Giant cell tumor of the extremity: retrospective analysis of 621 Chinese patients from one institution

En-Bloc Excision and Autogenous Fibular Reconstruction for Giant Cell Tumor of Distal Radius in a Developing Country: Lessons Learned

Giant cell tumors (GCT) are rare, locally aggressive tumors with a high rate of recurrence after treatment. Most tumors occur around the knee joint, but the distal radius is the most common location in the upper limb. While several treatment options have been proposed; management remains controversial. We present the first two cases of GCT of the distal radius treated with en-bloc resection and autogenous fibula grafting at our institution. The challenges that we encountered and the lessons learned from these initial cases are discussed, with the aim of guiding other surgeons who may need to manage similar cases in low-resource settings.

Comparative analysis of aggressiveness in giant cell tumor of bone between upper and lower extremities: A systematic review and meta-analysis

Background and Objective

Giant cell tumor of bone (GCTB) is among the most prevalent benign primary bone tumors, characterized by its potential for aggressive local recurrence, soft tissue invasion, and, though rare, lung metastasis. Emerging evidence suggests unique behavioral patterns of GCTB in extremities. This study seeks to rigorously compare the aggressiveness of GCTB in the upper versus lower extremities, centering on recurrence rates.

Method

This systematic review and meta-analysis, conducted in accordance with PRISMA guidelines, sourced data from MEDLINE/PubMed, Cochrane, Scopus, CINAHL/EBSCO, and reference lists of pertinent studies. Two independent reviewers screened studies, with discrepancies resolved by discussion. Eligible studies included a minimum of 10 participants. Data extraction and analysis were performed by an additional team of two researchers.

Results

Out of 1,283 studies spanning from 1984 to 2023, 30 met eligibility, encompassing 2,672 participants. The mean age was 32.77 ± 12.99 years, with an average follow-up of 75.53 ± 65.88 months. GCTB predominantly affected the lower extremities, accounting for 1,937 cases. Notably, comparisons of aggressiveness between upper and lower extremity GCTB revealed no statistically significant difference (OR = 1.10, p = 0.56 for Surgery Group; OR = 1.16, p = 0.45 for Local Adjuvant Group; and OR = 1.71, p = 0.32 for Drug/Denosumab Group).

Conclusion

This analysis underscores the lower extremities as the primary site for GCTB but finds no significant difference in aggressiveness between upper and lower extremities. These findings challenge assumptions about GCTB behavior based on tumor location and highlight the need for further investigation to fully elucidate the complex biology of extremity GCTB.

Management and surveillance of metastatic giant cell tumour of bone

Giant cell tumour of bone (GCTB) is viewed as a benign, locally aggressive primary bone tumour with metastatic potential. Current management is surgery with bone curettage or resection and systemic therapy with denosumab. Diagnosis is confirmed histologically prior to surgery, with staging for pulmonary disease, as pulmonary metastases (PM) reportedly occur in <8%. This study aimed to assess incidence, surveillance and management of PM in patients with GCTB, with histopathological review. A retrospective audit of the Oxford bone tumour registry was performed from January 2014 - October 2023. Inclusion criterion was histological confirmation of GCTB. Exclusion criteria were incomplete medical, imaging or histology records, or referral for secondary MDT opinion for diagnosis. From an initial group of 126 GCTB patients, 83 patients met the full selection criteria. Pulmonary metastases were identified in 11 patients. Three with PM were excluded on histopathological review as being giant cell rich osteosarcoma rather than metastatic GCTB. This left 8 (9.6%) patients, one had PM at presentation and seven at follow-up between 2 and 42 months. Two were histologically confirmed after cardiothoracic surgery and biopsy, six radiologically diagnosed. Three (37.5%) patients with PM have died (between 1 and 12 months after confirmed PM), five are alive with stable disease. Seven (87.5%) of patients with pulmonary disease were treated with denosumab/chemotherapy (three before, four after pulmonary diagnosis). Five (62.5%) with pulmonary disease had recurrence of local disease requiring further surgery. Local recurrence was an independent risk factor for PM on statistical analysis. GCTB may present with PM, but more commonly, metastasis occurs after surgery, presenting on surveillance and can progress. There were no distinct differences in histopathological appearance between patients with GCTB that developed PM and those that did not, therefore morphological features of the tumour cannot be currently used to predict tumour behaviour. PM can behave aggressively, necessitating identifying histological markers to recognise patients at risk of metastatic GCTB, for example, through mRNA single cell analysis. We propose GCTB patients with PM receive regular chest surveillance with PET scan and/or CT to monitor disease progression, and a multi-centre audit of GCTB outcome undertaken to further define optimal clinical management.

Giant cell tumor of proximal femur managed by extended curettage with fibular strut allograft using long intramedullary interlocking nail: A case report and literature review

RATIONALE

We first report a unique case of proximal femoral Giant cell tumor of bone, a subtrochanteric lesion associated with femoral neck and intertrochanteric involvement. We chose a completely new surgical approach to treat the primary tumor and preserve the hip joint. No cases of this type have ever been reported.

PATIENT CONCERNS

The patient, a 26-year-old man, came to our hospital for treatment of right hip pain more than 4 months ago, had no family history of similar diseases.

DIAGNOSES

Based on the imaging results and pathology, a diagnosis of Giant cell tumor of bone was confirmed.

INTERVENTIONS

Based on the imaging grade and patients' wishes, the tumor managed by extended curettage and reconstructed with a fibular strut allograft and long intramedullary interlocking nail was used for prophylactic fixation of fractures. The patient did not undergo disuzumab.

OUTCOMES

After 40 months of follow-up, although the bone defect finally reached bone healing, the hip function was good, and the tumor did not recur, there were signs of internal fixation loosening at 12 months of the surgery.

LESSONS

For young patients with imaging grade <3 who need limb salvage, fibular strut allograft and intramedullary nail-fixation are also an alternative treatment option for hip reconstruction after tumor surgery when the lesion involves the entire proximal femur.

Efficacy and safety of JMT103 in patients with unresectable or surgically-challenging giant cell tumor of bone: a multicenter, phase Ib/II study

This was a multicenter, single-arm, open-label, phase Ib/II study (NCT04255576), aimed to evaluate the efficacy and safety of JMT103 in patients with unresectable or surgically-challenging giant cell tumor of bone (GCTB). JMT103 (2 mg/kg) was administered subcutaneously every four weeks, with loading doses on days 8 and 15. The primary endpoint was the objective tumor response rate (OTR) based on best response, defined as the proportion of patients who achieved elimination of at least 90% of the giant cells or radiologic complete or partial response per the modified Inverse Choi density/size (mICDS) or modified European Organization for Research and Treatment of Cancer (mEORTC) within 12 weeks. Secondary endpoints included objective response rate (ORR) per mICDS and mEORTC, and safety. A total of 139 patients were enrolled, and 135 were analyzed for efficacy. OTR, determined by the independent review committee (IRC) was 93.3% (95% CI 87.7-96.9). Treatment-related adverse events occurred in 90 (64.7%) patients, with hypophosphatemia and hypocalcemia being the most common. No serious treatment-related adverse events were observed. Thus, JMT103 demonstrates potential as a therapeutic option for GCTB.

Denosumab combined with en bloc resection and arthrodesis for recurrent grade 3 giant cell tumor of bone in distal radius

PURPOSE

This study aimed to analyse the clinical outcomes of preoperative adjuvant denosumab therapy (PADT) combined with resection and arthrodesis for recurrent grade 3 giant cell tumor of bone (GCTB) in the distal radius.

METHODS

A retrospective study was conducted on twenty-three patients (8 males, 15 females) who were treated with the adjuvant denosumab combined with en bloc resection (EBR) and arthrodesis for biopsy confirmed recurrent Campanacci III giant cell tumor of bone in the distal radius between January 2015 and December 2022. All 23 patients were treated with wrist arthrodesis reconstruction using autogenous free iliac crest bone graft (ICBG), bridging plate and screws. The local control, metastasis and overall survival were evaluated during the follow-up period. Functional outcomes were evaluated using the Disabilities of the Arm, Shoulder and Hand (DASH) score, Musculoskeletal Tumor Society Score (MSTS-87 and MSTS-93), and grip strength in the follow-up period. Additionally, all surgical or denosumab-related complications that occurred were recorded in this study.

RESULTS

Twenty-three patients were included in this retrospective study and no patients were lost in the follow-up period. The average patient age was 32.5 ± 10.2 years (range, 19-53 years) and the mean follow-up time was 35.5 ± 18.4 months (range, 13-72 months). The average tumor length was 71.7 ± 8.7 mm (range, 50 to 85 mm) and bone reconstruction length was 78.5 ± 8.5 mm (range, 60 to 90 mm). Four patients (17.4%) had secondary local recurrence after reoperation and two patients had (8.7%) multiple recurrences. One patient (4.3%) was deceased in the last follow-up due to multiple metastases. The estimated 5-year recurrence-free survival rate was 81.3% and 5-year metastasis-free survival rate was 95.7%. The mean union time was 8.5 ± 1.9 (6-12) months and the overall survivorship of the allograft was 82.7% (21/23) at an average 35 month follow-up. The average MSTS-87 and MSTS-93 scores were 27.8 ± 1.6 (range, from 23 to 30) and 91.5 ± 5.0 (range, from 76 to 100), and the average DASH score was 8.9 ± 3.2 (range, from 3 to 15), respectively. The average grip strength was 64.6 ± 15.7% (range, from 30 to 95%) of the uninvolved side. Eight patients (34.7%) had at least one complication in the follow-up time. Two autografts (8.7%) were removed due to local recurrence and bone nonunion, and the average autograft survival time was 32.8 ± 18.5 months (range, 12 to 72 months).

CONCLUSIONS

Preoperative adjuvant denosumab therapy (PADT) combined with en bloc resection and arthrodesis is a promising method for the treatment of recurrent Campanacci III GCTB in distal radius with acceptable short-term local control and functional satisfaction.

LEVEL OF EVIDENCE

level IV Therapeutic.

Combined preoperative denosumab and adjuvant microwave ablation for high-risk giant cell tumor of bone: a retrospective study in a single center

BACKGROUND

Giant cell tumor of bone (GCTB) is a locally aggressive neoplasm with a high propensity for recurrence following intralesional curettage. The introduction of denosumab, a RANKL inhibitor, has shown potential in facilitating joint-sparing surgery. However, concerns exist regarding its impact on local recurrence rates. This study aimed to evaluate the efficacy and safety of combined preoperative denosumab with adjuvant microwave ablation (MWA) for the treatment of high-risk GCTB.

METHODS

We conducted a retrospective review of 19 patients with high-risk GCTB who underwent preoperative denosumab treatment followed by curettage and adjuvant MWA. The primary outcome measure was the local recurrence rate, with secondary outcomes including functional status assessed by the Musculoskeletal Tumor Society (MSTS) score and safety profile of the treatment.

RESULTS

In this retrospective analysis, we evaluated the outcomes of 19 patients with high-risk GCTB treated with preoperative denosumab and adjuvant MWA. The median follow-up duration was 33.1 months, 3 patients (15.8%) experienced local recurrence at a median of 21.6 months postoperatively and the local recurrence-free survival was 81.2% at two years. Notably, no patient developed lung metastasis, and all recurrences were successfully managed with repeat curettage and MWA, with a mean MSTS score of 27.3. No patient required joint replacement due to tumor recurrence, resulting in a 100% joint preservation rate.

CONCLUSION

The combination of preoperative denosumab and adjuvant MWA is a feasible and effective strategy for the management of high-risk GCTB, providing effective local control with preserved joint function. This approach may offer a surgical alternative for young patients where joint preservation is paramount.

Clinical Perspectives on Surgical Reconstruction of Eccentric Tumors at the Distal Femur with Unicondylar Resection

The distal femur is one of the most common sites for primary bone tumors. As the tumor progresses and bone destruction worsens, it can severely affect knee function and even pose a threat to life. In cases where only one condyle is affected and requires resection, preserving the healthy contralateral condyle can substantially enhance the biomechanics of the knee. Furthermore, preserving bone stock may enable future salvage procedures in the event of initial surgery failure, be it from fractures or osteoarthritis. Distal femoral unicondyle resection can offer better functional outcomes in select cases. However, it is essential to prioritize oncological safety with adequate margins over short-term knee function. Currently, the primary methods for reconstruction after the excision of a unicondylar tumor include allograft transplantation (bi- or uni-condylar) and prosthetic or allograft-prosthesis composite replacement (APC). However, there is currently some controversy regarding the optimal surgical reconstruction method, and a consensus within the academic community has yet to be reached. Moreover, due to the rarity of bone tumors, extensive clinical data from a single center is limited. Current studies are mainly retrospective and single-center, lacking sufficient cases and follow-up duration. This article reviews surgical reconstruction after solitary condylar excision in distal femoral tumors. It summarizes, compares, and analyzes mainstream reconstruction methods, exploring their technical details and clinical outcomes to highlight their potential in bone oncology.

Reduced recurrence rate and comparable functionality after wide resection and reverse total shoulder arthroplasty with allograft-prosthetic composite versus curettage for proximal humeral giant cell tumor: a multicenter retrospective study

BACKGROUND

Giant cell tumors of bone (GCTBs) are rare, aggressive tumors, and the proximal humerus is a relatively rare location for GCTBs; limited evidence exists on which surgical approaches and reconstruction techniques are optimal. In the largest case series to date, we evaluated the recurrence rate of proximal humeral GCTBs and the functional outcomes of different resection and reconstruction options in this multicenter study.

METHODS

All 51 patients included in this study received initial surgical treatment for proximal humeral GCTBs from January 2007 to December 2020, with a minimum 2-year follow-up period. Local recurrence and functional outcomes were statistically analyzed in relation to demographic, clinical, and primary surgical variables. Functional outcomes were reported by patients and were assessed by the Musculoskeletal Tumor Society score and QuickDASH instrument (shortened version of the Disabilities of the Arm, Shoulder and Hand instrument).

RESULTS

The mean follow-up period was 81.5 months (range, 30-191 months), and the overall recurrence rate was 17.6% (9 of 51 patients). The majority of recurrences (n = 7) occurred in the first 2 years of follow-up. The intralesional curettage group (n = 23) showed a statistically significant difference in the recurrence rate compared with the en bloc resection group (n = 28) (34.8% vs. 3.6%, P = .007). Among shoulders receiving en bloc resection, 16 were reconstructed with hemiarthroplasty; 8, reverse total shoulder arthroplasty (rTSA) with allograft-prosthetic composite (APC) reconstruction; and 4, arthrodesis. On the basis of intention-to-treat analysis, the mean functional Musculoskeletal Tumor Society scores of the groups undergoing curettage, rTSA with APC, hemiarthroplasty, and arthrodesis were 26.0 ± 3.1, 26.0 ± 1.7, 20.3 ± 2.8, and 22.5 ± 1.3, respectively (P < .001 [with P < .001 for curettage vs. hemiarthroplasty and P = .004 for rTSA with APC vs. hemiarthroplasty]) and the mean QuickDASH scores were 14.0 ± 11.0, 11.6 ± 4.5, 33.1 ± 11.8, and 21.6 ± 4.7, respectively (P < .001 [with P < .001 for curettage vs. hemiarthroplasty and P = .003 for rTSA with APC vs. hemiarthroplasty]).

CONCLUSIONS

On the basis of our data, en bloc resection followed by reverse shoulder arthroplasty showed a lower recurrence rate and no significant difference in functional outcome scores for proximal humeral GCTBs compared with intralesional curettage. Therefore, we believe that rTSA with APC may be reasonable for the initial treatment of proximal humeral GCTBs.

The Evaluation and Management of Lung Metastases in Patients with Giant Cell Tumors of Bone in the Denosumab Era

Giant cell tumor of bone (GCTB) is characterized by uncertain biological behavior due to its local aggressiveness and metastasizing potential. In this study, we conducted a meta-analysis of the contemporary literature to evaluate all management strategies for GCTB metastases. A combination of the terms "lung metastases", "giant cell tumor", "bone", "treatment", and "oncologic outcomes" returned 133 patients meeting our inclusion criteria: 64 males and 69 females, with a median age of 28 years (7-63), at the onset of primary GCTB. Lung metastases typically occur at a mean interval of 26 months (range: 0-143 months) after treatment of the primary site, commonly presenting as multiple and bilateral lesions. Various treatment approaches, including surgery, chemotherapy, radiotherapy, and drug administration, were employed, while 35 patients underwent routine monitoring only. Upon a mean follow-up of about 7 years (range: 1-32 years), 90% of patients were found to be alive, while 10% had died. Death occurred in 25% of patients who had chemotherapy, whereas 96% of those not treated or treated with Denosumab alone were alive at a mean follow-up of 6 years (range: 1-19 years). Given the typically favorable prognosis of lung metastases in patients with GCTB, additional interventions beyond a histological diagnosis confirmation may not be needed. Denosumab, by reducing the progression of the disease, can play a pivotal role in averting or delaying lung failure.

Successful Surgical Management of a Giant Cell Tumor in the Proximal Tibia: A Case Report

Giant cell tumors (GCTs) of the bone present unique challenges in management due to their locally aggressive nature and potential for recurrence. This case report describes the successful surgical management of a GCT located in the proximal tibia of a 28-year-old female. The patient presented with six months of pain and swelling following a traumatic injury to the knee. Diagnostic imaging confirmed the presence of a GCT, leading to preoperative prophylactic embolization to reduce intraoperative bleeding. Surgical excision of the tumor was performed, followed by reconstruction using autologous fibula grafts and plate fixation. Postoperative care included analgesia, antibiotics, and physiotherapy. Regular follow-up demonstrated satisfactory clinical outcomes without evidence of recurrence. This case highlights the importance of a multidisciplinary approach combining surgical expertise, preoperative planning, and postoperative rehabilitation to achieve favorable outcomes in managing GCTs.

Denosumab Induces Neoplastic Stromal Cell Apoptosis Via p62 Downregulation Dependent on Autophagy Pathway in Giant Cell Tumour of Bone

BACKGROUND

As the only humanized monoclonal antibody against receptor activator of nuclear factor-κB ligand (RANKL) for giant cell tumour of bone (GCTB) therapy, denosumab has limited antitumour effect on neoplastic stromal cells. Nevertheless, its mechanism of action has not yet been clarified. A previous study has revealed that p62 may play an important role in the antitumour activity of denosumab.

OBJECTIVE

The study aimed to investigate if the mechanism by which denosumab inhibits GCTB neoplastic stromal cells growth is via p62 modulation and other related mechanisms.

METHODS

p62 expression before and after denosumab therapy was analysed by RT‒qPCR, western blot, ELISA, and immunohistochemical assays. Two primary neoplastic stromal cells were isolated from fresh GCTB tumour tissue (L cell) and metastatic tissue (M cell). Cell proliferation, migration, apoptosis, and autophagy were investigated in p62 knockdown neoplastic stromal cells transfected by short hairpin RNA lentivirus in vitro. Tumor growth was evaluated in the chick chorioallantoic membrane model in vivo.

RESULTS

p62 expression was found to be downregulated following denosumab therapy. The patients with a decrease in p62 expression had lower recurrence-free survival rates. The proliferation of M cells was not inhibited by denosumab therapy, but it was restored by p62 knockdown. Moreover, p62 knockdown inhibited tumour growth in vivo. Denosumab induced M cell apoptosis and arrested the cell cycle at the G1/G0 transition and these effects were also enhanced by p62 knockdown. Autophagic flux assays revealed p62 modulation to be dependent on autophagy following denosumab incubation.

CONCLUSION

Denosumab induced neoplastic stromal cells apoptosis via p62 downregulation dependent on autophagy pathway. The combination of p62 and RANKL knockdown might be a better strategy than RANKL knockdown alone for GCTB targeted therapy.

"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.

Does the use of polymethyl-methacrylate cement after intralesional curettage of giant cell tumors of appendicular bone guarantee reduced local recurrence rates? A retrospective analysis

PURPOSE

Polymethyl-methacrylate cement (PMMA) is often used as bone defect reconstruction material after surgical removal of giant cell tumors. The purpose of this study was to investigate if the application of PMMA improves the local recurrence rates for giant cell tumors (GCT) of appendicular bone treated with intralesional curettage.

METHODS

A retrospective analysis of all appendicular GTCs treated at two major Danish sarcoma centres between the 1st of January 1998 and December 31st 2013; minimum follow-up of 3.0 years (median: 8.9; 1.3-18.7 years). Kaplan-Meier survival model, log-rank and multivariate Cox regression were used to calculate and compare local recurrence rates. p-values <0.05 were considered statistically significant.

RESULTS

102 patients (M59/F43), median age 31Y (11-84) were included in this study. The overall 3-years local recurrence-rate was 19.9% (95%CI: 11.9-27.9%); 91% had occurred within 3 years. In patients treated with intralesional curettage (n = 64), the 3-years recurrence-rate was 30.6% (95%CI: 18.8-42.4%), compared to 2.6% (95%CI: 0.0-7.8%) in patients treated with wide resection or amputation (n = 38), p < .001. The 3-years recurrence-rate for patients treated with intralesional curettage and reconstruction using PMMA was 29.0% (95%CI: 12.6-45.4%) and without PMMA: 31.8% (95%CI: 15.2-48.4%), p = .83.

CONCLUSION

We found that the use of PMMA for bone defect reconstruction after intralesional curettage of GTCs in the appendicular skeleton did not ensure a reduced risk of local recurrence.

Clinical evaluation of the three-dimensional printed strut-type prosthesis combined with autograft reconstruction for giant cell tumor of the distal femur

Propose

This study aimed to describe the design and surgical techniques of a three-dimensional (3D) printed strut-type prosthesis with a porous titanium surface for distal femur giant cell tumors of bone (GCTB) and evaluate the short-term clinical outcomes.

Methods

From June 2018 to January 2021, 9 consecutive patients with grade I or II GCTB in the distal femur underwent extended intralesional curettage followed by 3D-printed strut-type prosthesis combined with autograft reconstruction were retrospectively reviewed to assess their clinical and radiographic outcomes.

Results

All patients were followed up for 30.8 ± 7.5 months (18-42 months) after surgery. The mean affected subchondral bone percentage and the mean subchondral bone thickness before surgery was 31.8% ± 9.6% (range, 18.2% ~50.2%) and 2.2 ± 0.8 mm (range, 1.2-4.0 mm), respectively. At the final follow-up, all the patients were alive without local recurrence; no postoperative complications were observed. Patients had significant improvements in postoperative MSTS-93 score [(26.7 ± 2.4) vs. (18.8 ± 3.7), P < 0.05], and ROM [(122.8° ± 9.1°) vs. (108.3° ± 6.1°), P < 0.05] compared with their preoperative statuses. Furthermore, the mean subchondral bone thickness has increased to 10.9 ± 1.3 mm (range, 9.1-12.1 mm).

Conclusion

3D-printed strut-type prosthesis combined with autograft reconstruction provides acceptable early functional and radiographic outcomes in patients with grade I or II GCTB in distal femur due to the advantages of the prosthesis such as good biocompatibility, osseointegration capacity, and subchondral bone protection. If our early outcomes can be further validated in studies with more patients and sufficient follow-up, this method may be evaluated as an alternative for the treatment of grade I or II GCTB in the distal femur.

Reconstruction After En Bloc Resection of a Distal Radius Tumor. An Updated and Concise Review

The distal radius is rarely affected by either primary or metastatic bone cancers. The most frequent tumors of the distal radius are giant cell tumors, which are benign tumors with the propensity to invade. En bloc excision of giant cell tumors of the distal radius achieves a low recurrence rate but compromises the wrist joint, necessitates a significant reconstruction, and has functional consequences. Reconstruction after en bloc resection of a distal radius bone tumor is challenging. Furthermore, orthopedic oncologists disagree on treating such long bone anomalies most effectively. The present article summarizes the various biological and non-biological reconstruction techniques performed after en bloc resection of a distal radius tumor, discusses the advantages and disadvantages of each reconstruction strategy, and summarizes several case studies and case reports.

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.

A Retrospective Observational Study on Disease Characteristics and Treatment Patterns of Giant Cell Tumor of the Bone in China

Aims

Giant cell tumor of the bone (GCTB) is associated with considerable morbidity. As GCTB epidemiological data for China are limited, this study is aimed at describing the disease characteristics of GCTB in China and establishing the historical context for its treatment before recent advances in treatment options.

Methods

The disease characteristics, treatment patterns, and local GCTB recurrence rate after primary surgery for GCTB were evaluated in this single-center, retrospective, noninterventional, observational study of patients treated for GCTB at Ji Shui Tan Hospital, Beijing, from 2009 to 2016 based on medical chart review. Patients with unmet need were defined as those whose surgical treatment was difficult or who had to undergo high-morbidity surgery.

Results

Among the 668 patients with a primary GCTB diagnosis, 578 (86.5%) of target lesions were in the extremities, and 89 (13.3%) were in the pelvic or axial bone. Of these, 173 (25.9%) were characterized as having an unmet need. Almost all GCTB patients received surgical treatment at both primary diagnosis (666/668 (99.7%)) and last disease recurrence (196/200 (98.0%)). Additionally, about one-third of patients received nonsurgical treatment at primary diagnosis (205/668 (30.7%)) and disease recurrence (67/200 (33.5%)), with neoadjuvant therapy being the most common treatment. The rate of high-morbidity surgery increased for recurrent disease (65/200 (32.5%)) compared with primary diagnosis (111/668 (16.6%)). The 2-year cumulative incidence of postoperative disease recurrence was 29.2%, in line with rates observed in prior studies.

Conclusion

As many patients with primary and recurrent disease received high-morbidity surgery, more effective treatments are needed.

Diagnostic value of H3F3A mutation and clinicopathological features of giant cell tumours in non-long bones

Aims

A histone H3F3A (H3.3) mutation involving a substitution in H3.3 G34 recently has been reported in GCTB within the frequency range (from 69 % to 96 %) and is a helpful diagnostic indicator of GCTB. However, the relationship between H3F3A mutations and the clinicopathological feature of GCTB involving non-long bones (irregular bones and small bones) is unclear.

Methods and results

H3F3A mutations were observed in a cohort of specimens (230 samples of GCTB) using immunohistochemistry and Sanger sequencing. The relationship between H3F3A mutations and the clinicopathological characteristics of patients with GCTB occurring in the non-long bones of the appendicular skeleton was investigated. No significant difference between H3F3A mutations in GCTB arising in non-long bones and the classic sites was found (P = 0.483). GCTB in non-long bones occurred more common in female (31/49, 63.3 %) than in male patients (P = 0.016). GCTB with H3.3 G34L/V/R mutation occurred more often in younger patients compared with those with H3.3 G34W mutation (P = 0.009). The majority of GCTB with soft tissue extension developed in irregular bones but not in small bones (P = 0.061). The H3.3 G34L/V/R mutations rate (7/45) in the non-long bones was significantly higher than that in long bones. The recurrence rate of the GCTB in long bones and non-long bones was 23.3 % (45/193) including 43 cases with local recurrene and 2 cases with lung metastasis. No recurrence occurred in cases with G34V/L/R mutations.

Conclusions

H3F3A was an effective diagnostic marker for GCTB of the non-long bones. The younger patients with GCTB of the non-long bones harboured H3.3 G34L/V/R mutations and may had a female preference and rarely recurrent.

Mid-term results of giant cell tumours with pathologic fractures around the knee: a multicentre retrospective study

OBJECTIVE

The aims of this work are to present a classification of "complex fracture" and "simple fracture", to compare their features, treatments and prognosis in patients with giant cell tumour with pathologic fractures around the knee, and to determine the best surgical method for patients who have giant cell tumour around the knee with different degrees of fracture.

METHODS

Data from 130 patients with pathologic fractures from giant cell tumour around the knee who underwent surgical treatment from March 2000 to November 2015 at 6 institutes around China were collected and analysed. A multicentric study design was used to explore the epidemiological features and to compare differences in the surgical procedures and prognosis of the two fracture groups. The mean age at diagnosis was 37.1 years old (range, 13-77 years). The median follow-up was 126.5 months, ranging from 68 to 370 months.

RESULTS

The general clinical and imaging features of the groups of patients with simple and complex fractures, namely, sex, age, the lesion site, living or working environment, eccentric growth patterns, Campanacci grading system, and duration of symptoms before treatment, showed varying degrees of differences, but with no statistical significance (p > 0.05). The incidence rate of surrounding soft tissue mass was 35.2% (32/91) in the group with simple fractures, whereas it was 87.2% (34/39) in the group with complex fractures, which showed a significant difference (p < 0.05). Wide resection and reconstruction with joint replacement were performed more often in patients with complex fractures (61.5%, 24/39). Intralesional procedures were performed more often in patients with simple fractures (56.0%, 51/91). The difference showed significant differences (p < 0.05). The local recurrence rate was 17.6% (16/91) in the group with simple fractures, whereas it was 10.3% (4/39) in the complex fracture group, showing a significant difference (p < 0.05). A total of 2.3% of patients (n = 3,3/130) developed a skip lesion. The complication rates were 4.6% (4/87) and 14.7% (5/34), respectively, in the two groups with simple or complex fractures, showing a significant difference (p < 0.05). The mean MSTS and TESS scores with simple fractures were 26.6 (range, 13-30) and 84.1 (range, 29-100), respectively, whereas the mean scores in the group with complex fractures were 25.5 (range, 18-30) and 78.3 (range, 30-100), respectively, also showing a significant difference (p < 0.05).

CONCLUSION

Our classification of "simple fracture" and "complex fracture" could guide decisions regarding the best surgical method for lesions in patients who have giant cell tumour around the knee with different degrees of fracture.

Premalignant Conditions of Bone

Development of malignancy is a multifactorial process, and there are multitude of conditions of bone that may predispose patients to malignancy. Etiologies of malignancy include benign osseous conditions, genetic predisposition, and extrinsic conditions. New-onset pain or growth in a previously stable lesion is that should concern for malignant change and should prompt a diagnostic workup for malignancy.

A Tertiary Care Centre Experience of Recurrent Giant Cell Tumor Around the Knee Joint

Introduction: Giant cell tumor (GCT) is a benign but locally aggressive bone tumor. It has a peak incidence between 30-40 years with a predilection for the epiphyseal/metaphyseal region of bone. The most common locations for bone GCT are the distal femur, proximal tibia, distal radius, and sacrum in decreasing order.

Material and Methods: In this retrospective study, 22 patients (13 females and nine males) with recurrent giant cell tumors around the knee joint between 2009-2022, with a mean age of 30.2 years (range: 18-55) were included. The patients were followed up monthly for three months, three-monthly for the next two years, six-monthly for the next five years, and thereafter, yearly. The mean follow-up period was 36.97 months (range 23-120 months).

Results: There were 19 recurrences after curettages and three after resections. Re-extended curettage was done in 17 cases and the resultant cavities were filled with autologous bone grafts in six and with polymethyl methacrylate (PMMA) cement in the other 11 cases. Reconstruction with megaprosthesis was done in two patients whereas knee arthrodesis was done in two patients after wide resection. The average Musculoskeletal Tumor Society (MSTS) score of our series of 22 patients was 23.1 (Range: 19-30).

Conclusion: Campanacci grade 1 and 2 lesions can be successfully treated with extended curettage and bone grafting/bone cementing. For patients with grade 3 lesions, there are two options available according to the financial status of the patient; the first option is reconstruction with prosthesis and the other option is arthrodesis.

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.

Imaging Features of Aggressive Giant Cell Tumors of the Mobile Spine: Retrospective Analysis of 101 Patients From Single Center

STUDY DESIGN

Retrospective study.

OBJECTIVES

Giant cell tumors (GCTs) of the mobile spine can be locally aggressive. This study described and classified the typical and atypical appearance of aggressive spinal GCTs according to imaging findings to help the imaging diagnosis, especially for patients with rapid neurological deficit that may require emergent surgery without biopsy.

METHODS

Computed tomography (CT) and magnetic resonance imaging (MRI) scans of patients diagnosed with aggressive spinal GCTs at single center were reviewed.

RESULTS

Overall, 101 patients with 100 CT images and 94 MR images were examined. All lesions were osteolytic with cortical destruction; 95 lesions showed epidural extension; 90 were centered in the vertebral body; 82 showed pathological fracture and/or collapse of the vertebral body; 78 had pseudotrabeculation on CT; 80 showed low-to-iso signal intensity or heterogeneous high-signal intensity with cystic areas on the T2-weighted images; 9 showed fluid-fluid level on T2-weighted images; and 61 patients showed marked enhancement on contrast-enhanced CT and/or MRI. Forty-one lesions (40.6%) had at least 1 atypical radiographic feature: 19 involved ≥2 segments; 11 were centered in the posterior neural arch; 10 had a paravertebral mass over 2 segments; 16 showed partial margin sclerosis with partial cortical destruction on CT scans; and 3 showed mineralization within the tumor on CT. Eighty-eight patients underwent CT-guided biopsy with a diagnostic accuracy rate of 94.3%.

CONCLUSIONS

Spinal GCTs might appear more radiologically atypical, and about 40% of the lesions may have at least 1 atypical feature. CT-guided biopsies are recommended for definitive diagnosis.

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.

Burden of complications after giant cell tumor surgery. A single-center retrospective study of 192 cases

BACKGROUND

Surgical complications are frequent with giant cell tumor of bone; recurrence is the best known and most widely studies; other causes of failure have been less well investigated. We therefore performed a retrospective study to identify and assess the main reasons for surgical revision.

HYPOTHESIS

Recurrence is the main cause of surgical revision in giant cell tumor of bone, but other complications, such as mechanical issues or infection, are underestimated.

PATIENTS AND METHODS

A single-center retrospective study included 192 patients (included from 2000 to 2016) undergoing first giant cell tumor of bone surgery in a bone tumor reference center. Surgery consisted in curettage for 152 patients (79%) and resection for 40 (21%). The 3 main reconstruction techniques were filling (136 patients; 71%), prosthesis (18 patients; 9%), and fusion (14 patients: 7%). Filling used cement in 9 cases (7%) and bone graft in 127 (93%). Cumulative incidence functions were calculated.

RESULTS

There were 171 revision procedures in 92 patients: 43 for mechanical reasons, 30 for infection, 86 for tumor recurrence, 12 for other causes. Cumulative incidence of revision at 10years was 36% (95% CI: 27-44) for recurrence, 26% (95% CI: 17-36) for mechanical causes, and 13% (95% CI: 9-19) for infection, for overall cumulative incidence of revision of 61% (95% CI: 50-69).

DISCUSSION

Risk of all-cause surgical revision in giant cell tumor of bone was 61% at 10years, with recurrence accounting for only half of cases.

LEVEL OF EVIDENCE

IV.

Metastatic giant cell tumour of bone: a narrative review of management options and approaches

Giant cell tumour of bone (GCTB) is a locally aggressive bone neoplasm with a rare tendency to metastasise, most commonly to the lungs. The management of metastatic GCTB (metGCTB) is controversial due to its unpredictable behaviour. Asymptomatic patients should be monitored radiologically and undergo treatment only when disease progression occurs. Surgery is recommended for resectable metGCTB. Denosumab, a monoclonal antibody which inhibits receptor activator of nuclear factor-κB ligand, is recommended for unresectable metGCTB with evidence from phase II trials demonstrating its safety and efficacy. Relapse after denosumab withdrawal may occur and prolonged treatment may be associated with serious adverse events, thus further research is warranted to inform a maintenance regimen with reduced dosing and frequency. Combined denosumab and bisphosphonate therapy has the potential to achieve sustained disease control or remission in unresectable metGCTB without requiring long-term treatment and should be evaluated in prospective trials. Various novel agents have demonstrated in vitro and anecdotal efficacy and warrant further evaluation.

A biomechanical comparison between cement packing combined with extra fixation and three-dimensional printed strut-type prosthetic reconstruction for giant cell tumor of bone in distal femur

BACKGROUND

The most common reconstruction method for bone defects caused by giant cell tumor of bone (GCTB) is cement packing combined with subchondral bone grafting and extra fixation. However, this method has several limitations involving bone cement and bone graft, which may lead to poor prognosis and joint function. A titanium-based 3D-printed strut-type prosthesis, featured with excellent biocompatibility and osseointegration ability, was developed for this bone defect in our institution. The goal of this study is to comparatively analyze the biomechanical performance of reconstruction methods aimed at the identification of better operative strategy.

METHODS

Four different 3D finite element models were created. Model #1: Normal femur; Model #2: Femur with tumorous cavity bone defects in the distal femur; Model #3: Cavity bone defects reconstructed by cement packing combined with subchondral bone grafting and extra fixation; Model #4: Cavity bone defects reconstructed by 3D-printed strut-type prosthesis combined with subchondral bone grafting. The femoral muscle multiple forces were applied to analyze the mechanical difference among these models by finite element analysis.

RESULTS

Optimal stress and displacement distribution were observed in the normal femur. Both reconstruction methods could provide good initial stability and mechanical support. Stress distributed unevenly on the femur repaired by cement packing combined with subchondral bone grafting and extra fixation, and obvious stress concentration was found around the articular surface of this femur. However, the femur repaired by 3D-printed strut-type prosthetic reconstruction showed better performance both in displacement and stress distribution, particularly in terms of the protection of articular surface and subchondral bone.

CONCLUSIONS

3D-printed strut-type prosthesis is outstanding in precise shape matching and better osseointegration. Compared to cement packing and extra fixation, it can provide the almost same support and fixation stiffness, but better biomechanical performance and protection of subchondral bone and articular cartilage. Therefore, 3D-printed strut-type prosthetic reconstruction combined with subchondral bone grafting may be evaluated as an alternative for the treatment of GCTBs in distal femur.

Study of imaging changes following preoperative denosumab for giant cell tumor of bone

•

The preoperative application of denosumab can reduce tumor blood supply.

•

The decrease of blood supply was the most significant in the initial stage of treatment.

•

It is not recommended to apply denosumab long before surgical treatment.

Background

The changes in the characteristics of the tumor blood supply of giant cell tumor of bone over time after treatment with denosumab remain unclear. The purpose of this study was to evaluate the change in the blood supply imaging characteristics of giant cell tumor of bone after preoperative denosumab treatment and to provide evidence for evaluating the reasonable time for preoperative treatment.

Methods

A total of 59 patients with giant cell tumor of bone who were treated in our hospital from 2014 to 2019 were enrolled in the study. All patients underwent enhanced CT examination of the tumor site before denosumab treatment and every month after treatment. The plain CT value and enhanced CT value of the tumor were measured, and the CT enhancement rate of the tumor was calculated. The change in the CT enhancement rate of the tumor over time after denosumab treatment was analyzed.

Results

The average tumor enhancement rates were 2.14 (1.22–4.05), 1.60 (1.12–2.53), 1.38 (1.02–2.24), and 1.25 (1–2.11) before denosumab treatment and one month, three months, and six months after treatment, respectively. After denosumab treatment, the average monthly CT enhancement rate decreased as follows: 0.54 (25.2%) in the first month, 0.11 (5.15%) in the second to third months, and 0.04 (1.87%) in the fourth to sixth months. The tumor enhancement rate was no longer significantly reduced three months post-treatment. There was a significant correlation between the reduction in the CT enhancement rate and the initial CT enhancement rate (P = 0.000).

Conclusion

The preoperative application of denosumab can reduce tumor blood supply. The decrease in the blood supply is the most significant in the initial stage of treatment. Following treatment, the decrease in the blood supply gradually reduces over time. Therefore, for the purpose of reducing intra-operative bleeding and facilitating surgery, application of denosumab treatment is not recommended more than three months before surgery.

Giant Cell Tumor of Bone Versus Tenosynovial Giant Cell Tumor - Similarities and Differences

Giant cell tumor of bone (GCTB) and tenosynovial giant cell tumor (TGCT) share misleadingly similar names, soft texture and brown color macroscopically, osteoclast-like multinucleated giant cells microscopically and localisation in the musculoskeletal system. However, these two tumor types are biologically and clinically two distinct entities with different natural courses of progression and considerably different modes of surgical and medical treatment. In this article, we provide a detailed update on the similarities and the differences between both tumor types.GCTB is a locally aggressive osteolytic bone tumor, commonly seen in patients in their third decade of life. It usually occurs as a solitary lesion in the meta-epiphyseal region of long bones. It can be diagnosed using plain radiographic imaging, CT radiography or MRI to estimate the tumor extent, soft tissue and joint involvement. GCTB is usually treated with intralesional excision by curettage. Systemically, it can be treated with bisphosphonates and denosumab or radiotherapy.TGCT is a rare, slowly progressing tumor of synovial tissue, affecting the joint, tendon sheath or bursa, mostly seen in middle-aged patients. TGCT is usually not visible on radiographs and MRI is mostly used to enable assessment of potential bone involvement and distinguishing between two TGCT types. Localised TGCT is mostly treated with marginal surgical resection, while diffuse TGCT is optimally treated with total synovectomy and is more difficult to remove. Additionally, radiotherapy, intraarticular injection of radioactive isotopes, anti-TNF-α antibodies and targeted medications may be used.

Comparative Analysis of Two Surgical Treatment Options for Giant Cell Tumor of the Proximal Femur: Extended Curettage and Segmental Resection

Aim

As a locally destructive intermediate bone tumor with low incidence, high recurrence rate, and difficulty in reconstruction, giant cell tumor of bone (GCTB) in the proximal femur has no unified surgical treatment standard. This study aimed to compare the differences in local recurrence, reconstruction durability, and postoperative function after treatment with either extended curettage (EC) or segmental resection (SR) for GCTB in the proximal femur so as to provide constructive suggestions for the rational selection of EC or SR operation scheme.

Patients and Methods

29 patients (15 men and 14 women) were included in this retrospective study, with a mean age of 32.1 years. According to the division method of proximal femur of International Society Of Limb Salvage (ISOLS), there was 1 case in the H1 area, 17 cases in the H2 area, 10 cases in the H1+H2 area, and 1 case in the H1+H2+H3 area. Among them were 11 cases of Campanacci grade II GCTB, 18 cases of Campanacci grade III GCTB, and 7 cases with pathological fractures. All patients underwent either EC or SR surgery. The Musculoskeletal Tumor Society (MSTS) score was used for patient evaluation. The operation effectiveness was analyzed according to the Mankin evaluation standard. Regular follow-up was performed to evaluate the recurrence rate, limb function, and long-term complications of the two surgical methods.

Results

All patients were followed up for a mean of 60.4 months. Local recurrence occurred in one of 19 patients treated with EC (5.3%) and one of 10 patients treated with SR (10%). The MSTS score of lower limb function in patients in the EC group was better compared to patients in the SR group (P = 0.002). Complications occurred in 2 cases (10.5%) and 5 cases (50%) in the EC group (osteoarthritis, osteonecrosis) and SR group (joint stiffness, infection, prosthesis loosening), respectively, with significant differences between the two groups (P = 0.03). The operation effectiveness was analyzed according to the Mankin evaluation standard. The EC group showed an optimal rate of 94.7% (18/19) as opposed to 80% (8/10) in the SR group.

Conclusions

For GCTB in the proximal femur, when the tumor does not extensively involves the surrounding soft tissues, the articular surface was not damaged, and there is no pathological fracture with apparent displacement, EC surgery should be fully considered.

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.].

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.

Reconstruction and repair, using mini-plate and bone graft for persons living with HIV with giant cell tumor of long bone: retrospective analysis of a single-center experience

Background

To evaluate the effect of reconstruction and repair, using a mini-plate and bone graft for HIV -positive patients with giant cell tumor of long bone.

Methods

We conducted a retrospective analysis of 12 HIV positive patients with giant cell tumor of long bone. A non-HIV-positive cohort of patients, matched for age, sex, and disease type, was selected as the control group. From June 2012 to August 2020, curettage by ultrasonic scalpel was performed in all patients, combined with min- plate and bone graft treatment. All patients were followed- up for 18 to 60 months. Limb function was evaluated, using the MSTS93 scoring system, and any examples of postoperative recurrence, distant metastasis, complications, MSTS93 score, and fracture prognosis were recorded.

Results

The mean age of HIV group was 43.5 years. The ratio of men to women was 11: 1. In all cases the histopathological diagnosis was clear, except the patients with primary malignant giant cell tumor of bone, including five, three, two, and two cases in the proximal tibia, distal femur, distal tibia, and talus, respectively. Following their surgery, all patients were followed up with an average of 31.24 ± 11.84 months. No local recurrence or pulmonary metastases were observed. Post-surgery, all the 12 patients showed good bone morphologic repair and reconstruction, good bone healing, good joint function, and no pathological fractures around their lesion. In the HIV group, one case of giant cell tumor in the proximal tibia showed mild articular surface collapse and mild valgus deformity of the knee joint but retained good joint function. The MSTS scores of excellent or good in the two groups comprised 83.3%, thus, there was no significant difference between them (P > 0.05). Compared with preoperatively, the MSTS scores in the HIV group were significantly improved, ranging from 7 to 11 points preoperatively to 24 to 27 points postoperatively; this difference was statistically significant (P < 0.05).

Conclusion

Reconstruction and repair, using a mini-plate and bone graft for HIV -positive patients with giant cell tumor of long bone can achieve satisfactory results. The mini- plate requires little space and is flexible during reconstruction and fixation, significantly reducing complications such as surgical site infection, as well as preserving joint function and avoiding amputation; therefore, it is a safe and effective treatment method.

Reliability and Role of Mutation-specific H3F3A (Histone 3-3) G34W Immunohistochemistry to Differentiate Giant Cell Tumor of Bone From its Clinicoradiologic and Histologic Mimics: An Institutional Study

Giant cell tumor of bone (GCTB) is a benign neoplasm, which can sometimes be a diagnostic challenge, especially in small biopsies, due to its histologic benign and malignant mimics. We evaluated the role of H3.3 G34W immunohistochemistry (IHC) antibody in diagnosing GCTB and its role in differentiating it from its close histologic mimics. A total of 120 cases (80 cases of GCTB and 40 cases of histologic mimics) were retrieved and subjected to IHC. Of 80 cases of GCTB, 72 cases showed a positive nuclear immunoexpression, while all 40 cases of histologic mimics of GCTB showed a negative staining for H3.3 G34W IHC. Sensitivity and specificity of this mutation-specific antibody for diagnosis of GCTB was 90% and 100%, respectively, while, the positive predictive value and the negative predictive value were 100% and 83.3%, respectively. A positive expression of H3.3 G34W was seen in all 5 cases of GCTB, postdenosumab therapy, as well as, in all 3 cases of malignant giant cell tumor. The presented study showed that H3.3 G34W mutation-specific IHC is a reliable and specific marker for GCTB and can help distinguish it from the histologic mimics due to distinct therapeutic implications.

Establishment and characterization of novel patient-derived cell lines from giant cell tumor of bone

Giant cell tumor of bone (GCTB) is a locally aggressive and rarely metastasizing tumor. GCTB is characterized by the presence of unique giant cells and a recurrent mutation in the histone tail of the histone variant H3.3, which is encoded by H3F3A on chromosome 1. GCTB accounts for ~ 5% of primary bone tumors. Although GCTB exhibits an indolent course, it has the potential to develop aggressive behaviors associated with local recurrence and distant metastasis. Currently, complete surgical resection is the only curative treatment, and novel therapeutic strategies are required. Patient-derived cancer cell lines are critical tools for basic and pre-clinical research. However, only a few GCTB cell lines have been reported, and none of them are available from public cell banks. Therefore, we aimed to establish novel GCTB cell lines in the present study. Using curetted tumor tissues of GCTB, we established two cell lines and named them NCC-GCTB2-C1 and NCC-GCTB3-C1. These cells harbored a typical mutation in histones and exhibited slow but constant growth, formed spheroids, and had invasive capabilities. We demonstrated the utility of these cell lines for high-throughput drug screening using 214 anticancer agents. We concluded that NCC-GCTB2-C1 and NCC-GCTB3-C1 cell lines were useful for the in vitro study of GCTB.

Use of three-dimensional-printed custom-made prosthesis to treat unicondylar femoral defect secondary to pathological fracture caused by giant cell tumor

Objective

To evaluate the short-term effectiveness of using a three-dimensional (3D)-printed custom-made prosthesis to repair unicondylar femoral defects.

Methods

We retrospectively reviewed 26 patients with a primary pathological fracture of the distal femur caused by a giant cell tumor. All patients had unicondylar defects involving the articular surface. Twelve patients were treated with a 3D-printed custom-made prosthesis to repair the unicondylar defect (3D-printed group). The other 14 patients were treated with total knee replacement (TKR group). The operation time, blood loss, Musculoskeletal Tumor Society score, range of motion, local recurrence, and complications were statistically compared.

Results

The operation time was significantly shorter and the blood loss was significantly less in the 3D-printed group than in the TKR group. The Musculoskeletal Tumor Society scores were significantly higher in the 3D-printed group than in the TKR group from 3 to 24 months postoperatively. The range of motion was significantly better in the 3D-printed group than in the TKR group at 6 and 9 months postoperatively.

Conclusions

3D-printed custom-made prostheses provide better short-term functional results than does TKR.

Surgical treatment of benign osteolytic lesions in the femoral head and neck: a systematic review

Background and objectives

Treatment of benign osteolytic lesions in the femoral head and neck can be extremely challenging, particularly in children with open physis or for aggressive tumors with pathological fracture. There remains the difficult management decision as to whether to perform complete excision of the involved area or only curettage. Moreover, there is no agreed consensus on the optimal approach to lesion access when performing curettage, which included the transcervical, open and direct approach. The current systematic review aims to provide guidance for selection of surgical methods in clinical practice by comparing the advantages and drawbacks of different procedures.

Methods

A comprehensive literature search of PubMed, Embase and Web of Science databases were executed for human studies restricted to the English language. The search was filtered to include studies published from January 1980 to January 2020.

Results

A total of 33 articles including 274 patients were enrolled in the final analysis. The most common diagnosis was chondroblastoma (CBT) (104, 38.0%), followed by giant cell tumor (GCT) (56, 20.4%). There were 57 (20.8%) patients with pathological fracture. Intralesional curettage was performed in 257 (93.8%) patients with the local recurrence of 12.5% at the mean follow-up of 51.5 months. The patients who were presented with open physis or curetted via transcervical approach developed higher local recurrence in patients with CBT (P < 0.001). The local recurrence rate of GCT is 33.3% after curettage, while 8 of 9 (88.9%) patients with fracture were treated successfully with joint preservation. Two of 45 (4.4%) patients developed avascular necrosis (AVN) of femoral head after surgical hip dislocation. The reported Musculoskeletal Tumor Society (MSTS) Score was comparable among patients with different approaches to curettage.

Conclusion

The majority of benign osteolytic lesions in the femoral head and neck can be treated with intralesional curettage with acceptable local tumor control and satisfactory function. The incidence of local recurrence might be decreased dramatically for lesion access under direct visualization. The native joint maintenance could be achieved even in patients with aggressive lesions presenting pathological fracture.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04442-y.

A Giant Cell Tumor of the Distal Femur Managed by Excision and Knee Arthrodesis Using a Custom Made Long Intramedullary Interlocking Nail: A Case Report and Review of the Literature

Giant cell tumors (GCTs) are primary bone tumors that occur most commonly in long bones, with half such tumors occurring in the distal femur, proximal tibia, and fibula. Around 12% of patients present with a pathological fracture indicating more aggressive disease. Arthrodesis after tumor resection is a popular choice due to its affordability and early postoperative mobilization, as well as low risks of implant loosening, infections, malignant lesions, or mortality. A free fibular graft is a popular option in limb-sparing surgery for long bone tumors. A bone graft and nail can be used to reconstruct long bones and bridge defects up to 25 cm. In developing countries, the cost of the imported mega prosthesis, around 8,500 US$, means many patients cannot afford the treatment. We describe a case of a GCT of the distal femur treated by excision of the tumor and reconstruction using a fibular bone graft, with knee arthrodesis using a custom-made long intramedullary interlocking nail fixation across the femur to the knee and the tibia. The length was achieved with 1 cm shortening post-surgery. The result was satisfactory, and partial weight-bearing was allowed three months after the surgery. At the one-year follow-up, there was no recurrence, and the patient had the full weight-bearing ability.

Three-dimensional-printed porous implant combined with autograft reconstruction for giant cell tumor in proximal tibia

BACKGROUND

This study is to describe the design and surgical techniques of three- dimensional-printed porous implants for proximal giant cell tumors of bone and evaluate the short-term clinical outcomes.

METHODS

From December 2016 to April 2020, 8 patients with giant cell tumor of bone in the proximal tibia underwent intralesional curettage of the tumor and reconstruction with bone grafting and three-dimensional-printed porous implant. Detailed anatomy data were measured, including the size of lesion and thickness of the subchondral bone. Prostheses were custom-made for each patient by our team. All patients were evaluated regularly and short-term clinical outcomes were recorded.

RESULTS

The mean follow-up period was 26 months. According to the different defect sizes, the mean size of the plate and mean length of strut were 35 × 35 mm and 20 mm, respectively. The mean affected subchondral bone percentage was 31.5%. The average preoperative and postoperative thickness of the subchondral bone was 2.1 mm and 11.1 mm, respectively. There was no wound infection, skin necrosis, peroneal nerve injury, or other surgical related complications. No degeneration of the knee joint was found. Osseointegration was observed in all patients. The MSTS improved from an average of 12 preoperatively to 28 postoperatively.

CONCLUSION

The application of three-dimensional-printed printed porous prosthesis combined autograft could supply enough mechanical support and enhance bone ingrowth. The design and operation management lead to satisfactory subchondral bone reconstruction.

Novel Strategy of Curettage and Adjuvant Microwave Therapy for the Treatment of Giant Cell Tumor of Bone in Extremities: A Preliminary Study

OBJECTIVES

To evaluate whether curettage with adjuvant microwave therapy was successful in the treatment of giant cell tumor of the bone (GCTB) in extremities, especially for GCTB with pathological fractures and GCTB of the distal radius.

METHODS

This was a retrospective study of 54 cases of GCTB of the extremities treated by curettage with adjuvant microwave therapy between 2007 and 2019. Five patients were lost to follow up and excluded from the study. A total of 33 male and 21 female patients were included in this study. Patients were aged 15-57 years (mean 29.72 ± 10.48 years). Among these patients, there were 10 cases of GCTB with pathological fractures and eight cases of GCTB of the distal radius; one of these cases was combined with a pathological fracture. Comprehensive imaging examinations (X-rays [including lesion site and chest], CT, MRI, emission computed tomography, and pathology examination) of all patients were reviewed. The clinical staging of these patients were evaluated radiologically using the Campanacci classification system based on the extent of spread of the tumor. All patients underwent curettage with adjuvant microwave therapy. Clinical and imaging evaluations were performed in all cases to check for recurrence or metastasis. Lower limb and upper limber function were assessed using the Musculoskeletal Tumor Society score (MSTS), and wrist function was assessed according to the disabilities of the arm, shoulder and hand (DASH) score. Data on surgical-related complications were recorded.

RESULTS

All cases were followed up for 24-126 months (mean 60.69 ± 29.61 months). There were 24 patients with a Campanacci grade of 3 and 30 with a Campanacci grade of 2. The 52 patients were continuously disease-free. The local recurrence rate was 3.70% (2 patients). One patient had recurrence in the proximal femur, and the other developed in soft tissue of the calf muscle. No recurrence occurred for GCTB of the distal radius. One recurrence occurred in a GCTB with pathological fractures. The intervals were 9 and 28 months, respectively. The cases of recurrence all had a Campanacci grade of 3 (8.33%). The median MSTS among the 54 patients was 27.67 ± 3.81. The mean wrist function DASH score was 8.30 ± 2.53. The mean MSTS was 28.67 ± 1.63 and 26.71 ± 5.49 for patients with GCTB of the distal radius and for those with pathological fractures, respectively. In comparing patients with and without pathological fractures, there was no significant difference in the MSTS functional score. Five patients had complications after the surgery.

CONCLUSION

Curettage with adjuvant microwave ablation therapy provided favorable local control and satisfactory functional outcomes in the treatment of GCTB, especially for cases with pathological fractures and those with GCTB of the distal radius.

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.

Epidemiological characteristics of 1385 primary sacral tumors in one institution in China

Background

Sacral tumors and tumor-like lesions are a rare group of lesions that can affect children and adults of all ages. Little is known about clinical characteristics of age, gender, histologic type, and anatomic site in China.

Methods

A total of 1385 patients with sacral tumors and tumor-like lesions, which had the clinical record at our bone tumor center from January 2000 to November 2018 were analyzed. The metastatic cancers were not included in the present study.

Results

A total of 51.7% (716 cases) were malignant and 48.3% (669 cases) were benign tumors or tumor-like lesions. Of malignant tumors, chordoma was the most common malignant tumor (316 cases, 22.8% of all tumors), followed by chondrosarcoma, myeloma, and other histologic types. The most common histological type of benign tumors was a giant cell tumor accounting for 14.8% (205 cases) of all tumors, followed by neurofibroma, schwannoma, and other types. The most common age group affected by malignant bone tumors was the 51- to 60-year-old group, followed by the 41- to 50-year-old group. The most commonly affected age group for benign tumors and tumor-like lesions was the 31- to 50-year-old group, followed by the 21- to 30-year old group. Furthermore, the following histologic types had gender predilection. Chordoma, chondrosarcoma, myeloma, and osteosarcoma affected more frequently males than females. Malignant peripheral nerve sheath tumor, lymphoma, giant cell tumor, neurofibroma, tuberculosis, teratoma, and epidermoid cyst more frequently affected females than males.

Conclusions

The large cohort of sacral tumors and tumor-like lesions in our database may reveal their clinical characteristics of age, gender, histologic type, and anatomic site in China and features of sacral tumors and tumor-like lesions are fairly distinct from the mobile spine and extremities.

Outcome of lung metastases due to bone giant cell tumor initially managed with observation

Background

The outcomes of patients with lung metastases from giant cell tumor of bone (GCTB) vary from spontaneous regression to uncontrolled growth. To investigate whether observation is an appropriate first-line management approach for patients with lung metastases from GCTB, we evaluated the outcomes of patients who were initially managed by observation.

Methods

We retrospectively reviewed the data of 22 patients with lung metastases from histologically confirmed GCTB who received observation as a first-line treatment approach. The median follow-up period was 116 months.

Results

Disease progression occurred in 12 patients (54.5%). The median interval between the discovery of lung metastases and progression was 8 months. Eight patients underwent metastasectomy following initial observation. The median interval between the discovery of lung metastases and treatment by metastasectomy was 13.5 months. None of the patients experienced spontaneous regression. Of the 22 patients, 36.4% needed a metastasectomy, and 9.1% required denosumab treatment during the course of the follow-up period. Disease progression occurred in 45.5% of the 11 patients with lung nodules ≤ 5 mm, while all five of the patients with lung nodules > 5 mm experienced disease progression. Progression-free survival was significantly worse in the group with lung nodules > 5 mm compared to the group with lung nodules ≤ 5 mm (p = 0.022).

Conclusions

Observation is a safe first-line method of managing patients with lung metastases from GCTB. According to radiological imaging, approximately half of the patients progressed, and approximately half required a metastasectomy or denosumab treatment. However, patients with lung nodules > 5 mm should receive careful observation because of the high rate of disease progression in this group.

Malignancy in giant cell tumor of bone in the extremities

Background

Malignancy in giant cell tumor of bone (GCTB) is a rare tumor with relevant literature being sparse. In primary malignant GCTB, distinct areas of benign GCTB are juxtaposed with high-grade sarcoma, while in secondary malignant GCTB sarcoma occurs at the site of previously managed GCTB. This study assesses the distinguishing characteristics of patients with this condition, the time interval for development of secondary malignant GCTB, the outcome of treatment, and explores factors associated with oncologic outcomes.

Methods

This is a retrospective case series of patients from a prospectively collected institutional musculoskeletal oncology database. From January 1998 to December 2016, 1365 patients were managed for extremity GCTBs. 32 (2.3%) patients had malignant GCTB, including 12 with primary malignant GCTB and 20 with secondary malignant GCTB. The study population comprised 18 males and 14 females presenting at a mean age of 33.7 years (±13.0) and followed for a mean of 9.5 years (±7.4). Data were collected on patient and treatment-related factors, and the occurrence of local recurrence, metastasis, and death. The time from the diagnosis of GCTB to the secondary malignant GCTB was defined as the latent period.

Results

Malignant GCTB most commonly presents in the distal femur and proximal tibia with pain and swelling. Radiologically, they are aggressive Campanacci Grade III tumors with prominent bony destruction and soft tissue extension. In the 20 patients with secondary malignant GCTB, the tumors were osteosarcoma in 15, undifferentiated pleomorphic sarcoma in 4 patients and fibrosarcoma in one patient. The mean latent period in patients with secondary malignant GCTB was 7.9 year (±7.3). The median recurrence-free survival (RFS) of secondary malignant GCTB (latent period) and benign GCTB were 61.5 and 19 months respectively (p < 0.001), receiver operating curve analysis found 49.5 months to be the critical threshold, with a longer interval to recurrence being seen in malignant recurrence. The 5 and 10-year overall survival rate of malignant GCTB were 45.8% and 36.1% respectively. The 5-year survival rates of primary malignant GCTB and secondary malignant GCTB were 56.2% and 40.0% respectively (p = 0.188). Adequate surgical margins decreased the local recurrence (LR) rate (P = 0.006). Pulmonary metastasis developed in 69% of patients. The median distant metastasis-free survival between malignant GCTB and benign GCTB were 9 and 21 months (p = 0.002). Chemotherapy was associated with a longer pulmonary metastasis free survival (13 months Vs 6 months, P = 0.002), but not with increased overall survival (57.0% Vs 33.3%, P = 0.167).

Conclusions

Malignant GCTB carries a poor prognosis. Accurate diagnosis is critical to avoid inadequate surgical margins when treating primary malignant GCTB. Aggressive tumors and pulmonary metastasis should raise suspicion for malignant GCTB. Secondary malignant transformation should be suspected in patients presenting with recurrence especially after 4 years. Adjuvant chemotherapy use did not benefit survival, but was associated with increased pulmonary progression-free survival.

The impact of curettage technique on local control in giant cell tumour of bone

INTRODUCTION

Although consensus has been reached regarding the main aspects of intralesional surgery for giant cell tumour of the bone (GCTB), debates continue about the most effective combination of local adjuvants. The purpose of study was to analyze the previous experience and determine the most effective curettage approach for GCTB.

METHODS

We summarized the findings from 89 papers published from 1962 to 2020 related to this subject. Database consisted of 137 treated groups that included 6441 patients who underwent different curettage techniques without pre-operative administration of bisphosphonates or RANKL inhibitors.

RESULTS

Recurrence rates after simple curettage ranged between 27 and 82% with a median value at 47%. The use of one or two local adjuvants reduced the incidence of recurrences approximately by 50% when compared with simple curettage. High-speed burring combined with chemical adjuvants or followed by poly(methyl methacrylate) cementation with or without bone grafting further improved the local control leading to good and excellent results; however, these were not documented in all studies. Simultaneous use of burring, chemical adjuvants, and cementation, which we named here as combined curettage, allowed to down local relapses to the range of 0-26%, with a median at 11%. Oncologic outcomes after combined curettage are significantly better when compared with simple curettage (p < 0.0001) and other variants of enhancement (p = 0.001).

CONCLUSIONS

Combined curettage appears to provide the most potent and comprehensive impact on residual tumour cells located in risk zones. This approach should be considered for locally advanced tumours when function-preserving surgery is planned. Additional comparative studies are required to define the optimal curettage enhancement for each individual patient.

CT and MRI features of giant cell tumours with prominent aneurysmal bone cysts in the extremities: a comparison with primary aneurysmal bone cysts

AIM

To test the hypothesis that computed tomography (CT) and magnetic resonance imaging (MRI) could help distinguish between giant cell tumours with prominent aneurysmal bone cysts (GABCs) and primary aneurysmal bone cysts (PABCs) of the extremities.

MATERIALS AND METHODS

CT and MRI features of 13 patients with GABCs and 13 patients with PABCs in the extremities were analysed retrospectively. The ages and sex of the patients were also recorded. Independent-samples t-tests were used for continuous variables and Fisher's exact tests were used for categorical variables to compare the differences between the two groups. Diagnostic accuracy, sensitivity, and interobserver agreement were calculated.

RESULTS

The average age of patients with GABCs (38.2±15.8 years) was higher than that of patients with PABCs (19.3±12.7 years; p=0.003). The transverse/longitudinal diameter ratio was different between GABCs (0.8±0.3) and PABCs (0.6±0.2; p=0.007). Subchondral bone involvement (92.3% versus 30.8%, p=0.004) and deep lobulation (38.5% versus 0%, p=0.039) were more likely to be noted in patients with GABCs. Surrounding blood vessels were identified in six cases of PABCs (6/13), but not in GABCs (p=0.015). The following characteristics were suggestive of GABCs, older patient age, higher transverse/longitudinal diameter ratio, subchondral bone involvement, and deep lobulation indicated a sensitivity of 84.6%, 76.9%, 75%, and 100%, and a specificity of 84.6%, 69.2%, 90%, and 61.9%, respectively. Conversely, surrounding blood vessels were suggestive of PABCs, with a sensitivity of 46.2% and specificity of 100%. The concordance between the two readers was moderate to nearly perfect.

CONCLUSION

Age, subchondral bone involvement, lobulation, transverse/longitudinal diameter ratio, and surrounding blood vessels can be used to distinguish GABCs from PABCs.

Mid-term results of intralesional extended curettage, cauterization, and polymethylmethacrylate cementation in the treatment of giant cell tumor of bone: A retrospective case series

OBJECTIVE

The aim of this study was to present the mid-term functional outcomes and recurrence rate in patients with giant cell tumor of bone (GCTB) treated by intralesional extended curettage, electrocauterization, and polymethylmethacrylate (PMMA) cementation.

METHODS

In this retrospective observational study, 79 consecutive patients (41 females, 38 males; mean age=39 years; age range=19-62 years) who were diagnosed and treated for GCTB between 2005 and 2017 were identified from hospital medical records. All patients were treated by intralesional extended curettage using high-speed burr, electrocauterization of the cavity, and filling the defect with PMMA. No additional local adjuvants were used. The mean follow-up period was 47 months (range=24-96). The tumors were graded according to the radiological classification system described by Campanacci. Functional outcomes were evaluated using the Musculoskeletal Tumor Society Score (MSTS) preoperatively, one year postoperatively, and at the final follow-up. Postoperative complications and recurrence rates were recorded.

RESULTS

Twenty-nine tumors were located in the distal femur, 23 in the proximal tibia, nine in the distal radius, five in the proximal humerus, five in the pelvis, three in the proximal fibula, two in the distal ulna, two in the distal tibia, and one in the second metatarsal. According to Campanacci classification, 37 tumors were grade III, 32 grade II, and 10 grade I. The mean MSTS score was 46.1% (range 40.2 to 71.4%) preoperatively, 91.7% (range 73.3% to 100%) one year postoperatively, and 86.3 % (range 66.2% to 96,1%) at the final follow-up. The overall complication rate was 7.6%; which included local tumor recurrence in four patients, superficial wound infection in one, and deep wound infection in another. The recurrence rate was 5.1% (4 patients). Recurrent tumors were located at the distal femur in three patients and proximal tibia in one.

CONCLUSION

With satisfactory functional results and low recurrence rates at the mid-term follow-up, GCTB can be treated effectively with intralesional extended curettage, electrocauterization, and PMMA cementation.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.