximal fibular giant cell tumour

Background

Currently, there are no known reports on the aetiology of local giant cell tumour (GCT) recurrence in the proximal fibula following en bloc resection. We analysed 21 cases of proximal fibular GCT, focusing on the presence of residual bone in the tibiofibular joint, its causes and its impact on postoperative recurrence.

Methods

We retrospectively analysed 21 cases with proximal fibular GCT occurring between 2000 and 2017.

Results

There were 14 males and 7 females. The average patient age was 25.0 years. Seventeen patients were diagnosed and treated at our facility, while 4 were referred after local recurrence.

Six patients presented with residual bone fragments in the tibiofibular joint during their first month of follow-up. Patients with residual bone fragments had a higher local recurrence rate (83.3%) than those without (0%, p = 0.0003). Upon further analysis, patients with a preoperative Campanacci grade III tumour (p = 0.0055) and pathological fractures (p = 0.0109) were at a higher risk of exhibiting postoperative residual bone fragments.

Conclusions

The presence of residual bone fragments in the tibiofibular joint was the main cause of postoperative local recurrence. The presence of residual bone fragments may be related to the preoperative Campanacci grade and pathological fractures. Therefore, close attention should be paid to postoperative follow-up examinations, and if recurrence is suspected, surgical resection should be planned.

Epidemiology of benign giant cell tumor of bone in the Chinese population

Background

Quantifying the incidence of giant cell tumor (GCT) of bone is challenging because it is a rare, histologically benign bone tumor for which population-level statistics are unavailable in most countries. We estimated the 2017 incidence of GCT in China using a direct (registry-based) approach with available population-based data.

Materials and Methods

The most recent age- and sex-specific incidence rates of GCT recorded in the Bone Tumor Registry in Japan (2015) were applied to 2017 age- and sex-matched populations projected by the United Nations for China in order to estimate 2017 incidence. An adjustment factor calculated using registry data suggesting that GCT may represent a greater proportion of bone tumors in China than in Japan (Guo, 1999) was applied to provide secondary estimates.

Results

Annual GCT incidence was estimated to be 1.49 per million population or 2094 new cases in China for 2017. A comparison of this estimated incidence with Japan (1.25 per million) and the United States (1.38 per million) indicates that the incidence is somewhat higher in China using identical methods. Secondary estimates suggest that GCT incidence in China may be as high as 2.57 per million or 3625 new cases in 2017. The corresponding 3-year limited-duration prevalence of GCT in China using a registry-based approach and general age-specific mortality is 6276 (secondary estimate: 10,876).

Conclusions

Leveraging unique population-based registry data, we estimated that GCT is a rare disease in the Chinese population with an incidence ranging between 1.49 and 2.57 cases per million persons per year. Possible differences in diagnostic classification of GCT, urban-rural demographics, and the younger demographic distribution of the Chinese population may underlie observations that GCT, a condition that primarily affects young individuals (20-40 years of age), accounts for a higher proportion of skeletal tumors in China than in other regions.

Expression of MMP-2 and TIMP-3 with incidence and prognosis of giant-cell tumor of the bone

The expression of matrix metalloproteinase-2 (MMP-2) and tissue inhibitor of matrix metalloproteinase-3 (TIMP-3) in giant-cell tumor of bone (GCT), and the correlation of their expression with the clinicopathologic features and prognosis were investigated. A total of 70 GCT patients treated in our hospital from September, 2013 to September, 2015, were selected, and the tumor and para-carcinoma tissues were obtained by surgery. The expression levels of MMP-2 and TIMP-3 in GCT and para-carcinoma tissues were detected via semi-quantitative polymerase chain reaction (PCR) and western blot analysis, as well as immunohistochemical staining. Moreover, the clinicopathological data of the GCT patients were collected to study the correlation of MMP-2 and TIMP-3 with clinicopathological features and prognosis of GCT. The results of semi-quantitative PCR and western blot analysis revealed that the expression level of MMP-2 in tissues of the 70 GCT patients was significantly higher than that in para-carcinoma tissues, and the difference was statistically significant (P<0.01), while the expression level of TIMP-3 was obviously lower than that in para-carcinoma tissues (P<0.01). The results of immunohistochemical staining revealed that the positive expression rate of MMP-2 was 57.6% in GCT tissues and 18.9% in para-carcinoma tissues, while that of TIMP-3 was 63.2% in GCT tissues and 13.8% in para-carcinoma tissues, and the differences were statistically significant (P<0.01). The expression levels of MMP-2 and TIMP-3 were correlated with the diameter of tumor, clinical staging, lymph node metastasis and relapse of GCT (P<0.01), but were not correlated with the age and sex of GCT patients (P>0.05). There was a negative correlation between MMP-2 and TIMP-3 expression levels (r=−0.258, P<0.05). The expression levels of MMP-2 and TIMP-3 are closely related to the clinicopathological features and prognosis of patients, which can be used as one of the clinical examination indexes of GCT and also provide new insights for the clinical treatment of GCT.

A prospective study on predicting local recurrence of giant cell tumour of bone by evaluating preoperative imaging features of the tumour around the knee joint

PURPOSE

To evaluate the role of medical imaging in predicting local recurrence of giant cell tumour of bone (GCTB) by assessing the preoperative imaging features of GCTB around the knee.

METHODS

Forty-eight consecutive GCTBs in the proximal tibia and distal femur treated with curettage were prospectively enrolled. Patients were grouped in terms of their imaging features on radiography, computed tomography (CT) and magnetic resonance imaging (MRI). All patients were followed up for at least two years after surgery. The association between preoperative imaging features and local recurrence was investigated. Imaging features were retrospectively studied by correlation analysis. The differences between rates were tested by the Chi square and Fisher exact tests; independent factors were determined by multivariate logistic regression analysis.

RESULTS

Cystic change and adjacent soft tissue invasion were associated with a higher rate of local recurrence compared to the negative groups (P < 0.05). Cystic change was identified as an independent risk factor for local recurrence of GCTB (P < 0.05). Expansibility was correlated with the "soap bubble" sign and the fluid-fluid level (P < 0.05); the "soap bubble" sign was correlated with osteosclerosis and the fluid-fluid level (P < 0.05); cortical bone involvement was correlated with adjacent soft tissue invasion (P < 0.05); and cystic change was correlated with the fluid-fluid level (P < 0.05).

CONCLUSION

Cystic change was an independent risk factor for local recurrence of GCTB. Adjacent soft tissue invasion might indirectly relate to local relapse. A cluster of association relationships between imaging features was revealed.