Recurrence Rate of Giant Cell Tumor With the Treatment of Scooping Curettage, Burr Down Technique, Phenolization, and Bone Cement

Primary malignant giant cell tumor (PMGCT): Diagnosis and management challenges in low resource settings

Bone primary malignant giant cell tumor (PMGCT) cases are extremely rare, and the optimal management remains unclear. This case report details the diagnosis and successful management of PMGCT in a 45-year-old female presenting with left knee pain, swelling, and restricted movement for one year. Accompanying weight loss and loss of appetite led the patient to seek tertiary care after unsuccessful prior treatment. Imaging, including X-ray and magnetic resonance imaging (MRI), revealed a tumor measuring 7.9 × 7.7 × 6.6 cm, and histopathological examination using fine needle aspiration cytology confirmed the diagnosis of PMGCT. A multidisciplinary approach was taken, involving orthopedic surgery to remove the tumor successfully, and physiotherapy for postoperative care. The patient underwent tumor excision and curettage under spinal and epidural anesthesia, followed by a week of bed rest, and then physiotherapy was started to aid in limb mobilization. Postoperative care involved blood transfusions, femoral artery stenting, continued physiotherapy and adjuvant radiotherapy, initiated two weeks post-surgery, with a total dose of 50 Gy delivered in 25 sessions to reduce the risk of recurrence. Initial monthly follow-ups, later transitioning to quarterly, showed improved joint mobility and function, with no recurrence at the 9-month follow-up. This case highlights the importance of early diagnosis and a multidisciplinary approach to managing PMGCT. Collaboration across specialties contributed to the positive outcome, even in a resource- limited setting. Long-term monitoring remains essential to detect recurrence, and further research is needed to refine treatment strategies for malignant GCTs.

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

Background and Objective

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

Method

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

Results

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

Conclusion

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

Treatment outcomes of pathological fractures in patients with benign bone tumors

Pathological fractures of benign bone tumors can be difficult to treat, and the underlying pathogenesis remains unclear. Herein, we aimed to determine preventive measures for pathological fractures in patients with benign bone tumors based on fracture outcomes. Between April 2015 and July 2023, we enrolled 18 consecutive patients with oncological pathological fractures treated at our department. Age, sex, histopathological diagnosis, site of origin, whether incisional or pathological fracture, treatment, operative time, blood loss, recurrence, and characteristics of impending and pathological fractures were examined. The median patient age was 22 years, comprising 9 males and 9 females. The pathology included bone cysts (n = 6), enchondromas (n = 5), fibrous dysplasia (n = 4), giant cell tumors (n = 2), and aneurysm bone cysts (n = 1). Six cases involved the humerus, 5 the femur, 3 the phalanges, 2 the toes, 1 the ribs, and 1 the tibia. Five and 13 cases were impending and pathological fractures, respectively. Thirteen patients underwent surgery, whereas 5 were treated conservatively. Surgical methods included curettage and artificial bone graft (n = 6); curettage and artificial bone graft plus compression hip screw fixation (n = 3); and curettage and artificial bone graft plus plate fixation, intramedullary nail, artificial head replacement, and plate fixation (n = 1 case each). The mean operative time and blood loss were 76 ± 56 minutes and 10 ± 80.1 mL, respectively. Recurrence occurred in 1 case. All impending fractures had onset in the lower extremity bones. Pathological fractures due to benign bone tumors of the lower extremities should not be overlooked as symptoms of pain.

Clinical results of knee juxta-articular giant-cell tumors treated with bone cement filling and internal fixation after extensive curettage

OBJECTIVES

This study was to evaluate the radiological and clinical outcomes of patients with juxta-articular giant-cell tumors (GCTs) around the knee treated with bone cement filling and internal fixation after extensive curettage.

PATIENTS AND METHODS

A total of 15 patients (6 males, 9 females; mean age: 35.3±8.4 years; range, 24 to 53 years) with juxta-articular GCTs around the knee were retrospectively reviewed between January 2010 and June 2020. Wound healing, functional status as assessed by the Musculoskeletal Tumor Society (MSTS) scores, local recurrence, metastasis, and complications were evaluated.

RESULTS

The mean follow-up was 41.3±9.9 (range, 24 to 69) months with an overall survival of 93.3%. The mean distance between tumor and cartilage was 6.29±3.73 mm. Five patients underwent reconstruction with cancellous allografts and the mean distance between tumor and cartilage was 2.20±1.48 mm in these patients. At the final follow-up, three patients had Kellgren-Lawrence Grade 2 tibiofemoral osteoarthritis in the operated knee. Lucent zones around the bone cement with no further progression were found in five patients. One patient experienced recurrence 17 months after surgery and was treated by en-bloc resection and reconstructed with a tumor endoprosthesis. The remaining 14 patients had a mean MSTS score of 26.86±2.11 (range, 23 to 30) at the final follow-up. The mean overall range of motion at the final follow-up was 109.20±14.20° (range, 85 to 130°).

CONCLUSION

Bone cement filling and internal fixation after extensive curettage is a viable strategy for accessing juxta-articular GCTs around the knee. The choice of local adjuvants, subchondral bone grafting, and the thickness of subchondral bone require more attention to preserve the continuity of articular cartilage.

Indocyanine green fluorescence imaging may detect tumour residuals during surgery for bone and soft-tissue tumours

The aim of this study was to determine the rate of indocyanine green (ICG) staining of bone and soft-tissue tumours, as well as the stability and accuracy of ICG fluorescence imaging in detecting tumour residuals during surgery for bone and soft-tissue tumours. ICG fluorescence imaging was performed during surgery in 34 patients with bone and soft-tissue tumours. ICG was administered intravenously at a dose of 2 mg/kg over a period of 60 minutes on the day prior to surgery. The tumour stain rate and signal-to-background ratio of each tumour were post hoc analyzed. After tumour resection, the tumour bed was scanned to locate sites with fluorescence residuals, which were subsequently inspected and biopsied. The overall tumour stain rate was 88% (30/34 patients), and specific stain rates included 90% for osteosarcomas and 92% for giant cell tumours. For malignant tumours, the overall stain rate was 94%, while it was 82% for benign tumours. The ICG tumour stain was not influenced by different pathologies, such as malignant versus benign pathology, the reception (or lack thereof) of neoadjuvant chemotherapies, the length of time between drug administration and surgery, the number of doses of denosumab for patients with giant cell tumours, or the tumour response to neoadjuvant chemotherapy. The overall accuracy rate of successfully predicting tumour residuals using fluorescence was 49% (23/47 pieces of tissue). The accuracy rate after en bloc resection was significantly lower than that after piecemeal resection (16% vs 71%; p < 0.001). A high percentage of bone and soft-tissue tumours can be stained by ICG and the tumour staining with ICG was stable. This approach can be used in both benign and malignant tumours, regardless of whether neoadjuvant chemotherapy is adopted. The technique is also useful to detect tumour residuals in the wound, especially in patients undergoing piecemeal resection.

En Bloc Resection With Reconstruction Using a Customized Megaprosthesis in a Case of Proximal Humerus Giant Cell Tumor: A Case Report

A giant cell tumor is a common, benign but locally aggressive bone tumor faced by orthopedic surgeons. The proximal humerus is a rare site of occurrence for this tumor, and the challenges posed while approaching such a case are discussed in this report of a 29-year-old male who presented with pain, swelling, and restricted motion at the left shoulder. Plain radiographs and MRI were suggestive of an aggressive giant cell tumor of the proximal humerus, which was confirmed on histopathological examination. Due to the lesion's extensive soft-tissue involvement, en-bloc resection with reconstruction was planned, but due to the COVID-19 pandemic, surgery was delayed. During the same period, the patient had trivial trauma to the same shoulder, following which the size of the lesion began increasing. The patient was operated on with en-bloc resection and reconstruction with a custom megaprosthesis; following the surgery, there was a complete resolution of pain and improvement in the range of motion. En bloc resection and replacement with a customized megaprosthesis, though technically demanding, offer a safe and cost-effective modality for limb salvage surgery for large giant cell tumors, with good functional outcomes and decreased chances of recurrence.

Role of denosumab before resection and reconstruction in giant cell tumors of bone: a single-centered retrospective cohort study

BACKGROUND

Denosumab has been approved by Food and Drug Authority in 2013 for use in surgically unresectable Giant cell tumor (GCT) to achieve resectable tumor margins. The aim of this study is to investigate the functional outcome and surgical convenience with the use of neoadjuvant denosumab before resection and reconstruction in Campanacci grade III GCT.

METHODS

We retrospectively reviewed 70 cases of Campanacci grade III GCT receiving resection and reconstruction between January 2014 and December 2019. They were stratified into two groups: one group of 29 patients received once-weekly denosumab 120 mg for 4-weeks before resection and reconstruction, while the other group of 41 patients did not receive denosumab before resection and reconstruction. Quality of life by musculoskeletal tumor society score where 0-7 means poor, 8-14 means fair, 15-22 means good; above 22 means excellent, incidence of tumor recurrence, intraoperative duration in minutes and postoperative positive margins were assessed for each cohort after 12 months follow-up.

RESULTS

There was no significant difference in musculoskeletal tumor society score (25.75 vs. 27.41; P  = 0.178), incidence of recurrence (3.45% vs. 4.88%; P  < 0.001), and postoperative positive margins (10.34% vs. 4.88%; P  = 0.38) for both groups. However, the intraoperative duration (133.38 vs. 194.49; P  < 0.001) was significantly higher in the non-denosumab group compared with denosumab group.

CONCLUSIONS

Neoadjuvant denosumab is equally effective considering postoperative functional outcomes and surgical convenience except intraoperative duration where it is highly helpful in saving the operating time duration. Easier identification, resection and lesser reconstruction are the key surgical convenience offered by neoadjuvant denosumab.