Disappearance of giant cells and presence of newly formed bone in the pulmonary metastasis of a sacral giant-cell tumor following denosumab treatment: A case report

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.

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

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

Progress on Denosumab Use in Giant Cell Tumor of Bone: Dose and Duration of Therapy

Giant cell tumor of bone (GCTB) is an aggressive non-cancerous bone tumor associated with risks of sarcoma and metastasis. Once malignancy occurs, the prognosis is generally poor. Surgery remains the main treatment for GCTB. Multidisciplinary management is a feasible option for patients wherein surgical resection is not an option or for those with serious surgery-related complications. Denosumab is an anti-nuclear factor kappa B ligand approved for the treatment of postmenopausal women with osteoporosis, bone metastases, and advanced or inoperable GCTB. However, the guidelines for treating GCTB are unclear; its short-term efficacy and safety in inoperable patients have been demonstrated. Lengthier therapies (high cumulative doses) or pre-operative adjuvant therapy may be associated with severe complications and high local recurrence rates. Short-term administration helps attain satisfactory local control and functionality. As a result, lately, the impact of different doses and lengths of treatment on the efficacy of denosumab in GCTB treatment, the incidence of complications, and recurrence rates have gained attention. The efficacy and safety of denosumab against GCTB, its impact on imaging assessment, related complications, and recurrence of GCTB were previously reviewed. For further research direction, this paper reviews the progress of studies evaluating the impact of the dose and duration of denosumab therapy for GCTB.

Radiologic and clinical changes after denosumab treatment for giant cell tumors of the mobile spine: a quantitative study

Objectives

To analyze the radiologic and clinical changes after denosumab treatment in patients with giant cell tumors (GCTs) in the mobile spine.

Methods

Clinical data and images by computed tomography and magnetic resonance imaging at a single center were retrospectively reviewed before and after denosumab treatment.

Results

Pre- and post-treatment data from 24 patients were evaluated. On imaging, marginal ossification and/or bone formation was observed in 22 patients (91.7%). The median maximum diameter of the GCT reduced from 52.5 to 48.2 mm (p < 0.001), and the mean proportion of tumor to spinal canal area decreased from 36.8 to 18.5% (p < 0.001). Out of six patients with compression, three patients (50%) showed no compression after treatment. The signal intensity (SI) ratio between the solid part of the tumor and the normal spinal cord on T2-weighted MR images was 0.77 ± 0.22 and decreased to 0.58 ± 0.22 (p = 0.001). On clinical symptoms, the mean visual analog scale scores were reduced from 5.3 to 2.0 (p < 0.001) and the Karnofsky Performance Scale scores increased from a median of 65 to 80 (p < 0.001). Post-treatment, performance scores improved in eight patients (33.3%) (p = 0.003), and the neurological function of four patients improved according to Frankel grade (p = 0.046).

Conclusions

Bone formation, tumor reduction, regression of epidural lesion and the decrease in SI ratio on T2-weighted image should be considered as the effectiveness of denosumab in the treatment of spinal GCT. In clinical application, denosumab can relieve pain, improve neurological function, and improve the quality of life of spinal GCT patients.

Denosumab in Giant Cell Tumor of Bone: Multidisciplinary Medical Management Based on Pathophysiological Mechanisms and Real-World Evidence

Simple Summary

The widely accepted local therapy in extremity giant cell tumor of bone (GCTB) is surgery, in the form of extended intralesional curettage with adequate disease clearance and retention of the limb, wherever possible. Denosumab is a relevant therapy option for advanced GCTB, to benefit tumor response and surgical down-staging. Most GCTB patients with localized disease can be successfully treated with surgical curettage; patients with primary unresectable lesions or metastases may experience long-term clinical and radiological remission and pain control with denosumab treatment, and in this clinical situation, denosumab is currently the treatment of choice.

Abstract

(1) Despite the benign nature of the giant cell tumor of bone (GCTB), it shows a local recurrence rate of up to 50% and a chance of malignant transformation. The widely accepted local therapy in extremity GCTB is surgery, in the form of extended intralesional curettage with adequate disease clearance and retention of the limb, wherever possible. Denosumab, a human monoclonal antibody directed against the RANKL and associated inhibition of the RANKL pathway, is a relevant therapy option for advanced GCTB, to benefit tumor response and surgical down-staging. (2) The literature review of patients with GCTB treated with denosumab is performed via PubMed, using suitable keywords from January 2009 to January 2021. (3) Current indications for denosumab use are not definitively clear and unambiguous. Most GCTB patients with localized disease can be successfully treated with surgical curettage, and the role of denosumab in preoperative therapy in this patient population remains unclear. (4) However, patients with primary unresectable lesions or metastases may experience long-term clinical and radiological remission and pain control with denosumab treatment, and in this clinical situation, denosumab is currently the treatment of choice.

Radiomics on radiography predicts giant cell tumor histologic response to denosumab

OBJECTIVE

Denosumab is an established targeted systemic therapy for treatment of giant cell tumor of bone (GCTB). We sought to determine whether treatment response could be quantified from radiomics analysis of radiographs taken longitudinally during treatment.

MATERIALS AND METHODS

Pre- and post-treatment radiographs of 10 GCTB tumors from 10 patients demonstrating histologic response after treatment with denosumab were analyzed. Intensity- and texture-based radiomics features for each manually segmented tumor were calculated. Radiomics features were compared pre- and post-treatment in tumors.

RESULTS

Mean intensity (p = 0.033) significantly increased while skewness (p = 0.028) significantly decreased after treatment. Post-treatment increases in fractal dimensions (p = 0.057) and abundance (p = 0.065) approached significance. A potential linear correlation in mean (p = 0.005; ΔMean = 0.022 * duration - 0.026) with treatment duration was observed.

CONCLUSION

Radiomics analysis of plain radiographs quantifies time-dependent matrix mineralization and trabecular reconstitution that mark positive response of giant cell tumors of bone to denosumab.

Denosumab for Effective Tumor Size Reduction in Patients With Giant Cell Tumors of the Bone: A Systematic Review and Meta-Analysis

BACKGROUND

Denosumab is a human monoclonal antibody that has been used successfully in the treatment of giant cell tumors of bone. These tumors are rare and, in principle, benign, but they are highly aggressive, locally advanced, osteolytic bone tumors that can metastasize to the lungs. Denosumab is an effective treatment when these tumors cannot be surgically removed or when surgical resection is likely to lead to severe morbidity (eg, loss of limbs or joints). The aim of this systematic review and meta-analysis was to investigate patients with giant cell tumors of bone who experienced tumor progression during treatment with denosumab and to compare them with patients who experienced reduction of their giant cell tumors of bone during treatment with denosumab.

METHODS

Embase, Cochrane Library, and MEDLINE/PubMed databases were searched for trials submitted by January 7, 2020, that reported the efficacy and safety of denosumab in patients with giant cell tumors of bone.

RESULTS

Sixty studies were reviewed, involving a total of 1074 patients who had giant cell tumors of bone and were treated with denosumab. Of the 60 studies, 58% of the patients were from case series studies, 39% from open-label phase II studies, and 3% from case reports. The response rate for denosumab as a treatment for giant cell tumors of bone was 97.5%, with statistical significance (P < .0001). Pain in the limbs was statistically the most common adverse event for denosumab treatment in case series studies (P < .0001). No treatment-related deaths occurred in the reviewed studies.

CONCLUSION

Cumulative evidence supports the addition of surgery to optimal medical therapy with denosumab to reduce tumor size, clinical symptoms, and mortality among patients with giant cell tumors of bone.

Response to Denosumab in 2 Children With Recurrent Giant Cell Tumor of the Bone With Pulmonary Metastasis

Giant cell tumor of the bone (GCTB) is an uncommon bone tumor, usually localized, and rarely presents at <20 years of age. Denosumab, a fully human monoclonal antibody against RANKL (receptor activator of nuclear factor κB ligand), is approved for the treatment of unresectable GCTB in skeletally mature individuals. We present a case series of 2 pediatric patients with recurrent GCTB with pulmonary metastasis, with clinical response to denosumab therapy.

Radiological findings of denosumab treatment for giant cell tumours of bone

Giant cell tumours of bone (GCTB) are benign giant cell-rich tumours typically occurring in the epi-metaphysis of skeletally mature patients. Despite their benign classification, GCTB may be locally aggressive with local recurrence as a challenging issue. Denosumab is a human monoclonal antibody that inhibits osteolysis via the RANK-RANK ligand pathway. There is currently no consensus on optimal treatment duration or imaging modality for monitoring patients on denosumab therapy. This review illustrates the radiological findings of GCTB on denosumab treatment seen on plain radiographs, CT, MRI, PET-CT and DEXA, with reference to the current literature. Recognizing imaging features indicative of a positive response to denosumab is important for therapeutic decision-making. Imaging findings with respect to duration of denosumab treatment, tumour upregulation during treatment, tumour recurrence and malignant transformation are discussed. The development of a sclerotic neocortex and varying degrees of matrix osteosclerosis are seen on plain radiographs. Reconstitution of subarticular bone and articular surface irregularity are optimally evaluated on CT which can also quantify tumour density. MRI demonstrates heterogeneous low signal matrix and is useful to assess decrease in size of cystic and/or soft tissue components of GCTB. A fat-suppressed fluid-sensitive MR sequence is important to detect tumour reactivation. Reduction in ¹⁸F-FDG-PET avidity represents an early sensitive sign of response to denosumab treatment. Regardless of imaging modality, close follow-up in a specialist centre and careful evaluation of nonresponders is necessary as local recurrence after cessation of denosumab treatment and malignant transformation of GCTB have been described.

Surgical treatment outcome of giant cell tumor of distal ulna: En bloc resection vs. curettage and bone graft

Background: Giant cell tumor (GCT) of the bone is a benign neoplasm with local aggressive behavior. Distal ulna is a very rare place for GCT. Published studies have mainly focused on case reports, and thus there is no consistent treatment strategy for this tumor at this location. This retrospective study was conducted to evaluate the oncological and functional results of 2 different surgical treatment methods for GCT in distal ulna.

Methods: In this study, 9 patients with GCT of distal ulna were followed after surgical treatment of GCT of distal ulna. Of the patients, 2 had local recurrence after surgery in other hospitals and 7 had primarily been admitted to our hospital. Four patients, all with grade 2 Enneking and Campanacci’s classification, were treated by extended curettage and bone grafting, while 5 patients with grade 3 were managed by distal ulnar resection. Minimum follow-up time was 24 months.

Results: Patients with grade 3 GCT of distal ulna, who had extended curettage, had a local recurrence up to one year after surgery. Local recurrence was never seen in those with grade 3 disease with resection or in those with grade 2 disease with extended curettage as the treatment of GCT in this location.

Conclusion: Based on our study, which is the largest cohort of GCT of distal ulna, extended curettage, and en bloc resection can be suggested as valuable methods of treatment for grades 2 and 3 tumors, respectively.

Denosumab in Patients with Giant Cell Tumor and Its Recurrence: A Systematic Review

Recent studies suggest that Denosumab reduces tumor size, therefore, makes the surgery easier with lower morbidity. However, some studies have reported several complications for this drug. So, this systematic review was performed to determine the effectiveness and safety of Denosumab in reducing bone destructions activity of giant cell tumor and skeletal-related events (SRE) in affected patients with giant cell tumor of bone (GCTB) and its recurrence. We explored studies in PubMed, and Cochrane Library. For this purpose, articles of various levels were retrieved until October 22, 2016. Two reviewers assessed the articles independently based on predefined criteria to extract the relevant data. Primary outcomes associated with skeletal-related event, overall survival, and secondary outcomes such as pain, quality of life and adverse events were evaluated and analyzed. The total population of this meta-analysis consisted of 686 patients. Of this population, 55% had primary GCTB and 45% had giant cell tumor recurrence, with 2% experiencing secondary recurrence. The results showed the effectiveness of Denosumab in reducing the tumor size due to inhibiting the Osteoclastogenesis. Denosumab didnot show any effect on reducing tumor recurrence, but, in cases where complete tumor surgery is not possible and tumor residuals may remain, Denosumab can be helpful. Also, the clinicians should consider the risk benefit of Denosumab.

Expression and role of microRNA-1271 in the pathogenesis of osteosarcoma

The aim of the current study was to investigate the expression and role of microRNA (miR)-1271 in the pathogenesis of osteosarcoma, and the associated underlying mechanisms. Tissue samples from 45 patients with osteosarcoma were collected, while the 143B, MG-63 and U-2 OS osteosarcoma cell lines were also cultured. The expression levels of miR-1271 in the tissues and cells were detected with reverse transcription-quantitative polymerase chain reaction, and 143B osteosarcoma cells were subjected to miR-1271 manipulation. In addition, the cell proliferation, cell cycle progression, and migration and invasion abilities were assessed by Cell Counting Kit-8 assay, flow cytometry and Transwell chamber assay, respectively. Tissue inhibitor of metalloproteinases 2 (TIMP2) expression level was also detected with western blot analysis. Dual-luciferase reporter assay was performed to investigate the interaction between miR-1271 and TIMP2. The results revealed that miR-1271 expression was significantly elevated in the osteosarcoma tissue and was closely correlated with the clinical TNM staging. The expression levels of miR-1271 were also upregulated in the osteosarcoma cells, with the highest expression observed in 143B cells. Inhibition of miR-1271 significantly inhibited the cell proliferation, G1/S phase transition, and the migration and invasion abilities of 143B cells, while it also resulted in upregulated TIMP2 expression in these cells. Furthermore, overexpression of TIMP2 significantly inhibited the cell proliferation, G1/S phase transition, and migration and invasion abilities of 143B cells. Dual-luciferase reporter assay demonstrated that miR-1271 targeted on the 3′-untranslated region of TIMP2 mRNA. In conclusion, the expression levels of miR-1271 were significantly elevated in osteosarcoma tissues and cells. miR-1271 downregulated the expression of TIMP2 to promote the proliferation and enhance the migration and invasion abilities of 143B osteosarcoma cells, functioning as an oncogene.

In Vitro Study of the Effects of Denosumab on Giant Cell Tumor of Bone: Comparison with Zoledronic Acid

Giant cell tumor of bone (GCTB) is a locally aggressive primary bone tumor that contains numerous osteoclasts formed from marrow-derived precursors through receptor activator of nuclear factor κ-B ligand (RANKL), an osteoclast differentiation factor expressed in neoplastic cells of GCTB. Denosumab, a fully human monoclonal antibody targeting RANKL, has recently been used for the treatment of GCTB, and superior treatment effects have been reported. The aim of this work was to elucidate the mechanism of action of denosumab, and the differences between denosumab and zoledronic acid at the level of GCTB cells. We isolated GCTB cells from 3 patients and separated them into osteoclasts, osteoclast precursors and proliferating spindle-shaped stromal cells (the true neoplastic component), and examined the action of denosumab on differentiation, survival and bone resorption activity of osteoclasts. Denosumab and zoledronic acid inhibited osteoclast differentiation from mononuclear cells containing osteoclast precursors. Zoledronic acid inhibited osteoclast survival, whereas an inhibitory effect of denosumab on osteoclast survival was not observed. The inhibitory effect on bone resorption by both agents was confirmed in culture on dentin slices. Furthermore, zoledronic acid showed dose-dependent inhibition of cell growth of neoplastic cells whereas denosumab had no inhibitory effect on these cells. Denosumab has an inhibitory effect on osteoclast differentiation, but no inhibitory effects on survival of osteoclasts or growth of neoplastic cells in GCTBs.

Giant Cell Tumor of the Sacrum: Series of 19 Patients and Review of the Literature

There are still some debates regarding the best treatment of Giant Cell Tumor (GCT) of the sacrum. Since GCT of this location is rare, therapeutic strategies are mainly based on the treatment of GCT in other anatomic locations. The objective of this study was to evaluate the oncologic and clinical results of surgical management of sacral GCT with and without local adjuvant therapy. Medical records of 19 patients diagnosed with GCT of the sacrum, were retrospectively reviewed. Sixteen patients were treated by intralesional curettage and three patients with marginal resection. Musculoskeletal tumor society (MSTS) score was used for the evaluation of functional outcome. Prolonged pain was the most common complication after treatment. Mean Pre and post-operative pain based on visual analogue scale (VAS) was 6.1 ± 1.99 and 3.05 ± 1.64, respectively. Postoperative neurologic deficit appeared in six patients. In addition, infection occurred in five patients. One case of spinopelvic instability was also observed after surgery. At average follow up of 158.5 ± 95.9 months (25 to 316 months), recurrence was seen in eight (42.7%) out of seventeen patients treated by intralesional curettage. The size of the tumor significantly correlated with the tumor recurrence (r=0.654, P=0.001). Mean MSTS score was 74.7 ± 16.78. Those patients, in whom sacral nerve roots remained intact before and after surgery, had better functional outcome. Preservation of sacral nerve roots is associated with better functional outcome and less pain. Although an acceptable surgical outcome was observed in our cohort, the problem of local recurrence still warrants further investigations for better local control of the tumor.

Radiological and Histopathological Outcome of Giant Cell Tumor of Femur with Denosumab Treatment: A Case Report

Giant Cell Tumour of Bone (GCTB) is a benign but locally aggressive osteolytic skeletal neoplasm of young adults consisting of giant cells expressing RANK (Receptor Activator of Nuclear Factor-κB) and mesenchymal spindle-like stromal cells expressing RANKL (RANK ligand). The interaction of these cells leads to bone resorption. Recently, the RANKL inhibitor, denosumab, has demonstrated activity against giant-cell tumours. The current article reports a case of a Giant cell tumour of left distal femur with pathological fracture. A 34-year-old male patient presented with history of on and off dull aching pain in the left knee for 4 months followed by a history of trivial fall. He sustained a closed injury in the left knee, following which he was unable to bear weight and developed pain and swelling in left knee. Conventional radiographs and Computerized tomography (CT) was done which showed the presence of a left distal femoral osteolytic lesion and a histological analysis of a biopsy specimen confirmed the diagnosis of GCTB. The patient was treated with neoadjuvant denosumab therapy which resulted in successful downstaging of the tumour followed by extended curettage of the lesion with high speed burr and argon laser cautery. The post-curettage microscopic examination revealed the absence of osteoclast-type giant cells.