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.

Denosumab combined with precision radiotherapy for recurrent giant cell tumor of the thoracic spine: a case report and literature review

Giant cell tumors of the spine have a high recurrence rate owing to their special anatomical site; hence, further treatment after recurrence is very challenging. Achieving effective tumor control and improving the long-term quality of life of the patients are the main treatment purposes to consider for recurrent giant cell tumors of the spine. A patient showing giant cell tumor recurrence of the thoracic spine after curettage received denosumab combined with precision radiotherapy, through which the tumor gained good control and the patient could regain normal functioning. A review of the relevant literature suggested that denosumab combined with radiotherapy is an effective new approach for the treatment of recurrent giant cell tumors of the spine.

Giant Cell Tumor of the Frontal Bone: A Rare Case Report and Review of Literature

Giant cell tumors (GCTs), typically benign, predominantly manifest in individuals aged 20-40, with the most common locations being the metaphysis or epiphysis of the femur or tibia. Infrequently, they may occur in the skull. Despite their benign nature, these tumors can exhibit aggressive behavior and have the potential to metastasize. In the case at hand, a 20-year-old female presented to the hospital with a progressively enlarging right frontal swelling over the preceding months. The patient reported intermittent headaches, alleviated by analgesics, and exhibited a normal neurological examination along with a Glasgow Coma Scale (GCS) score of 15 out of 15. Imaging revealed an expansive soft tissue mass in the right frontal bone involving both inner and outer tables. Surgical intervention was pursued through a right frontal incision followed by tumor excision. Histopathological examination of the specimen confirmed the presence of a GCT. The limited existing literature on this topic highlights the need for further research and insights into effective strategies. This case contributes to addressing this gap in knowledge, offering valuable information to enhance our understanding of the challenges associated with similar rare cases and improve patient outcomes.

Investigation of Giant Cell Tumor of Bone and Tissue Engineering Approaches for the Treatment of Giant Cell Tumor of Bone

Primary bone tumors such as Ewing sarcoma, osteosarcoma, and chondrosarcoma, secondary bone tumors developed from progressive malignancies, and metastasized bone tumors are more prevalent and studied descriptively through biology and medical research. Less than 0.2% of cancer diagnoses are caused by rare bone-originating tumors, which despite being rare are particularly difficult due to their high death rates and substantial disease burden. A giant cell tumor of bone (GCTB) is an intramurally invasive but rare and benign type of bone tumor, which seldom metastasizes. The most often prescribed medication for GCTB is Denosumab, a RANKL (receptor activator of nuclear factor κB ligand) inhibitor. Because pharmaceutical drug companies rely on two-dimensional and animal models, current approaches for investigating the diverse nature of tumors are insufficient. Cell line based medication effectiveness and toxicity studies cannot predict tumor response to antitumor medicines. It has already been investigated in detail why molecular pathways do not reproduce in vitro, a phenomenon known as flat biology. Due to physiological differences between human beings and animals, animal models do not succeed in identifying side effects of the treatment, emulating metastatic growth, and establishing the link between cancer and the immune system. This review summarizes and discusses GCTB, the disease, its cellular composition, various bone tumor models, and their properties and utilization in research. As a result, this study delves deep into in vitro testing, which is vital for scientists and physicians in various fields, including pharmacology, preclinical investigations, tissue engineering, and regenerative medicine.

Preliminary Results of Preoperative Planning Using 3D Printing and Augmented Reality in Cryotherapy Treatment of Giant Cell Tumor of Bone-CRIO2AR Project

Giant Cell Tumor of Bone is a benign tumor with high local aggressive expansion, which, in rare cases, spreads metastasis. Surgical treatment, which often consists of wide curettage to reduce recurrence risk, can lower the quality of life for those affected. Along with aggressive surgery, adjuvant intraoperative techniques have been implemented such as PMMA and cryotherapy. One of the most widely used cryotherapy techniques involves the use of probes to generate ice balls, which have been scientifically shown to have various impacts on the tumor. Although this has been acknowledged, no one has yet tested a way to accurately plan the positioning of cryotherapy probes before surgery, according to the research conducted by the authors. CRIO2AR is a randomized clinical prospective ongoing study by which it will be experimented via preoperative planning of ice probes placement using AR and 3D printing technologies. By studying a single clinical case with these technologies, the surgeon gains better awareness of patient's anatomy and tumor localization. Preliminary results are shown in the article. The first results are confirming that these technologies are applicable in clinical practice. Secondly, preoperative planning is proving to be reliable, easily replicable, and useful for the surgeon.

Ischiopubic Ramus Resection as Treatment for Giant Cell Tumor of the Bone: Surgical Techniques in Two Clinical Cases

Giant cell tumors (GCTs) of the ischium are rare and often diagnosed at an advanced stage. In fact, there is no defined treatment algorithm to treat this lesion. We present two case reports of Campanacci's stage three ischiopubic GCT confirmed with biopsy. They were effectively treated with excision of the ischiopubic ramus, aggressive curettage, drilling, and phenolization at the margins. The surgery was performed in a gynecological position with an approach over the ischiopubic ramus. Both cases present no recurrence (two and 10-year follow-up), and neither has a significant impact on the quality of life. A thorough plan and surgical technique were essential for the success of this intervention.

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.

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.

Current therapies and future prospective for locally aggressive mesenchymal tumors

Locally aggressive mesenchymal tumors comprise a heterogeneous group of soft tissue and bone tumors with intermediate histology, incompletely understood biology, and highly variable natural history. Despite having a limited to absent ability to metastasize and excellent survival prognosis, locally aggressive mesenchymal tumors can be symptomatic, require prolonged and repeat treatments including surgery and chemotherapy, and can severely impact patients' quality of life. The management of locally aggressive tumors has evolved over the years with a focus on minimizing morbid treatments. Extensive oncologic surgeries and radiation are pillars of care for high grade sarcomas, however, play a more limited role in management of locally aggressive mesenchymal tumors, due to propensity for local recurrence despite resection, and the risk of transformation to a higher-grade entity following radiation. Patients should ideally be evaluated in specialized sarcoma centers that can coordinate complex multimodal decision-making, taking into consideration the individual patient's clinical presentation and history, as well as any available prognostic factors into customizing therapy. In this review, we aim to discuss the biology, clinical management, and future treatment frontiers for three representative locally aggressive mesenchymal tumors: desmoid-type fibromatosis (DF), tenosynovial giant cell tumor (TSGCT) and giant cell tumor of bone (GCTB). These entities challenge clinicians with their unpredictable behavior and responses to treatment, and still lack a well-defined standard of care despite recent progress with newly approved or promising experimental drugs.

Enterothecal fistula as a rare cause of adult pneumocephalus and meningitis: a case report

Background

Enterothecal fistulas are pathological connections between the gastrointestinal system and subarachnoid space. These rare fistulas occur mostly in pediatric patients with sacral developmental anomalies. They have yet to be characterized in an adult born without congenital developmental anomaly yet must remain on the differential diagnosis when all other causes of meningitis and pneumocephalus have been ruled out. Good outcomes rely on aggressive multidisciplinary medical and surgical care, which are reviewed in this manuscript.

Case Description

A 25-year-old female with history of a sacral giant cell tumor resected via anterior transperitoneal approach followed by posterior L4-pelvis fusion presented with headaches and altered mental status. Imaging revealed that a portion of small bowel had migrated into her resection cavity and created an enterothecal fistula resulting in fecalith within the subarachnoid space and florid meningitis. The patient underwent a small bowel resection for fistula obliteration, and subsequently developed hydrocephalus requiring shunt placement and two suboccipital craniectomies for foramen magnum crowding. Ultimately, her wounds became infected requiring washouts and instrumentation removal. Despite a prolonged hospital course, she made significant recovery and at 10-month following presentation, she is awake, oriented, and able to participate in activities of daily living.

Conclusions

This is the first case of meningitis secondary to enterothecal fistula in a patient without a previous congenital sacral anomaly. Operative intervention for fistula obliteration is the primary treatment and should be performed at a tertiary hospital with multidisciplinary capabilities. If recognized quickly and appropriately treated, there is a possibility of good neurological outcome.

Giant cell tumor of bone with secondary aneurysmal bone cyst does not have a higher risk of local recurrence

BACKGROUND

Fluid-fluid levels (FFLs) is found in 10%-16% of giant cell tumor of bone (GCTB), and the presence of FFLs raises the suspicion of GCTB with secondary aneurysmal bone cyst (ABC), which can lead to increased intraoperative bleeding and, blurring the operative field, be associated with a risk of local recurrence. The first objective of this study is to determine whether secondary ABC is associated with a higher risk of local recurrence after curettage in patients with GCTB of the extremities. The second objective of this study is to investigate the sensitivity, specificity, positive predictive value, and negative predictive value of the presence of FFLs detected on magnetic resonance imaging (MRI) to diagnose secondary ABC associated with GCTB.

METHODS

Two hundred and eighty patients with GCTB of the extremities who underwent curettage at the authors' institutions between 1980 and 2021 were included in this study.

RESULTS

Secondary ABC was found in 36 of 280 patients (12.9%) and local recurrence occurred in 66 of 280 patients (23.6%). Multivariate analysis showed no significant correlation between secondary ABC and local recurrence (hazard ratio [HR]: 1.87 (95% confidence interval [CI]: 1.00-3.53]; p = 0.051). Preoperative MRI revealed FFLs in 13 of 82 patients (15.9%). Sensitivity, specificity, positive predictive value, and negative predictive value of FFLs detected on preoperative MRI to diagnose secondary ABC were 36.8%, 90.5%, 53.8%, and 82.6%, respectively.

CONCLUSION

The results of this study showed that secondary ABC does not increase the risk of local recurrence after curettage in patients with GCTB of the extremities. Although rare, FFLs were present in patients with GCTB and half of those with FFLs detected on preoperative MRI had secondary ABC.

Giant Cell Tumor of Bone Without Giant Cells with a Long Clinical Course: A Case Report

Giant cell tumor of bone (GCTB) consists of a mixture of neoplastic mononuclear cells and non-neoplastic cells, including polynuclear giant cells. Recently, with the spread of the immunohistochemical staining marker H3.3 G34W corresponding to specific genetic abnormalities, the histological diversity of GCTB has been recognized. GCTB without giant cells is uncommon, although it has also been reported previously. Herein, we describe a 45-year-old man with GCTB without giant cells who was successfully diagnosed using H3.3 G34W immunohistochemistry. Other unusual findings in GCTB that were identified in this patient include bone and osteoid formation with a long clinical course of 13 years. We also compared the histological findings of the current patient to those who received denosumab therapy.

Bioactive Glass Inhibits Tumor Development from Giant Cell Tumor of Bone-Derived Neoplastic Stromal Cells in a Chicken Chorioallantoic Membrane Assay

Tumor recurrence is a major problem during the treatment of giant cell tumors of bone (GCTB). We recently identified tumor cell-specific cytotoxic effects of bioactive glasses (BGs) toward neoplastic stromal cells derived from GCTB tissue (GCTSCs) in vitro. Since these data indicated a promising role of BGs in the adjuvant treatment of GCTBs, we aimed to investigate the transferability of the in vitro data into the more complex in vivo situation in the current study. We first analyzed the cytotoxicity of three different BGs in vitro by WST-1 assay after co-cultivation with primary GCTSC cell lines. The effects of BGs on tumor engraftment and growth were analyzed by chicken chorioallantoic membrane (CAM) assays and subsequent quantification of tumor take rates and tumor volumes. In vitro, all tested BGs displayed a cytotoxic effect on GCTSCs that was dependent on BG composition, concentration, and particle size. Comparable effects could be observed within the in vivo environment resulting in reduced tumor take rates and tumor volumes in BG-treated samples. These data indicate a possible clinical application of BGs in the context of GCTB therapy, mediating a reduction of recurrence rates with the simultaneous promotion of bone regeneration.

Inhibition of RANKL Expression in Osteocyte-like Differentiated Tumor Cells in Giant Cell Tumor of Bone After Denosumab Treatment

Giant cell tumors of bone (GCTBs) are locally aggressive tumors with the histological features of giant cells and stromal cells. Denosumab is a human monoclonal antibody that binds to the cytokine receptor activator of nuclear factor-kappa B ligand (RANKL). RANKL inhibition blocks tumor-induced osteoclastogenesis, and survival, and is used to treat unresectable GCTBs. Denosumab treatment induces osteogenic differentiation of GCTB cells. In this study, the expression of RANKL, special AT-rich sequence-binding protein 2 (SATB2, a marker of osteoblast differentiation), and sclerostin/SOST (a marker of mature osteocytes) was analyzed before and after treatment with denosumab in six cases of GCTB. Denosumab therapy was administered a mean of five times over a mean 93.5-day period. Before denosumab treatment, RANKL expression was observed in one of six cases. After denosumab therapy, spindle-like cells devoid of giant cell aggregation were RANKL-positive in four of six cases. Bone matrix-embedded osteocyte markers were observed, although RANKL was not expressed. Osteocyte-like cells were confirmed to have mutations, as identified using mutation-specific antibodies. Our study results suggest that treatment of GCTBs with denosumab results in osteoblast-osteocyte differentiation. Denosumab played a role in the suppression of tumor activity via inhibition of the RANK-RANKL pathway, which triggers osteoclast precursors to differentiate into osteoclasts.

Characteristics of Patients with Giant Cell Tumor of Bone and High Serum Tartrate-Resistant Acid Phosphatase 5b Levels: Comparison of Tumor Volume and Clinical Factors

BACKGROUND

Serum tartrate-resistant acid phosphatase 5b is well known to be increased in giant cell tumors of bone. However, there are only a few studies that analyzed the association with tartrate-resistant acid phosphatase 5b expression in those patients. Therefore, we analyzed the characteristics of patients with giant cell tumors of bone and high tartrate-resistant acid phosphatase 5b expression.

METHODS

This retrospective study included 26 patients with giant cell tumors of bone. The correlation between tartrate-resistant acid phosphatase 5b before initial treatment and tumor volume was evaluated. Patients were divided into two groups according to tartrate-resistant acid phosphatase 5b level. Statistical analysis was performed between the two groups.

RESULTS

Tartrate-resistant acid phosphatase 5b was elevated in 17/26 patients, and the mean value was 852 mU/dL. There was no correlation with tumor volume (r = 0.034, P = 0.86). The mean age of 34.5 years in the HT group was significantly younger than the mean age of 47.4 years in the LT group (P = 0.040). Pathologically, 19/26 cases showed at least one focal area with features of typical giant cell tumor of bone. Although 11/18 patients in the LT group exhibited relatively noticeable secondary changes, all patients in the HT group exhibited typical features (P = 0.0074).

CONCLUSIONS

Tartrate-resistant acid phosphatase 5b levels were not elevated in some giant cell tumors of bone. This study suggested that tartrate-resistant acid phosphatase 5b may be elevated in younger patients and in cases with fewer pathological secondary changes, regardless of tumor volume.

Association between preoperative denosumab and the risk of local recurrence in patients with giant cell tumor of bone: A meta-analysis and systematic review

Objectives

This meta-analysis aimed at determining the association between preoperative denosumab and the risk of local recurrence in patients with giant cell tumors of the bone.

Methods and Materials

Web of Science, EMBASE, Cochrane Library, and PubMed were comprehensively searched on April 20^th, 2022. Data from the included articles were analyzed using meta-analysis. The bias of all included studies was evaluated according to ROBINS-I. Also, subgroup and sensitivity analyses were performed.

Results

Eight studies with 1270 cases (195 in the denosumab group and 1075 in the control group) were eventually included. Patients receiving denosumab before curettage had a higher risk of local recurrence than those who underwent curettage alone (odds ratio: 2.29, 95% confidence intervals: 1.44-3.64, P = 0.0005). The denosumab group showed a significantly higher risk of local recurrence in most subgroup analyses, except for those with preoperative denosumab duration ≤six months/doses (P = 0.66) and sample size ranging from 100 to 180 (P = 0.69).

Conclusion

Denosumab before curettage may increase the risk of local recurrence in patients with giant cell tumor of the bone. Preoperative denosumab should be used with caution after weighing an increased risk of local recurrence against the clinical benefits and a duration time of less than six months before surgery is recommended.

Association between Inflammatory Markers and Local Recurrence in Patients with Giant Cell Tumor of Bone: A Preliminary Result

Giant cell tumor of bone (GCTB) has a high local recurrence rate of approximately 20%. Systemic inflammatory markers, such as neutrophil-lymphocyte ratio (NLR), modified Glasgow prognostic score (mGPS), prognostic nutritional index (PNI), lymphocyte-monocyte ratio (LMR), platelet-lymphocyte ratio (PLR), hemoglobin (Hb), alkaline phosphatase (ALP), and lactate dehydrogenase (LDH), have been reported as prognostic markers in patients with malignant tumors. This study aimed to investigate the correlation between these markers and the local recurrence rate of GCTB. In total, 103 patients with GCTB who underwent surgery at the authors' institutions between 1993 and 2021 were included. Thirty patients experienced local recurrence. Univariate and multivariate analysis showed that tumor site, preoperative and postoperative denosumab treatment, and surgery were significantly associated with local recurrence-free survival. LDH was associated with local recurrence-free survival on univariate analysis only. NLR, mGPS, PNI, LMR, and PLR score did not correlate with the local recurrence rate. In conclusion, NLR, mGPS, PNI, LMR, PLR score, Hb, ALP, and LDH levels are not correlated with the local recurrence rate of GCTB. However, due to the small number of patients included in this study, this result should be re-evaluated in a multicenter study with a larger sample size.

Packing with alpha-tricalcium phosphate followed by curettage and phenol-ethanol ablation for appendicular giant cell tumor of bone

Giant cell tumor of bone (GCTB) is an intermediate and locally aggressive bone tumor. Alpha-tricalcium phosphate (alpha-TCP) is an adjustable bone substitute used to fill various sizes of bone cavities after curettage for GCTB. This study aimed to evaluate the surgical outcome of packing with alpha-TCP followed by curettage and phenol-ethanol ablation. We retrospectively reviewed data of 16 patients with GCTB who underwent primary surgery in our institute between January 2009 and April 2021. Data of Campanacci grading system; number of local recurrences and distant metastases; local recurrence-free survival rate using the Kaplan-Meier method; oncological outcomes; and complications after surgery (secondary osteoarthritis and postoperative fracture) were evaluated in this study. Regarding the Campanacci grading system, 2 patients were classified as grade I, 14 as grade II, and none as grade III. The 5-year local recurrence-free survival rate was 77.8% in all cases. Lung metastasis was not detected in this study. Oncological outcomes were: continuous disease free, 13 patients; alive with disease, 3 patients; and no evidence of disease or death of disease, none of the patients. Secondary osteoarthritis after surgery was not detected in the present study. Packing with alpha-TCP followed by curettage and phenol-ethanol ablation for appendicular GCTB may be safe and effective in suppressing the risk of secondary osteoarthritis.

Wrist Reconstruction Using Free Vascularized Fibular Head Graft Following Intralesional Excision for Campanacci Grade 3 Giant Cell Tumors Involving the Articular Surface of the Distal Radius

Reconstruction with a free vascularized fibular head graft after en bloc excision of a Campanacci grade 3 giant cell tumor of bone in the distal radius can effectively control local recurrence. However, it leads to the loss of wrist movement, subsequent radiocarpal subluxation, and an osteoarthritic change. Another treatment option for grade 3 lesions is intralesional excision and cementation, which preserves wrist movement but does not restore the articular surface. We report a case of wrist reconstruction using a free vascularized fibular head graft after the intralesional excision of a Campanacci grade 3 giant cell tumor of bone with invasion of the articular surface of the distal radius. In patients with this type of a lesion, wrist reconstruction using a free vascularized fibular head graft after intralesional excision can help prevent local tumor recurrence, restore the articular surface, and maintain movements of the wrist joint.

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.

Emerging trends and focus of giant cell tumor of bone research from 2001-2021: A visualization research

Giant cell tumor of bone is a highly invasive benign tumor with a high postoperative recurrence rate.

OBJECTIVE

This study aims to analyze the research hotspots and trends of global research on giant cell tumor of bone in the past 20 years, to provide a reference for relevant personnel in this field to carry out academic research.

METHODS

The literature related to giant cell tumor of bone from 2001 to 2021 was retrieved from the Web of Science. The bibliometrics research method and VOS Viewer were used to extract and analyze the keywords of the journal authors' research institutions, and the research status and development direction in the recent 20 years were visualized.

RESULTS

A total of 2063 articles were included. The number of global publications is increasing every year. The United States contributes the most to global research, with the most citations and the highest H-index. The journal Clinical Orthopaedics and Related Research published the most articles on this issue. "Denosumab" and "h3f3a" will get more attention and be the next popular hotspot in the future.

CONCLUSION

The study of giant cell tumor of bone is a hot spot of continuous development and has an important contribution to human health.

Prognostic Value and Quantitative CT Analysis in RANKL Expression of Spinal GCTB in the Denosumab Era: A Machine Learning Approach

The receptor activator of the nuclear factor kappa B ligand (RANKL) is the therapeutic target of denosumab. In this study, we evaluated whether radiomics signature and machine learning analysis can predict RANKL status in spinal giant cell tumors of bone (GCTB). This retrospective study consisted of 107 patients, including a training set (n = 82) and a validation set (n = 25). Kaplan-Meier survival analysis was used to validate the prognostic value of RANKL status. Radiomic feature extraction of three heterogeneous regions (VOIentire, VOIedge, and VOIcore) from pretreatment CT were performed. Followed by feature selection using Selected K Best and least absolute shrinkage and selection operator (LASSO) analysis, three classifiers (random forest (RF), support vector machine, and logistic regression) were used to build models. The area under the curve (AUC), accuracy, F1 score, recall, precision, sensitivity, and specificity were used to evaluate the models' performance. Classification of 75 patients with eligible follow-up based on RANKL status resulted in a significant difference in progression-free survival (p = 0.035). VOIcore-based RF classifier performs best. Using this model, the AUCs for the training and validation cohorts were 0.880 and 0.766, respectively. In conclusion, a machine learning approach based on CT radiomic features could discriminate prognostically significant RANKL status in spinal GCTB, which may ultimately aid clinical decision-making.

Siglec-15 as a New Perspective Therapy Target in Human Giant Cell Tumor of Bone

The main features of a giant cell tumor of bone (GCTB) are frequent recurrence and aggressive osteolysis, which leads to a poor prognosis in patients. Although the treatment methods for a GCTB, such as scraping and resection, effectively inhibit the disease, the tendency toward malignant transformation remains. Therefore, it is important to identify new treatment methods for a GCTB. In this study, we first found high Siglec-15 expression in GCTB tissues, which was significantly associated with Campanacci staging and tumor recurrence. In Spearman's analysis, Siglec-15 expression was significantly correlated with Ki-67 levels in tumor tissues. In vitro, the mRNA and protein levels of Siglec-15 were high in GCTB stromal cells (Hs737. T), and Siglec-15 knockdown inhibited the biological characteristics of GCTB stromal cells. The RNA sequencing results enabled a prediction of the downstream genes by using the Kyoto Encyclopedia of Genes and Genomes (KEGG), Gene Ontology (GO), and MCODE analyses, and the findings showed that CXCL8 was significantly regulated by Siglec-15 and might be a promising downstream target gene of Siglec-15. Therefore, Siglec-15 may be a potential immunotherapy target for a GCTB.

Combined fibrinogen and neutrophil-lymphocyte ratio as a biomarker in predicting recurrence of giant cell tumor of bone

Aims: The present study investigated the combined clinical significance of fibrinogen and neutrophil-lymphocyte ratio (F-NLR) in predicting postoperative recurrence of giant cell tumor of bone. Methods: A total of 113 participants were included in this retrospective study to examine the effects of inflammatory factors on postoperative tumor recurrence. Results: The high-score F-NLR group was significantly associated with larger tumor size (p = 0.001), advanced tumor stage (p = 0.018), wide resection (p = 0.004) and greater local recurrence (p = 0.014). Univariate and multivariate survival analyses revealed that F-NLR (p = 0.035) remained an independent factor influencing tumor recurrence rates. Conclusions: This study reveals that the F-NLR score is a promising blood biomarker for predicting giant cell tumor recurrence.

Comprehensive treatment outcomes of giant cell tumor of the spine: A retrospective study

There is no consensus on a treatment strategy for spinal giant cell tumor of bone (GCTB) because of the difficulty in their treatment. Treatment options often include the use of the controversial denosumab, an antibody therapy aimed at tumor shrinkage, different curettage techniques, resection, or a combination of these therapies. The current study aimed to identify treatment methods associated with favorable outcomes in patients with spinal GCTB. We retrospectively reviewed 5 patients with spinal GCTB, including patients with tumors of the sacrum, treated at our hospital between September 2011 and November 2020. Two men and 3 women were included in the study. The median follow-up period was 74 months (range: 14-108 months). We surveyed the tumor site, treatment method, denosumab use, and outcomes. The median age was 17 years (range: 17-42 years). There were 2 cases of sacral GCTB and 1 case each of lumbar, cervical, and thoracic vertebral GCTB. The comorbidities observed included hepatitis, malignant lymphoma, atopic dermatitis, and asthma. The treatment method included zoledronic acid after embolization and denosumab, denosumab only, curettage and posterior fusion, and curettage resection after embolization and anterior and posterior fusion. Denosumab was used in all cases. Three patients were continuously disease-free, 1 patient with no evidence of disease, and 1 patient alive with disease. Aggressive treatment, especially surgical treatment, may lead to good results in spinal GCTB.

A validation based on analysis of 198 cases from a single centre in India

CONTEXT

The diagnosis of giant cell tumor of bone (GCTB) is difficult in small biopsies with unusual age of presentation, location, and extensive secondary changes. Most of the GCTBs harbor H3F3A G34W mutations with a subset of cases showing alternate G34V, G34R, and G34L mutations.

OBJECTIVES

To analyze the expression of anti-histone H3.3G34W antibody in different cellular components of GCTB across different locations and presentations (including the unusual ones) and validate the utility of this antibody in the diagnosis of GCTB and differentiate it from the other osteoclast-like giant-cell-rich lesions.

DESIGN

Immunohistochemistry was performed using anti-histone H3.3G34W antibody in the diagnosed cases of GCTB (136 cases of GCTB from 133 patients, including two malignant GCTBs) and other giant cell-containing lesions (62 cases). The presence of unequivocal crisp nuclear staining was considered positive.

RESULTS

Immunohistochemistry revealed unequivocal nuclear positivity in the mononuclear cells in 87.3% of the cases of GCTB. Of these, most showed diffuse expression with moderate to strong intensity staining. The positive staining was restricted to the nuclei of mononuclear cells with the nuclei of osteoclastic giant cells being distinctly negative. In addition to conventional GCTBs, two cases each of multicentric and malignant GCTB showed positive staining. The other giant-cell containing lesions were distinctly negative. The present study showed a sensitivity of 87.3% with specificity and positive predictive value of 100%.

CONCLUSION

The anti-histone G34W antibody is a highly sensitive and specific marker for the diagnosis of GCTB and differentiating it from its mimics. The positive staining is restricted to the mononuclear cell component of GCTB with sparing the osteoclastic giant cells further reiterating the fact that the mononuclear stromal cells are the true neoplastic component of GCTB.

Bone Turnover Marker (BTM) Changes after Denosumab in Giant Cell Tumors of Bone (GCTB): A Phase II Trial Correlative Study

Background: Giant cell tumors of bone (GCTB) are osteolytic tumors. Denosumab, a RANK-L inhibitor, is approved for GCTB. Data on serum bone turnover marker (sBTM) changes are lacking. We present a phase II correlative study on sBTMs in GCTB patients treated with denosumab. Methods: All GCTB patients receiving denosumab within a multicentre, open-label, phase 2 study were enrolled. Serum levels of carboxyterminal-crosslinked-telopeptide of type I collagen (s-CTX), alkaline phosphatase (ALP), bone-alkaline phosphatase (bALP), parathyroid hormone (sPTH), and osteocalcin (OCN) were prospectively assessed (baseline, T0, 3 months, T1, 6 months, T2). The primary endpoint was assessment of sBTM changes after denosumab; the secondary endpoints were disease-free survival (DFS) and sBTM correlation. Results: In 54 cases, sBTMs decreased during denosumab treatment except for sPTH. With a median follow-up of 59 months, 3-year DFS was 65% (%CI 52−79), with a significantly worse outcome for patients with high (≥500 UI/mL) s-CTX at baseline, as compared to low s-CTX (<500 UI/mL) (3-year DFS for high CTX 45% (95%CI 23−67) vs. 75% (95%CI 59−91) for low s-CTX. Higher median ALP and s-CTX were found for patients with tumor size ≥ 5 cm (p = 0.0512; p = 0.0589). Conclusion: Denosumab induces ALP/OCN and s-CTX reduction. High baseline s-CTX identifies a group of patients at higher risk of progression of the disease.

Treatment of giant cell tumors of the distal radius: A long-term patient-reported outcomes study

INTRODUCTION

The distal radius is a common location for giant cell tumors (GCTs) of bone. Management includes intralesional curettage or wide excision, however, long-term comparisons of treatment options are limited. The purpose of the current study was to evaluate our institutions' outcomes of treatment of these tumors.

METHODS

We reviewed 24 GCT of the distal radius in 23 patients (12 males: 11 females) with a mean age of 42 years at the time of surgery. Functional outcomes were collected including the Musculoskeletal Tumor Society Score (MSTS), QuickDash, the Visual Analog Scale (VAS), and the Patient Rated Wrist Evaluation (PRWE). The mean follow-up was 13 years.

RESULTS

Tumor grade included Campanacci Grade II (n = 14) and Grade III (n = 10). Treatment included extended intralesional curettage (n = 16) and wide excision (n = 8). Reconstruction mainly included bone grafting/cement (n = 16) or free vascularized fibula radiocarpal arthrodesis (n = 5). At most recent follow-up, there was no difference in MSTS, VAS, and PRWE (p > 0.05) between patients undergoing a joint sparing or arthrodesis. Patients undergoing arthrodesis had a lower QuickDASH score (13.7 vs. 20.8, p = 0.04) CONCLUSIONS: Treatment for GCT of the distal radius is individualized however in the setting of articular surface involvement, arthrodesis can lead to superior functional results at long-term follow-up.

JCOG1610

OBJECTIVES

The aim of JCOG1610 (randomized controlled phase III trial) was to confirm the superiority of preoperative denosumab to curettage with adjuvant local therapy for patients with giant cell tumor of bone without possible post-operative large bone defect.

METHODS

The primary endpoint was relapse-free survival and the total sample size was set at 106 patients. Patient accrual began in October 2017. However, the accrual was terminated in December 2020 due to a recommendation from the Data and Safety Monitoring Committee because of poor patient accrual. Now, we report the descriptive results obtained in this study.

RESULTS

A total of 18 patients had been registered from 13 Japanese institutions at the time of termination on December 2020. Eleven patients were assigned to Arm A (curettage and adjuvant local therapy) and 7 to Arm B (preoperative denosumab, curettage and adjuvant local therapy). Median follow-up period was 1.6 (range: 0.5-2.8) years. Protocol treatment was completed in all but one patient in Arm A who had a pathological fracture before surgery. All patients in Arm B were treated with five courses of preoperative denosumab. Relapse-free survival proportions in Arm A and B were 90.0% (95% confidence interval: 47.3-98.5) and 100% (100-100) at 1 year, and 60.0% (19.0-85.5) and 62.5% (14.2-89.3) at 2 years, respectively [hazard ratio (95% confidence interval): 1.51 (0.24-9.41)].

CONCLUSION

In terms of relapse-free survival, the superiority of preoperative denosumab was not observed in patients with giant cell tumor of bone without possible post-operative large bone defect.

Sclerostin immunohistochemical staining in surgically treated giant cell tumor of bone

BACKGROUND

Giant cell tumor of bone (GCTB) is a destructive lesion with a high potential for recurrence. RANK-ligand targeted therapy has provided promising, yet mixed results. Sclerostin (SOST) inhibition results in a net anabolic response and is currently used in the treatment of osteoporosis. The application to GCTB is unknown.

OBJECTIVES

We sought to determine if GCTB stained for SOST on immunohistochemistry and correlate its expression with predictor variables.

METHODS

All patients at a single institution undergoing surgery for GCTB between 1993 and 2008 with a minimum of 6 months follow-up were included. Primary outcomes included the presence of SOST staining, secondary outcomes included the correlation of patient and tumor-specific predictor variables.

RESULTS

SOST antibody staining of any cell type was present in 47 of 48 cases (97.9%). Positivity of the stromal cells was present in 39 of 48 cases (81.3%) and was associated with radiographic aggressiveness (p = 0.023), symptomatic presentation (p = 0.032), prior surgery (p = 0.005), and patient age (p = 0.034). Positivity of giant cells was present in 41 of 48 cases (85.4%) and was not significant with predictive factors.

CONCLUSIONS

Sclerostin staining in GCTB is a novel finding and warrants further research to define the role of sclerostin as a prognostic factor and therapeutic target.

Recurrent Fusion of the Genes for High-mobility Group AT-hook 2 (HMGA2) and Nuclear Receptor Co-repressor 2 (NCOR2) in Osteoclastic Giant Cell-rich Tumors of Bone

BACKGROUND/AIM

Chimeras involving the high-mobility group AT-hook 2 gene (HMGA2 in 12q14.3) have been found in lipomas and other benign mesenchymal tumors. We report here a fusion of HMGA2 with the nuclear receptor co-repressor 2 gene (NCOR2 in 12q24.31) repeatedly found in tumors of bone and the first cytogenetic investigation of this fusion.

MATERIALS AND METHODS

Six osteoclastic giant cell-rich tumors were investigated using G-banding, RNA sequencing, reverse transcription polymerase chain reaction, Sanger sequencing, and fluorescence in situ hybridization.

RESULTS

Four tumors had structural chromosomal aberrations of 12q. The pathogenic variant c.103_104GG>AT (p.Gly35Met) in the H3.3 histone A gene was found in a tumor without 12q aberration. In-frame HMGA2-NCOR2 fusion transcripts were found in all tumors. In two cases, the presence of an HMGA2-NCOR2 fusion gene was confirmed by FISH on metaphase spreads.

CONCLUSION

Our results demonstrate that a subset of osteoclastic giant cell-rich tumors of bone are characterized by an HMGA2-NCOR2 fusion gene.

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.

State of the Art and New Concepts in Giant Cell Tumor of Bone: Imaging Features and Tumor Characteristics

Simple Summary

The 2020 World Health Organization classification of soft tissue and bone tumors classified the giant cell tumor of bone (GCTB) as an intermediate malignant tumor, with locally aggressive behavior and high recurrence rate. Imaging plays a pivotal role in the assessment of GCTB, and this review tries to summarize the main concepts about GCTB histopathogenesis and new biomarkers, describing those GCTB imaging findings which could possibly be explained by tumor molecular alterations. We have illustrated pre-operative imaging features related to prognosis and radiological findings for response evaluation after surgical treatment and denosumab administration. We have also reported the results described in literature regarding the role of radiomics in aiding GCTB diagnosis, predicting possible post-treatment recurrence and providing a quantitative assessment of the response to denosumab treatment.

Abstract

Giant cell tumor of bone (GCTB) is classified as an intermediate malignant tumor due to its locally aggressive behavior, burdened by high local recurrence rate. GCTB accounts for about 4–5% of all primary bone tumors and typically arises in the metaphysis and epiphyses of the long tubular bones. Mutation of gene H3F3A is at the basis of GCTB etiopathogenesis, and its immunohistochemical expression is a valuable method for practical diagnosis, even if new biomarkers have been identified for early diagnosis and for potential tumor recurrence prediction. In the era of computer-aided diagnosis, imaging plays a key role in the assessment of GCTB for surgical planning, patients’ prognosis prediction and post treatment evaluation. Cystic changes, penetrating irregular margins and adjacent soft tissue invasion on preoperative Magnetic Resonance Imaging (MRI) have been associated with a higher rate of local recurrence. Distance from the tumor edge to the articular surface and thickness of unaffected cortical bone around the tumor should be evaluated on Computed Tomography (CT) as related to local recurrence. Main features associated with local recurrence after curettage are bone resorption around the graft or cement, soft tissue mass formation and expansile destruction of bone. A denosumab positive response is represented by a peripherical well-defined osteosclerosis around the lesion and intralesional ossification. Radiomics has proved to offer a valuable contribution in aiding GCTB pre-operative diagnosis through clinical-radiomics models based on CT scans and multiparametric MR imaging, possibly guiding the choice of a patient-tailored treatment. Moreover, radiomics models based on texture analysis demonstrated to be a promising alternative solution for the assessment of GCTB response to denosumab both on conventional radiography and CT since the quantitative variation of some radiomics features after therapy has been correlated with tumor response, suggesting they might facilitate disease monitoring during post-denosumab surveillance.

Stromal cells of giant cell tumor of bone show primary cilia in giant cell tumor of bone

Giant cell tumor of bone (GCTB) is a locally aggressive primary bone neoplasm composed by tumoral stromal cells (SCs) and a reactive component that consists of monocytic/histiocytic cells that give rise by fusion to osteoclast-like multinucleated cells. Recently, specific Histone 3.3 mutations have been demonstrated in SCs of GCTB. Many of the pathways related to bone proliferation and regulation depend on the primary cilium, a microtubule-based organelle that protrudes outside the cell and acts as a sensorial antenna. In the present work, we aimed to study the presence and role of primary cilia in GCTB. Ultrastructural, immunohistochemical, and immunofluorescence studies were performed in order to demonstrate, for the first time, that the primary cilium is located in spindle-shaped SCs of GCTB. Moreover, we showed Hedgehog (Hh) signaling pathway activation in these cells. Hence, primary cilia may play a relevant role in GCTB tumorogenesis through Hh signaling activation in SCs. RESEARCH HIGHLIGHTS: Transmission electron microscopy allows describing and differentiating cellular subpopulations in giant cell tumor of bone (GCTB). The primary cilium is present in some tumoral stromal cells of GCTB. Hedgehog signalling is activated in these cells.

Effect of Adjuvant Chemotherapy on Localized Malignant Giant Cell Tumor of Bone: A Systematic Review

Simple Summary

The effect of adjuvant chemotherapy on localized malignant giant cell tumors of the bone (GCTB) is unclear. We compared the mortality associated with wide resection compared to wide resection plus adjuvant chemotherapy for localized primary and secondary localized malignant GCTB. Among 745 relevant studies, 9 were included, with 39 and 73 primary and secondary malignant patients. In primary localized malignant GCTB, the mortality rates were 40% (6/15 patients) and 33% (8/24 patients) in the surgery plus adjuvant chemotherapy and surgery-only groups, respectively. The overall pooled odds ratio was 1.07 (p = 0.92). In secondary localized malignant GCTB, the mortality rates were 30.6% (11/36 patients) and 62.2% (23/37 patients) in the surgery plus adjuvant chemotherapy and surgery-only groups, respectively. The overall pooled odds ratio was 0.31 (p = 0.04). The effect of adjuvant chemotherapy remains unclear for primary localized malignant GCTB, but adjuvant chemotherapy improved the survival of patients with secondary localized malignant GCTB.

Abstract

A malignant giant cell tumor of the bone (GCTB) is a rare primary malignant tumor classified as primary or secondary. Wide resection of the primary tumor is recommended for localized malignant GCTB, but the effect of adjuvant chemotherapy is unclear. A systematic review was performed to compare the mortality associated with wide resection with that of wide resection plus adjuvant chemotherapy for primary and secondary localized malignant GCTB. Among the 745 studies identified, 9 were included. A total of 112 cases of localized malignant GCTB were included, with 39 and 73 cases being primary and secondary malignant GCTB. In primary localized malignant GCTB, the mortality rates were 40% (6/15 patients) and 33% (8/24 patients) in the surgery plus adjuvant chemotherapy and surgery-only groups, respectively. Overall pooled odds ratio was 1.07 (95% confidence interval, 0.26–4.37; p = 0.92). In secondary localized malignant GCTB, the mortality rates were 30.6% (11/36 patients) and 62.2% (23/37 patients) in the surgery plus adjuvant chemotherapy and surgery-only groups, respectively. The overall pooled odds ratio was 0.31 (95% confidence interval, 0.10–0.95; p = 0.04). The effect of adjuvant chemotherapy remains unclear for primary localized malignant GCTB, but adjuvant chemotherapy improved the survival of patients with secondary localized malignant GCTB.

Giant cell tumor of soft tissue: FNA cytopathology of 4 cases, review of the literature, and comparison with giant cell tumor of bone

BACKGROUND

The cytopathology of a giant cell tumor of soft tissue (GCT-ST), a fibrohistiocytic neoplasm distinct from other giant cell-rich soft tissue tumors, is rarely reported. The authors report their experience with a series of 4 GCT-ST fine-needle aspiration (FNA) biopsy cases and compare them with a set from giant cell tumors of bone (GCTBs).

METHODS

The authors' cytopathology files were searched for GCT-ST examples with histopathologic confirmation. FNA biopsy smears were performed and examined with standard techniques.

RESULTS

Four cases of GCT-ST presenting as a primary soft tissue mass from 4 patients (3 males and 1 female; age range, 28-75 years, mean age, 53 years) were retrieved. FNA sites included the anterior tibia, buttock, shoulder, and upper back. Three cases were interpreted as suspicious for sarcoma radiographically. The specific diagnoses were atypical giant cell tumor of tendon sheath, suspicious for GCT-ST, atypical myxoid lesion with giant cells, and benign with osteoclast-like giant cells (OLGCs). No case was interpreted as malignant. Aspirates consisted of mononuclear polygonal cells, spindled fibroblast cell clusters, and large OLGCs to the near exclusion of other cell types. OLGCs possessed 10 or more nuclei per cell. A comparison with GCTB aspirates and single case reports from the literature showed comparable cytomorphology.

CONCLUSIONS

GCT-ST FNA smears mimic those of GCTBs containing a limited population of uniform spindle cell clusters, single dispersed polygonal cells, and cytologically banal OLGCs. GCT-ST should be considered in the differential diagnosis of aspirates containing numerous osteoclast-like giant cells.

Spontaneous Regression of Brown Tumor in a Patient Treated With Peritoneal Dialysis

A 52-year-old man, with a history of diabetic nephropathy and renal cancer, had been treated with peritoneal dialysis for four months before consulting our hospital. At the time of imaging evaluation, three years after surgery for renal cancer, fluorodeoxyglucose accumulation was found at the distal metaphysis of the left radius. After the biopsy, he was diagnosed with giant cell tumor of bone (GCTB), and surgery was scheduled. However, osteogenesis was observed in the images retaken before surgery. It was found that his intact parathyroid hormone level had been abnormally high four months prior to his visit to us but had subsequently normalized. The tissue obtained by re-biopsy revealed osteogenesis with the disappearance of multinucleated giant cells, suggesting a brown tumor (BT). The tumor was thought to have been caused by secondary hyperparathyroidism (HPT) associated with peritoneal dialysis. When osteolytic lesions mimicking GCTB are found, the possibility of BT should be considered based on comorbidities and clinical information.

A novel model to culture cells from giant cell tumor of bone using three-dimensional (3D) polycaprolactone scaffold

Two-dimensional (2D) culture of cells from giant cell tumor of bone (GCTB) is affected by loss of the multinucleated giant cells in subsequent passages. Therefore, there is limited time to study GCTB with all its histological components in 2D culture. Here, we explored the possibility of culturing GCTB cells on a polycaprolactone (PCL)-printed scaffold. We also evaluated the viability of the cultured cells and their adherence to the PCL scaffold at day 14 days using immunofluorescence analysis with calcein, vinculin, and phalloidin. Using the histological technique with hematoxylin and eosin staining, we observed all the histological components of GCTB in this 3D model. Immunohistochemical assays with cathepsin K, p63, and receptor activator of nuclear factor (NF)-κB ligand (RANKL) yielded positive results in this construct, which allowed us to confirm that the seeded cells maintained the expression of GCTB markers. Based on these findings, we concluded that the PCL scaffold is an efficient model to culture GCTB cells, and the cell viability and adherence to the scaffold can be preserved for up to 14 days. Moreover, this model can also be used in subsequent studies to assess in vitro cell-cell interactions and antineoplastic efficacy of certain agents to establish a treatment against GCTB.

Combination of Melatonin and Zoledronic Acid Suppressed the Giant Cell Tumor of Bone in vitro and in vivo

Melatonin (Mlt) confers potential antitumor effects in various types of cancer. However, to the best of our knowledge, the role of Mlt in the giant cell tumor of bone (GCTB) remains unknown. Moreover, further research is required to assess whether Mlt can enhance the therapeutic effect of zoledronic acid (Zol), a commonly used anti-GCTB drug. In this research, we investigated the effects of Mlt, Zol, and the combination of these two drugs on GCTB cells’ characteristics, including cell proliferation, apoptosis, osteogenic differentiation, migration, and invasion. The cell counting kit-8 (CCK-8) assay, colony formation assay, terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assay (TUNEL), alkaline phosphatase (ALP) staining, alizarin red staining (ARS), scratch wound healing assay, and transwell experiment were performed, respectively. Our results showed that Mlt could effectively inhibit the proliferation, migration, and invasion of GCTB cells, as well as promote the apoptosis and osteogenic differentiation of tumor cells. Of note, a stronger antitumor effect was observed when Mlt was combined with Zol treatment. This therapeutic effect might be achieved by inhibiting the activation of both the Hippo and NF-κB pathways. In conclusion, our study suggests that Mlt can be a new treatment for GCTB, which could further enhance the antitumor effect of Zol.

Management of the Cavity After Removal of Giant Cell Tumor of the Bone

Purpose: To find out the most appropriate management scheme through the analysis and comparison of different inactivation methods and filling materials. Method: A systematic literature search was performed using the terms, anhydrous ethanol, phenol, hypertonic saline, cryotherapy, thermal therapy, bone reconstruction, GCTB, and etc., Selected articles were studied and summarized. The mechanism, clinical effects, and influence on bone repair of various methods are presented. Recent developments and perspectives are also demonstrated. Recent Findings: Compared to curettage alone, management of the residual cavity can effectively reduce the recurrence of giant cell tumours of bone. It is a complex and multidisciplinary process that includes three steps: local control, cavity filling, and osteogenic induction. In terms of local control, High-speed burring can enlarge the area of curettage but may cause the spread and planting of tumour tissues. Among the inactivation methods, Anhydrous ethanol, and hyperthermia therapy are relatively safe and efficient. The combination of the two may achieve a better inactivation effect. When inactivating the cavity, we need to adjust the approach according to the invasion of the tumour. Filling materials and bone repair should also be considered in management.

Current Concepts in the Treatment of Giant Cell Tumors of Bone

Simple Summary

According to the 2020 World Health Organization classification, a giant cell tumor of bone is an intermediate malignant bone tumor. Denosumab treatment before curettage should be avoided due to the increased risk of local recurrence. Administration of denosumab before en bloc resection of the giant cell tumors of the pelvis and spine facilitates en bloc resection. Nerve-sparing surgery after embolization is a possible treatment for giant cell tumors of the sacrum. Denosumab therapy with or without embolization is indicated for inoperable giant cell tumors of the pelvis, spine, and sacrum. A wait-and-see approach is recommended for lung metastases at first, then denosumab should be administered to the growing lesions. Radiotherapy is not recommended owing to the risk of malignant transformation. Local recurrence after 2 years or more should be indicative of malignant transformation. This review summarizes the treatment approaches for non-malignant and malignant giant cell tumors of bone.

Abstract

The 2020 World Health Organization classification defined giant cell tumors of bone (GCTBs) as intermediate malignant tumors. Since the mutated H3F3A was found to be a specific marker for GCTB, it has become very useful in diagnosing GCTB. Curettage is the most common treatment for GCTBs. Preoperative administration of denosumab makes curettage difficult and increases the risk of local recurrence. Curettage is recommended to achieve good functional outcomes, even for local recurrence. For pathological fractures, joints should be preserved as much as possible and curettage should be attempted. Preoperative administration of denosumab for pelvic and spinal GCTBs reduces extraosseous lesions, hardens the tumor, and facilitates en bloc resection. Nerve-sparing surgery after embolization is a possible treatment for sacral GCTBS. Denosumab therapy with or without embolization is indicated for inoperable pelvic, spinal, and sacral GCTBs. It is recommended to first observe lung metastases, then administer denosumab for growing lesions. Radiotherapy is associated with a risk of malignant transformation and should be limited to cases where surgery is impossible and denosumab, zoledronic acid, or embolization is not available. Local recurrence after 2 years or more should be indicative of malignant transformation. This review summarizes the treatment approaches for non-malignant and malignant GCTBs.

Late Local Recurrence of Bone Giant Cell Tumors Associated with an Increased Risk for Malignant Transformation

Simple Summary

In giant cell tumor of bone (GCTB), an intermediate malignant bone tumor, approximately 4% of cases can undergo malignant transformation. We analyzed risk factors for malignant transformation of GCTB treated without radiotherapy and retrospectively reviewed medical files of 461 patients with GCTB of the extremities who had undergone surgery alone, with no radiotherapy or denosumab therapy. Malignant transformation occurred in 15 of 461 patients (3.3%) at a median follow-up period of 192 months. The median follow-up duration was 89.4 months. Multivariate analysis revealed that local recurrence was an independent prognostic factor for unfavorable malignant transformation. The interval between the last surgery to local recurrence and malignant transformation was longer than that to local recurrence of benign GCTB, with a median of 15.2 (IQR, 5.2–25.4) years versus 1.3 (IQR, 0.8–2.6) months, respectively (p < 0.001). Late local recurrence of GCTB is associated with a higher risk of malignant transformation.

Abstract

In giant cell tumor of bone (GCTB), an intermediate malignant bone tumor, approximately 4% of all cases undergo malignant transformation. Accordingly, we analyzed risk factors for malignant transformation of GCTB treated without radiotherapy. We retrospectively reviewed medical records of 530 patients with GCTB of the extremities, admitted and treated at two institutions between January 1980 and December 2019. Overall, 4 patients with primary malignant GCTB, 4 patients with missing data, 3 patients with a history of radiotherapy, 22 patients with a follow-up of less than 6 months, and 36 patients who received denosumab were excluded. Accordingly, 461 patients were included for further analysis. Malignant transformation was observed in 15 of 461 patients (3.3%) at a median follow-up period of 192 months. The median follow-up duration was 89.4 months. Multivariate analysis revealed that local recurrence was an independent prognostic factor for unfavorable malignant transformation (Hazard ratio [HR], 11.33; 95% confidence interval [CI] 2.33–55.13; p = 0.003 for once versus none and HR, 11.24; 95% CI, 1.76–71.96; and p = 0.011 for twice or more versus none). The interval between the last surgery to local recurrence and malignant transformation was longer than that to local recurrence of benign GCTB, with a median of 15.2 years (interquartile range [IQR], 5.2–25.4) versus 1.3 months (IQR, 0.8–2.6), respectively (p < 0.001). Late local recurrence of GCTB is associated with a higher risk of malignant transformation.

Fibular Strut Arthrodesis for Salvage of Campanacci Grade III Giant Cell Tumor of the Hallucal Proximal Phalanx: A Case Report

Involvement of toe phalanges by giant cell tumor (GCT) is extremely rare; tumors in these locations tend to be aggressive. Whereas aggressive GCTs of the distal phalanx may be managed successfully by en-bloc resection without reconstruction or amputation, management of these lesions, when they involve the proximal phalanx, can be challenging. We present a Campannaci grade III GCT of the hallucal proximal phalanx in a 14-year old girl that had breached into the dorsal soft tissues and the metatarso-phalangeal joint. Wide local resection of the proximal phalanx along with reconstruction arthrodesis with an autologous, non-vascularized fibular strut graft was performed. There was no recurrence at 3 years of follow-up. The patient had an excellent functional outcome. To the best of our knowledge, this is the first case reporting the outcomes of fibular strut arthrodesis for salvage of GCT of the hallucal proximal phalanx.

Giant cell tumor of bone - Analysis of 213 cases involving extra-craniofacial bones

We elucidated clinicopathological characteristics of giant cell tumor of bone (GCTB) in Japan, and significant clinicopathological factors for predicting local recurrence. Clinicopathological profiles of 213 patients with GCTB (100 male, 113 female) involving extra‐craniofacial bones were retrieved. Pathological slides obtained at the initial surgery were reviewed. Fourteen pathological and five clinical features were statistically analyzed to disclose prognostic significance. Patient age ranged from 12–80 years (Average 38.7). Long bones were most frequently affected (86.4%), especially around the knee (62.9%). Histological features are basically similar to those previously reported. Within a follow‐up period (24–316 months, average 106.1 months), the local recurrence rate is 29.1%. Metastasis has occurred in 9 patients. Cox regression analysis of representative clinicopathological features shows that younger age, higher mitotic count, smaller zones of stromal hemorrhage, considerable vascular invasion and absence of ischemic necrosis are significant predictors for local recurrence. Initial operative method (curettage) is a significant risk factor in univariate analysis but not by multivariate analysis (P = 0.053). Denosumab administration increases risk but not significantly (P = 0.053). Histone 3.3 G34W immunopositivity is not significant for predicting local recurrence.

Multiple Pulmonary Metastases of Recurrent Giant Cell Tumor of Bone with Expression of VEGFR-2 Successfully Controlled by Denosumab and Apatinib: A Case Report and Literature Review

Giant cell tumor of bone (GCTB) is a rare, benign, but locally aggressive bone tumor. It has a high tendency for local recurrence, which may increase the incidence of lung metastasis. Currently, an optimal treatment strategy has not been established because of the rarity of pulmonary metastatic GCTB. Denosumab is the preferred regimen for unresectable metastatic lesions; however, there are no alternative treatment options when patients are resistant to denosumab. Apatinib is a small-molecule tyrosine kinase inhibitor that selectively competes for the vascular endothelial growth factor receptor 2 (VEGFR-2) ATP binding site, and several studies have analyzed the effectiveness of apatinib in advanced or metastatic tumors. However, there is no report of apatinib as an anti-angiogenesis therapy for pulmonary metastatic GCTB to date. Here, we present a case of a 26-year-old female who was diagnosed with recurrent and pulmonary metastatic GCTB. Immunohistochemical (IHC) staining indicated that the tumor cells were positive for VEGFR-2. Denosumab was administered to control the metastases; nevertheless, disease progression was confirmed after four months of treatment. Given the IHC results and rapid disease progression, apatinib was added to the treatment strategy. After 42 months of treatment, the patient showed noticeable symptomatic improvement and considerable tumor shrinkage.

Cell Cycle Regulatory Protein Expression in Multinucleated Giant Cells of Giant Cell Tumor of Bone: do They Proliferate?

Cells of the monocyte macrophage lineage form multinucleated giant cells (GCs) by fusion, which may express some cell cycle markers. By using a comprehensive marker set, here we looked for potential replication activities in GCs, and investigated whether these have diagnostic or clinical relevance in giant cell tumor of bone (GCTB). GC rich regions of 10 primary and 10 first recurrence GCTB cases were tested using immunohistochemistry in tissue microarrays. The nuclear positivity rate of the general proliferation marker, replication licensing, G1/S-phase, S/G2/M-phase, mitosis promoter, and cyclin dependent kinase (CDK) inhibitor reactions was analyzed in GCs. Concerning Ki67, moderate SP6 reaction was seen in many GC nuclei, while B56 and Mib1 positivity was rare, but the latter could be linked to more aggressive (p = 0.012) phenotype. Regular MCM6 reaction, as opposed to uncommon MCM2, suggested an initial DNA unwinding. Early replication course in GCs was also supported by widely detecting CDK4 and cyclin E, for the first time, and confirming cyclin D1 upregulation. However, post-G1-phase markers CDK2, cyclin A, geminin, topoisomerase-2a, aurora kinase A, and phospho-histone H3 were rare or missing. These were likely silenced by upregulated CDK inhibitors p15^INK4b, p16^INK4a, p27^KIP1, p53 through its effector p21^WAF1 and possibly cyclin G1, consistent with the prevention of DNA replication. In conclusion, the upregulation of known and several novel cell cycle progression markers detected here clearly verify early replication activities in GCs, which are controlled by cell cycle arresting CDK inhibitors at G1 phase, and support the functional maturation of GCs in GCTB.

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.

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

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

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.