Giant cell tumor of bone: treatment and outcome of 214 cases

Giant cell tumor of bone: current treatment options

OPINION STATEMENT

Giant cell tumor of bone (GCTB) comprises up to 20 % of benign bone tumors in the US. GCTB are typically locally aggressive, but metastasize to the lung in ~5 % of cases. Malignant transformation occurs in a small percentage of cases, usually following radiation therapy. Historically, GCTB have been treated primarily with surgery. When the morbidity of surgery would be excessive, radiation therapy may achieve local control. In most cases the primary driver of the malignant cell appears to be a mutation in H3F3A leading to a substitution of Gly34 to either Trp or Leu in Histone H3.3. This change presumably alters the methylation of the protein, and thus, its effect on gene expression. The malignant stromal cells of GCTB secrete RANKL, which recruits osteoclast precursors to the tumor and stimulates their differentiation to osteoclasts. The elucidation of the biology of GCTB led to trials of the anti-RANKL monoclonal antibody denosumab in this disease, with a clear demonstration of beneficial clinical effect. Surgery remains the primary treatment of localized GCTB. When surgery is not possible or would be associated with excessive morbidity, denosumab is a good treatment option. The optimal length of treatment and schedule of denosumab is unknown, but recurrences after apparent complete responses have been observed after stopping denosumab, and long-term follow-up of denosumab treatment may reveal unrecognized effects. The role of denosumab in the preoperative or adjuvant setting will require clinical trials. In some cases local radiation therapy may be useful, although long term effects should be considered.

Prognostic impact of reduced connexin43 expression and gap junction coupling of neoplastic stromal cells in giant cell tumor of bone

Missense mutations of the GJA1 gene encoding the gap junction channel protein connexin43 (Cx43) cause bone malformations resulting in oculodentodigital dysplasia (ODDD), while GJA1 null and ODDD mutant mice develop osteopenia. In this study we investigated Cx43 expression and channel functions in giant cell tumor of bone (GCTB), a locally aggressive osteolytic lesion with uncertain progression. Cx43 protein levels assessed by immunohistochemistry were correlated with GCTB cell types, clinico-radiological stages and progression free survival in tissue microarrays of 89 primary and 34 recurrent GCTB cases. Cx43 expression, phosphorylation, subcellular distribution and gap junction coupling was also investigated and compared between cultured neoplastic GCTB stromal cells and bone marow stromal cells or HDFa fibroblasts as a control. In GCTB tissues, most Cx43 was produced by CD163 negative neoplastic stromal cells and less by CD163 positive reactive monocytes/macrophages or by giant cells. Significantly less Cx43 was detected in α-smooth muscle actin positive than α-smooth muscle actin negative stromal cells and in osteoclast-rich tumor nests than in the adjacent reactive stroma. Progressively reduced Cx43 production in GCTB was significantly linked to advanced clinico-radiological stages and worse progression free survival. In neoplastic GCTB stromal cell cultures most Cx43 protein was localized in the paranuclear-Golgi region, while it was concentrated in the cell membranes both in bone marrow stromal cells and HDFa fibroblasts. In Western blots, alkaline phosphatase sensitive bands, linked to serine residues (Ser369, Ser372 or Ser373) detected in control cells, were missing in GCTB stromal cells. Defective cell membrane localization of Cx43 channels was in line with the significantly reduced transfer of the 622 Da fluorescing calcein dye between GCTB stromal cells. Our results show that significant downregulation of Cx43 expression and gap junction coupling in neoplastic stromal cells are associated with the clinical progression and worse prognosis in GCTB.

Giant Cell Tumor Bone in an Elderly Male- an Unusual Case Misdiagnosed on MRI as a Malignant Sarcoma

Giant cell tumor (GCT) of the bone is a benign locally aggressive neoplasm which accounts for 3-8 % of all primary bone tumors. 60-70 % of the patients with giant cell tumor of the bone occur in the age group of 20-40 years. Patients older than 55 years of age very rarely develop GCT. Although many case series have been published on giant cell tumor of the bone, even on extensive search of literature, we found only a single series of 10 cases focusing exclusively on giant cell tumors in elderly. They observed that there was no difference in behavior of GCT in elderly and younger patients in terms of location of tumor, radiographic features and clinical course. We present a case of GCT of tibia in an elderly male without any evidence of malignant transformation or dedifferentiation, despite magnetic resonance imaging revealing features of a malignant lesion.

Unusual Presentation of Giant Cell Tumor in Skeletally Immature Patient in Diaphysis of Ulna

Giant cell tumor is a locally aggressive benign tumor. Giant cell tumor of bone is characteristically found in skeletally mature patient at the end of long bones in the epiphyseal region or epiphysio-metaphyseal region. Giant cell tumor is very rare in skeletally immature patient. But we are presenting a very rare case of giant cell tumor in skeletally immature patient in diaphyseal region which is very uncommon location for giant cell tumor. From this case we concluded that irrespective of the location and skeletal maturity, a giant cell tumor should be diagnosed based on its histology because classical clinical-radiological features are not always present. Index case strengthens this view.

Giant cell tumor of the lower end of tibia. Curettage and cement reconstruction

Bone giant cell tumor (GCT) is a rare, generally benign and locally aggressive tumor. It accounts for about 5% of all primary bone tumors and is located preferentially on the epiphyseal long bone. Ankle localization is rare. We present two cases of GCT of the lower end of tibia, presenting as gradually increasing pain and swelling in the tibial pilon over the course of 3 months. Standard radiology and MRI showed large eccentric, expansile lesion in the distal tibia with rupture of the cortex suggestive of a malignant tumor of the bone. A biopsy was performed which confirmed a GCT of bone. Curettage of the lesion and packing the cavity with bone cement resulted in disappearance of the tumor with good functional recovery. We conclude that intralesional curettage and cement packing is a good treatment option for Campanacci grade 2 and 3 GCT lesions of lower tibia.

Giant cell tumour of bone: new treatments in development

Giant cell tumour of bone (GCTB) is a benign osteolytic tumour with three main cellular components: multinucleated osteoclast-like giant cells, mononuclear spindle-like stromal cells (the main neoplastic components) and mononuclear cells of the monocyte/macrophage lineage. The giant cells overexpress a key mediator in osteoclastogenesis: the RANK receptor, which is stimulated in turn by the cytokine RANKL, which is secreted by the stromal cells. The RANK/RANKL interaction is predominantly responsible for the extensive bone resorption by the tumour. Historically, standard treatment was substantial surgical resection, with or without adjuvant therapy, with recurrence rates of 20–56 %. Studies with denosumab, a monoclonal antibody that specifically binds to RANKL, resulted in dramatic treatment responses, which led to its approval by the United States Food and Drugs Administration (US FDA). Recent advances in the understanding of GCTB pathogenesis are essential to develop new treatments for this locally destructive primary bone tumour.

Treatment for giant cell tumor of the spine metastasizing to the lung: A report of two cases and a literature review

Giant cell tumors of the bone (GCTB) account for 5% of all primary skeletal tumors. Although the tumors are normally benign, recurrence and metastasis of GCTB does occur. The most usual sites of a primary GCTB lesion are the distal femur and proximal tibia, and ~3% of these metastasize to the lung. Primary GCTB lesions in the spine are rare, and there have been few cases reporting the pulmonary metastasis of GCTB in the spine. The present study reports two cases of thoracic and sacral spinal GCTB lesions with pulmonary metastasis. One of the patients was a 45-year-old male who presented to hospital with gradually worsening pain in the left buttock during the last two years and was diagnosed with GCTB of the sacrum. The other patient was a 30-year-old female who complained of persistent back pain for a year and was also diagnosed with GCTB of the sacrum. Arterial embolization was performed prior to surgery and computer navigation was used during the surgery, resulting in the two patients achieving en bloc resection of their respective tumors, with satisfactory rehabilitation to follow.

GCT: What happened after 10 years of curettage and cement? Retrospective study of 46 cases

OBJECTIVE:

To compare the functional outcome of patients with and without arthrosis, and to determine whether the development of arthrosis is related to the distance of the tumor from the subchondral bone.

METHODS:

Forty six patients treated for Giant-cell tumor (GCT) between 1975 and 1999 met inclusion criteria. GCT was diagnosed by percutaneous biopsy and confirmed after resection, in all cases. Campanacci's and Kellgren's classification, the distance of the cement to the articular surface and MSTS score were obtained throughout the sample.

RESULTS:

The distance of the cement to the subchondral bone was associated with greater risk of developing arthrosis, but there was no difference in MSTS scores between patients with or without arthrosis.

CONCLUSION:

We found that the distance from the cement to the subchondral bone has a prognostic value regarding future arthrosis, but it does not impact on the functional outcome. Level of Evidence IV, Therapeutic Study

Giant cell tumour of the distal humerus: a case report

Giant cell tumour of the distal humerus is rare. We report one such case in a 30-year-old man who underwent wide resection of the tumour followed by total elbow arthroplasty using a cemented 'sloppy-hinged' total elbow prosthesis. At the 18-month follow-up, the patient had pain-free range of motion of 15º to 120º and no evidence of recurrence.

Local control of giant cell tumors of the long bone after aggressive curettage with and without bone cement

Background

Aggressive curettage has been well established for the treatment of giant cell tumors (GCTs) of the bone. The purpose of this study was to review our experience and evaluate the role of different implant materials in patients with GCTs of the extremities after aggressive curettage.

Methods

A total of 119 patients with GCTs of the long bone were treated at the First Affiliated Hospital of Sun Yat-Sen University between 2004 and 2009. We excluded patients presenting metastases, recurrent tumors, and soft tissue involvement and those with Jaffe pathological grade III. The remaining 65 patients were treated with aggressive curettage using a bone graft or bone cement to fill the cavity. The recurrence rates and functional scores associated with the different fillings were analyzed.

Results

Aggressive curettage and bone grafting was performed in 34 cases (52.3%), and aggressive curettage with bone cement was performed in 31 cases (47.7%). The overall recurrence rate after the aggressive intralesional procedures was 35.3% with bone grafting and 12.9% when bone cement was used as an adjuvant filling. The recurrence rate following aggressive curettage and bone grafting was higher than that following aggressive curettage with cement (p = 0.038). The Musculoskeletal Tumor Society (MSTS) score for bone graft patients was 91.1%, which was significantly lower than that for patients treated with bone cement (94.7%).

Conclusions

The use of bone cement was associated with a significantly lower recurrence rate than bone grafting following aggressive intralesional curettage to treat benign giant cell tumors of the long bone. Better MSTS functional results were also observed in the bone cement group compared to the bone graft group.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-330) contains supplementary material, which is available to authorized users.

[Giant cell tumour of bone: a series of 97 cases with a mean follow-up of 12 years]

PURPOSE

To describe our series of patients with giant cell tumour of bone with a long-term follow-up to show the results obtained with our treatment protocol.

MATERIAL AND METHODS

A total of 97 histologically confirmed giant cell tumour of bone were treated in our center between 1982 and 2009. The mean follow-up period was 12 years (2-27 years). The treatment received was determined by the radiological grade based on the Campanacci classification. The series consisted of 53 women (54.6%) and 44 men (54.4%) with a median age of 34.16 years (15-71 years). The data collected was focused on the clinical presentation, location, phase, extension, recurrences, and complications.

RESULTS

The treatment most used in Campanacci grades i and ii was intralesional excision with high velocity drilling and filling with a graft. In grades iii that could not be treated with the aforementioned method, it was decided to perform en bloc resection. An overall recurrence rate of around 25.8% was observed. Seven cases (7.2%) presented with a recurrence of the malignancy. The death rate at the end of follow-up was 2.1% (2 cases).

CONCLUSIONS

Curettage with a high-velocity drill and a bone graft in giant cell tumour of bone Campanacci grades i and ii obtain good results after long-term follow-up. Some grade iii giant cell tumour of bone that cannot be treated with this therapeutic option require en bloc resection and reconstruction.

Pulmonary metastasis of giant cell tumor of bones

Giant cell tumor of bone (GCTB) accounts for 5% of primary skeletal tumors. Although it is considered to be a benign lesion, there are still incidences of pulmonary metastasis. Pulmonary metastasis of GCTB may be affected by tumor grading and localization as well as the age, gender and overall health status of the patient. Patients with local recurrence are more likely to develop pulmonary metastasis of GCTB. High expression of some genes, cytokines and chemokines may also be closely related to the metastatic potential and prognosis of GCTB. The treatment of the primary GCTB is key to the final outcome of the disease, as intralesional curettage has a significantly higher local recurrence and pulmonary metastasis rate than wide resection. However, even patients with pulmonary metastasis seem to have a good prognosis after timely and appropriate surgical resection. It is hoped that with the development of novel surgical methods and drugs, pulmonary metastasis of GCTB can be prevented and treated more effectively.

Giant cell tumor of the distal phalanx of the great toe: a case report

Giant cell tumors are rarely seen in the foot. They can cause a significant amount of pain and deformity due to their aggressive and recurrent nature. We present the unusual case of a giant cell tumor of the distal phalanx of the hallux in a 39-year-old man.

LEVELS OF EVIDENCE

Therapeutic Level IV, Case Report.

The clinical approach toward giant cell tumor of bone

We provide an overview of imaging, histopathology, genetics, and multidisciplinary treatment of giant cell tumor of bone (GCTB), an intermediate, locally aggressive but rarely metastasizing tumor. Overexpression of receptor activator of nuclear factor κB ligand (RANKL) by mononuclear neoplastic stromal cells promotes recruitment of numerous reactive multinucleated giant cells. Conventional radiographs show a typical eccentric lytic lesion, mostly located in the meta-epiphyseal area of long bones. GCTB may also arise in the axial skeleton and very occasionally in the small bones of hands and feet. Magnetic resonance imaging is necessary to evaluate the extent of GCTB within bone and surrounding soft tissues to plan a surgical approach. Curettage with local adjuvants is the preferred treatment. Recurrence rates after curettage with phenol and polymethylmethacrylate (PMMA; 8%-27%) or cryosurgery and PMMA (0%-20%) are comparable. Resection is indicated when joint salvage is not feasible (e.g., intra-articular fracture with soft tissue component). Denosumab (RANKL inhibitor) blocks and bisphosphonates inhibit GCTB-derived osteoclast resorption. With bisphosphonates, stabilization of local and metastatic disease has been reported, although level of evidence was low. Denosumab has been studied to a larger extent and seems to be effective in facilitating intralesional surgery after therapy. Denosumab was recently registered for unresectable disease. Moderate-dose radiotherapy (40-55 Gy) is restricted to rare cases in which surgery would lead to unacceptable morbidity and RANKL inhibitors are contraindicated or unavailable.

Risk factors for recurrence of giant cell tumours of bone

PURPOSE

To determine the risk factors for recurrence of giant cell tumours (GCTs) of bone.

METHODS

Medical records of 29 men and 29 women (mean age, 34 years) treated for primary (n=53) or recurrent (n=5) GCTs of bone and followed up for a mean of 40.2 months were reviewed. The tumours were located in the distal femur (n=18), proximal tibia (n=10), proximal femur (n=8), distal radius (n=7), proximal fibula (n=4), distal ulna (n=3), calcaneum (n=3), sacrum (n=2), vertebra (n=1), metatarsal (n=1), and distal humerus (n=1). 26 patients had pathological fractures, 12 had cortical break, and 20 had neither. The Campanacci grades of the tumours were I (n=1), II (n=18), and III (n=33); the grades of the remaining 6 tumours were unknown because radiographs were unavailable. The Enneking stages of the tumours were 1 (n=51), 2 (n=6), and 3 (n=1). Treatment included curettage and cementation (n=29), curettage, cementation, and adjuvant treatment with distilled water or liquid nitrogen for bones without fracture (n=18), wide resection for extensive soft tissue involvement (n=9), and amputation (n=2) for a recurrent GCT of the distal femur and a primary GCT of the calcaneus. Reconstruction included cementation (n=27), bone grafting (n=7), cementation/bone grafting with internal fixation (n=14), reconstruction with endoprosthesis (n=3), and none (n=7).

RESULTS

19 patients had recurrence after a mean of 23.1 months. The overall recurrence-free survival at years 1, 2, and 3 were 86%, 79%, and 72%, respectively. Recurrence did not correlate with patient age (p=0.20), primary or recurrent tumour at presentation (p=0.12), Campanacci grade (p=0.10), Enneking stage (p=0.54), or presence of pathological fracture (p=0.28). Compared to GCTs at other locations, GCTs in the proximal tibia were more likely to recur (27% vs. 60%, p=0.04).

CONCLUSION

GCTs of the proximal tibia are more likely to recur than those at other locations.

In-depth analysis of local recurrence of giant cell tumour of bone with soft tissue extension after intralesional curettage

PURPOSE

The aim of this study was to assess the local recurrence rate of giant cell tumour of bone (GCTB) with soft tissue extension, to identify characteristics of the soft tissue extension that can best indicate recurrence of GCTB after intralesional curettage.

MATERIALS AND METHODS

A total of 48 cases of GCTB with soft tissue extension after intralesional curettage were recruited. Patients were divided into two groups based on various objective features of soft tissue extension including size, number, margins, involvement of adjacent tissues, signal intensity, static enhancement and Jaffe grade. The local recurrence rate was compared using the Chi-square test and Chi-square value correction for continuity. Risk factors were assessed by multivariate logistic regression analysis.

RESULTS

The local recurrence rate was significantly different according to soft tissue extension size, number and margins (p < 0.05). There was no significant difference in the groups of adjacent tissue involvement and Jaffe grade (p > 0.05). Size, number and margins of the soft tissue extension were independent risk factors of local recurrence of GCTB after intralesional curettage (p < 0.05).

CONCLUSIONS

The local recurrence rate of GCTB with soft tissue extension after intralesional curettage is higher if the soft tissue extension is large, multiple and lacking bone envelope integrity. For cases with the above-mentioned features, we suggest that the higher recurrence rate can be taken into full consideration when choosing appropriate surgical procedures.

Liquid nitrogen or phenolization for giant cell tumor of bone?: a comparative cohort study of various standard treatments at two tertiary referral centers

BACKGROUND

The rate of recurrence of giant cell tumor of bone is decreased by use of adjuvant treatments such as phenol, liquid nitrogen, or polymethylmethacrylate (PMMA) during curettage. We assessed recurrence and complication rates and functional outcome after curettage with use of phenol and PMMA, liquid nitrogen and PMMA, and liquid nitrogen and bone grafts.

METHODS

We retrospectively compared the relative effectiveness of treatment of giant cell tumors of bone at two tertiary centers with a regional function from 1990 to 2010. The 132 (of 201) patients who met the inclusion criteria had a mean age of thirty-three years (range, eleven to sixty-nine years). Treatment assignment depended purely on the center, with primary treatment consisting of curettage with use of phenol and PMMA (n = 82) at one center and with use of either liquid nitrogen and PMMA (n = 26) or liquid nitrogen and bone grafts (n = 24) at the other center. Recurrence and complication rates were determined, and functional outcome was assessed on the basis of the Musculoskeletal Tumor Society (MSTS) score.

RESULTS

The mean duration of follow-up was eight years (range, two to twenty-two years). Recurrence rates were comparable among the groups (28% for phenol and PMMA, 31% for liquid nitrogen and PMMA, and 38% for liquid nitrogen and bone grafts; p = 0.52). Soft-tissue extension increased the recurrence risk (hazard ratio [HR] = 2.1, 95% confidence interval [CI] = 1.1 to 4.0, p = 0.024). The complication rate was 33% after use of liquid nitrogen and bone grafts, 27% after liquid nitrogen and PMMA, and 11% after phenol and PMMA (p = 0.019); complications included osteoarthritis, infection, postoperative fracture, nonunion, transient nerve palsy, and PMMA leakage. The complication risk was increased by the presence of a pathologic fracture (HR = 4.1, 95% CI = 1.7 to 9.5, p = 0.001) and use of liquid nitrogen (HR = 3.9, 95% CI = 1.5 to 10, p = 0.006 for liquid nitrogen and bone grafts; HR = 3.1, 95% CI = 1.1 to 8.6, p = 0.028 for liquid nitrogen and PMMA). The mean MSTS score was 26 (range, 8 to 30) and was comparable among all three groups (p = 0.52).

CONCLUSIONS

Recurrence rates were comparable for treatment with phenol and PMMA, liquid nitrogen and PMMA, and liquid nitrogen and bone grafts. Complication rates were higher after use of liquid nitrogen. The functional outcome was excellent in all three cohorts.

Mid-term outcome after curettage with polymethylmethacrylate for giant cell tumor around the knee: higher risk of radiographic osteoarthritis?

BACKGROUND

It has been suggested that, when a patient has a giant cell tumor, subchondral bone involvement close to articular cartilage and a hyperthermic reaction from polymethylmethacrylate (PMMA) are risk factors for the development of osteoarthritis. We determined the prevalence, risk factors, and clinical relevance of osteoarthritis on radiographs after curettage and application of PMMA for the treatment of giant cell tumors around the knee.

METHODS

This retrospective single-center study included fifty-three patients with giant cell tumor around the knee treated with curettage and PMMA between 1987 and 2007. The median age at the time of follow-up was forty-two years (range, twenty-three to seventy years). There were twenty-nine women. Radiographic evidence of osteoarthritis was defined, preoperatively and postoperatively, as Kellgren and Lawrence grade 3 or 4 (KL3-4). We studied the influence of age, sex, tumor-cartilage distance, subchondral bone involvement (≤3 mm of residual subchondral bone), subchondral bone-grafting, intra-articular fracture, multiple curettage procedures, and complications on progression to KL3-4. Functional outcomes and quality of life were assessed with the Short Form-36 (SF-36), Musculoskeletal Tumor Society (MSTS) score, and Knee injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

After a median duration of follow-up of eighty-six months (range, sixty to 285 months), six patients (11%) had progression to KL3, two (4%) had progression to KL4, and one had preexistent KL4. No patient underwent total knee replacement. The hazard ratio for KL3-4 was 9.0 (95% confidence interval [CI] = 2.0 to 41; p = 0.004) when >70% of the subchondral bone was affected and 4.2 (95% CI = 0.84 to 21; p = 0.081) when the tumor-cartilage distance was ≤3 mm. Age, sex, subchondral bone-grafting, intra-articular fracture, multiple curettage procedures, and complications did not affect progression to KL3-4. Patients with KL3-4 reported lower scores on the KOOS symptom subscale (58 versus 82; p = 0.01), but their scores on the other KOOS subscales, the MSTS score (21 versus 24), and the SF-36 (76 versus 81) were similar to those for the patients with KL0, 1, or 2 (KL0-2).

CONCLUSIONS

Seventeen percent of patients with giant cell tumor around the knee had radiographic findings of osteoarthritis after treatment with curettage and PMMA. A large amount of subchondral bone involvement close to articular cartilage increased the risk for osteoarthritis. The function and quality of life of the patients with KL3-4 were comparable with those for the patients with KL0-2, suggesting that radiographic findings of osteoarthritis at the time of intermediate follow-up had a modest clinical impact. Treatment with curettage and PMMA is safe for primary and recurrent giant cell tumors, even large tumors close to the joint.

LEVEL OF EVIDENCE

Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.

Segmental composite porous scaffolds with either osteogenesis or anti-bone resorption properties tested in a rabbit ulna defect model

A functional biomaterial with a therapeutic effect is desirable as an adjuvant therapy to enhance bone formation and prevent local recurrence of bone tumours, especially when the resection margins are not identifiable. In this study, novel composite materials were developed with dual properties of osteopromotion and bone resorption to mimic the tumour inhibition effect, including water-soluble phosphorylated chitosan (P-chitosan) for increasing osteoblasts activity and disodium (1 → 4)-2-deoxy-2-sulphoamino-β-d-glucopyranuronan (S-chitosan) for inhibiting bone resorption activity. First, P-chitosan and S-chitosan were respectively incorporated into two kinds of PLGA/TCP-based scaffold, i.e. PLGA-TCP-P-chitosan (P/T/P-chitosan) and PLGA-TCP-S-chitosan (P/T/S-chitosan) scaffolds. We subsequently tested combined scaffolds of PLGA-TCP-P-S-P-chitosan (P/T/PSP-chitosan) made of P/T/P-chitosan and P/T/S-chitosan to assess their integral effect, on enhancement of bone formation with P/T/P-chitosan and inhibition of tissue regeneration with P/T/S-chitosan, in an established rabbit ulnar bone defect model to imitate bone resection post-bone tumour. To compare bone healing in the defects, the P/T/P-chitosan group was regarded as a bone formation enhancement group, while the P/T group served as a control. Bone mineral density (BMD) in the P/T/P-chitosan and P/T/PSP-chitosan groups were found to be significantly higher than those in the P/T group, while that in the P/T/P-chitosan group was greater than that in the P/T/PSP-chitosan group (p < 0.05). These findings demonstrated that P/T/PSP-chitosan scaffolds possessed more osteogenic potential than the P/T scaffold but less osteogenic effect than the P/T/P-chitosan scaffold, as the S-chitosan component inhibited the activities of osteoblasts for bone formation. These findings implied a dual function of the designed P/T/PSP-chitosan for further preclinical validation and potential applications in the prevention of local recurrence and for enhancing bone repair after bone tumour resection. Copyright © 2013 John Wiley & Sons, Ltd.

Management of Giant cell tumor occupying the 5th metacarpal bone in 6 years old child

Giant cell tumor of the bone (GCTOB) is a relatively uncommon tumor of the bone. It is characterized by the presence of multinucleated giant cells. Giant-cell tumor of the bone accounts for 4-5% of primary bone tumors and ∼20% of benign bone tumors. Giant cell tumors of the hand are rare, accounting for only 2–4% of all giant cell tumors.

Giant cell tumor (GCT) of the bones of the hand has some special features as compared to GCT at other sites. Because of the aggressive nature of this lesion, adequate assessment of the treatment method is required.

The aim is to eradicate the disease but preserve as much hand function as possible. Methods of treatment include curettage with or without bone grafts, local resection possibly combined with reconstruction using homologous or autologous bone, amputation, and resection of one or more rays.

Local recurrence after curettage treatment of giant cell tumors in peripheral bones: retrospective study by the GSF-GETO (French Sarcoma and Bone Tumor Study Groups)

BACKGROUND

Curettage is a well-established treatment modality for giant cell tumors of bone. The purpose of this retrospective study by the French Sarcoma and Bone Tumor Study Groups (GSF-GETO) was to analyze various tumor-specific and surgery-specific factors that could influence the rate of local recurrence.

PATIENTS AND METHOD

Data was collected from patients with giant cells tumors of the appendicular skeletal who were treated by intralesional curettage. The hazard ratio for tumor recurrence was calculated for the different variables collected and a multifactorial analysis carried out.

RESULTS

One hundred and ninety-three surgical procedures were included from nine centers. One hundred and seventy-one (89%) were primary tumors and 22 had been referred after one or more recurrences. The mean follow-up was 6 years and 11 months. The distal femur and proximal tibia were the most common locations: 42.5 and 34.2% of cases, respectively. The bone defect after curettage was filled in 176 cases (91.2%) and left empty in 16 cases. Local adjuvant treatment (phenol, alcohol, cryotherapy or combination treatment) was used in 39 cases (20.2%) and systemic adjuvant treatment used in 24 cases (calcitonin 11 and zoledronic acid 13). Local recurrence occurred in 71 cases (36.8%). Risk factors for local recurrence were an empty defect, a defect filled with autograft, and patients treated before 2005. Multivariate analysis showed that the only risk factors for local recurrence were a surgical procedure before 2005 (odds ratio 3.6 (95% CI: 1.2, 7.9) P=0.017) and a bone defect filled with autograft (odds ratio 3.9 [95% CI: 1.3, 11.6] P=0.013) CONCLUSION: Neither tumor-specific nor surgery-specific factors such as adjuvant treatment were found to be as risk factors for local recurrence after curettage of giant cell tumors in the appendicular skeleton. As recently reported, high-quality local curettage is probably the most effective technique to prevent local recurrence. The current study suggests that two factors associated with more recent management of these tumors in France, high-speed burring and centralization to skilled surgical teams, can improve the quality of curettage.

LEVEL OF EVIDENCE

4, retrospective cohort study.

Contemporary adjuvant polymethyl methacrylate cementation optimally limits recurrence in primary giant cell tumor of bone patients compared to bone grafting: a systematic review and meta-analysis

Background

Reports of recurrence following restructuring of primary giant cell tumor (GCT) defects using polymethyl methacrylate (PMMA) bone cementation or allogeneic bone graft with and without adjuvants for intralesional curettage vary widely. Systematic review and meta-analysis were conducted to investigate efficacy of PMMA bone cementation and allogeneic bone grafting following intralesional curettage for GCT.

Methods

Medline, EMBASE, Google Scholar, and Cochrane databases were searched for studies reporting GCT of bone treatment with PMMA cementation and/or bone grafting with or without adjuvant therapy following intralesional curettage of primary GCTs. Pooled risk ratios and 95% confidence intervals (CIs) for local recurrence risks were calculated by fixed-effects methods.

Results

Of 1,690 relevant titles, 6 eligible studies (1,293 patients) spanning March 2008 to December 2011 were identified in published data. Treatment outcomes of PMMA-only (n = 374), bone graft-only (n = 436), PMMA with or without adjuvant (PMMA + adjuvant; n = 594), and bone graft filling with or without adjuvant (bone graft + adjuvant; n = 699) were compared. Bone graft-only patients exhibited higher recurrence rates than PMMA-treated patients (RR 2.09, 95% CI (1.64, 2.66), Overall effect: Z = 6.00; P <0.001), and bone graft + adjuvant patients exhibited higher recurrence rates than PMMA + adjuvant patients (RR 1.66, 95% CI (1.21, 2.28), Overall effect: Z = 3.15, P = 0.002).

Conclusions

Local recurrence was minimal in PMMA cementation patients, suggesting that PMMA is preferable for routine clinical restructuring in eligible GCT patients. Relationships between tumor characteristics, other modern adjuvants, and recurrence require further exploration.

Giant cell tumours of the small bones of the hands and feet

Giant cell tumours (GCTs) of the small bones of the hands and feet are rare. Small case series have been published but there is no consensus about ideal treatment. We performed a systematic review, initially screening 775 titles, and included 12 papers comprising 91 patients with GCT of the small bones of the hands and feet. The rate of recurrence across these publications was found to be 72% (18 of 25) in those treated with isolated curettage, 13% (2 of 15) in those treated with curettage plus adjuvants, 15% (6 of 41) in those treated by resection and 10% (1 of 10) in those treated by amputation.

We then retrospectively analysed 30 patients treated for GCT of the small bones of the hands and feet between 1987 and 2010 in five specialised centres. The primary treatment was curettage in six, curettage with adjuvants (phenol or liquid nitrogen with or without polymethylmethacrylate (PMMA)) in 18 and resection in six. We evaluated the rate of complications and recurrence as well as the factors that influenced their functional outcome.

At a mean follow-up of 7.9 years (2 to 26) the rate of recurrence was 50% (n = 3) in those patients treated with isolated curettage, 22% (n = 4) in those treated with curettage plus adjuvants and 17% (n = 1) in those treated with resection (p = 0.404). The only complication was pain in one patient, which resolved after surgical removal of remnants of PMMA. We could not identify any individual factors associated with a higher rate of complications or recurrence. The mean post-operative Musculoskeletal Tumor Society scores were slightly higher after intra-lesional treatment including isolated curettage and curettage plus adjuvants (29 (20 to 30)) compared with resection (25 (15 to 30)) (p = 0.091). Repeated curettage with adjuvants eventually resulted in the cure for all patients and is therefore a reasonable treatment for both primary and recurrent GCT of the small bones of the hands and feet.

Cite this article: Bone Joint J 2013;95-B:838–45.

Cytotoxic effect and tissue penetration of phenol for adjuvant treatment of giant cell tumours

Local adjuvant treatment of giant cell tumours (GCTs) of the bone with phenol has led to a significant reduction in recurrence rates. In the current study, the optimal phenol concentration and duration of intralesional exposure were evaluated. Specimens of GCTs were exposed to various concentrations of phenol solution (6, 60 and 80%) for either 1 or 3 min. Following embedding in glutaraldehyde, the tumour cell layers were examined by transmission electron microscopy. Destroyed cell organelles indicated the penetration depth as a sign of denaturation. Incubation of GCT specimens with 6% phenol solution for 3 min resulted in the most tissue damage and the deepest tissue penetration of ∼200 μm. Incubation with 60 and 80% phenol solution reached a penetration depth of only ∼100 μm. Phenol instillation may be used for the treatment of small scattered cellular debris following intralesional curettage; however, it is not suitable for treatment of remaining solid tumour tissue of GCT. The use of high phenol concentrations has no benefit and increases the risk of local or systemic intoxication.

Giant cell tumor with pathologic fracture: should we curette or resect?

BACKGROUND

Approximately one in five patients with giant cell tumor of bone presents with a pathologic fracture. However, recurrence rates after resection or curettage differ substantially in the literature and it is unclear when curettage is reasonable after fracture.

QUESTIONS/PURPOSES

We therefore determined: (1) local recurrence rates after curettage with adjuvants or en bloc resection; (2) complication rates after both surgical techniques and whether fracture healing occurred after curettage with adjuvants; and (3) function after both treatment modalities for giant cell tumor of bone with a pathologic fracture.

METHODS

We retrospectively reviewed 48 patients with fracture from among 422 patients treated between 1981 and 2009. The primary treatment was resection in 25 and curettage with adjuvants in 23 patients. Minimum followup was 27 months (mean, 101 months; range, 27-293 months).

RESULTS

Recurrence rate was higher after curettage with adjuvants when compared with resection (30% versus 0%). Recurrence risk appears higher with soft tissue extension. The complication rate was lower after curettage with adjuvants when compared with resection (4% versus 16%) and included aseptic loosening of prosthesis, allograft failure, and pseudoarthrosis. Tumor and fracture characteristics did not increase complication risk. Fracture healing occurred in 24 of 25 patients. Mean Musculoskeletal Tumor Society score was higher after curettage with adjuvants (mean, 28; range, 23-30; n = 18) when compared with resection (mean, 25; range, 13-30; n = 25).

CONCLUSIONS

Our observations suggest curettage with adjuvants is a reasonable option for giant cell tumor of bone with pathologic fractures. Resection should be considered with soft tissue extension, fracture through a local recurrence, or when structural integrity cannot be regained after reconstruction.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Predictors of local recurrence in high-grade soft tissue sarcomas: hydrogen peroxide as a local adjuvant

Soft tissue sarcomas have a mortality rate of 40% to 60%, with local recurrence being a poor prognostic factor for overall survival. Three-percent nondiluted hydrogen peroxide is hypothesized to be an effective local adjuvant. The purpose of this study was to identify risk factors for local recurrence in high-grade soft tissue sarcomas and to determine whether using hydrogen peroxide as a local adjuvant reduced the risks of local recurrence and surgical-site infection. Retrospective data were collected for 106 patients surgically treated for high-grade soft tissue sarcomas between 2002 and 2010. The primary endpoint was local recurrence. Eighteen (16.98%) cases of local recurrence occurred. Predictors of local recurrence were margin status, estimated blood loss, and histology (ie, malignant peripheral nerve sheath tumor), with hazard ratios of 4.44 (95% confidence interval [CI], 1.32-14.95), 1.19 (95% CI, 1.06-1.35), and 9.21 (95% CI, 2.11-40.16), respectively. Hydrogen peroxide yielded a statistically insignificant improvement in local recurrence, with a hazard ratio of 0.81 (95% CI, 0.27-2.48) and a reduced risk of surgical site infection, with a hazard ratio of 0.52 (95% CI, 0.15-1.81). Margin status, increased blood loss, and histologic subtype are associated with increased local recurrence risk. Using hydrogen peroxide improved local control and infection rates, but the difference was not statistically significant.

Overexpression of hexokinase-2 in giant cell tumor of bone is associated with false positive in bone tumor on FDG-PET/CT

INTRODUCTION

The aim of the current study was to evaluate the usefulness of maximum standardized uptake value (SUV(max)) in 2-deoxy-2-F(18)-fluoro-D-glucose positron emission tomography combined with computed tomography (18F-FDG-PET/CT) for preoperative differential diagnosis between benign and malignant bone tumors.

MATERIALS AND METHODS

Seventy-nine patients with bone tumors were examined by FDG-PET prior to histopathological diagnosis. The SUV(max) was calculated and compared between benign and malignant lesions, and among different histopathological subgroups, to identify false-positive histological subtypes.

RESULTS

There was a statistically significant difference in the SUV(max) of benign (3.7 ± 3.3; n = 17) and malignant (5.3 ± 3.3; n = 62) bone tumors. However, receiver operating characteristic curve analysis revealed the poor accuracy of this distinction. The cut-off value was determined to be 2.6, while the value of sensitivity and specificity was calculated to be 74.2 and 64.7 %, respectively. Giant cell tumor of bone (9.0 ± 2.0; n = 5) displayed a higher SUV(max) than osteosarcoma (4.2 ± 2.3; n = 18). Immunohistochemical analysis demonstrated that markers of these cancers, hexokinase-2 (HK-2) and glucose transporter type 1 (GLUT-1), supported our findings.

CONCLUSION

The poor accuracy of SUV(max) in 18F-FDG-PET/CT in distinguishing malignant from benign bone tumors was confirmed; some benign bone tumors showed high FDG uptake. Giant cell tumor of bone was a major false-positive histopathological subtype of bone tumors, showing high FDG accumulation. HK-2 contributed significantly to FDG uptake, whereas GLUT-1 appeared to play no role in FDG uptake in giant cell tumor of bone.

Giant cell tumour of bone: a new evaluating system is necessary

Giant cell tumour (GCT) of bone is still one of the most obscure and intensively studied tumours of bone. The histogenesis of GCT remains unclear. The recommended therapy of GCT evolved during the 20th century. The best treatment should ensure local control and maintain function. Curettage has been the preferred treatment for most GCTs. Good results have also been published on the use of high-speed burr and local adjuvants. Local tumour control can be satisfactorily achieved by wide excision. However, treatment options for GCT have remained fairly static over the past 30 years and there is no widely held consensus regarding the standard treatment selection for all patients. This challenge may result from the fact that there are no single clinical, radiographic, histological or morphological aspects that allow surgeons to accurately predict the trend of a single lesion to recur. In this research, a comprehensive review of the previously described radiographic staging systems by Enneking and Campanacci et al. and the shortfalls associated with them are provided, and then the possible risk factors of predicting local recurrence or evaluating functional outcome of GCT are also discussed. A new preoperative evaluating system of GCT may be necessary and feasible, so that surgeons may accurately assess the aggressiveness or severity of GCT in order to reliably guide treatment decisions and predict outcomes.

Late malignant transformation of giant cell tumor of bone 41 years after primary surgery

Giant cell tumor of bone is an uncommon benign tumor that frequently recurs locally. Spontaneous malignant transformation of conventional giant cell tumor of bone is rare and usually occurs with irradiation.This article describes a case of malignant transformation of a giant cell tumor 41 years after initial curettage and subsequent resection. A 68-year-old man presented with a 6-month history of left hip pain. He had been diagnosed 41 years previously with giant cell tumor in the left femoral neck treated by simple curettage and bone grafting, followed by resection of the femoral head 1 year later for local recurrence. On presentation, radiographs revealed a destructive lesion in the left proximal femur. Incisional biopsy revealed recurrence of giant cell tumor with suspected malignant transformation. The patient underwent en bloc resection of the proximal femur with adequately wide margins and reconstruction of the hip joint with a prosthesis. Pathological findings showed malignant transformation of a giant cell tumor to osteosarcoma and leiomyosarcoma. No recurrence or metastasis developed during 2-year follow-up. Benign local recurrences usually arise in the first 3 postoperative years, whereas malignant transformation tends to take longer than 3 years. To the authors' knowledge, the 41-year interval from primary surgery to diagnosis of malignancy for the current patient is the longest interval reported among cases in which patients received no radiation therapy.

Which treatment is the best for giant cell tumors of the distal radius? A meta-analysis

BACKGROUND

Intralesional excision and en bloc resection are used to treat giant cell tumors (GCTs) of the distal radius. However, it is unclear whether one provides lower rates of recurrences and fewer complications, and whether the use of polymethylmethacrylate (PMMA) after curettage reduces the risk of recurrence.

QUESTIONS/PURPOSES

We examined whether curettage was associated with lower rates of recurrence and fewer major complications compared with en bloc excision, and whether PMMA resulted in lower rates of recurrence compared with a bone graft.

METHODS

We systematically searched the literature using the criteria, "giant cell tumor" AND "curettage" OR "intralesional excision" OR "resection". Six relevant articles were identified that reported data for 80 curettage cases (PMMA, n = 49; bone graft, n = 26; no PMMA or bone grafts, n = 5) and 59 involving en bloc excision. A meta-analysis was performed using these data.

RESULTS

Overall, patients in the intralesional excision group had a higher recurrence rate (relative risk [RR], 2.80; 95% CI, 1.17-6.71), especially for Campanacci grade 3 GCTs (RR, 4.90; 95% CI, 1.36-17.66), yet fewer major complications (RR, 0.21; 95% CI, 0.09-0.54) than the en bloc resection group. The use of PMMA versus bone graft did not affect the recurrence rate (RR, 0.98; 95% CI, 0.44-2.17).

CONCLUSIONS

Based on data obtained from the limited number of studies available, intralesional excision appears to be more appropriate for the treatment of local lesions (e.g., grades 1 and 2) than grade 3 GCTs of the distal radius. Moreover, PMMA was not additionally effective as an adjuvant.

LEVEL OF EVIDENCE

Level III, therapeutic study (systematic review). See Guidelines for Authors for a complete description of levels of evidence.

Giant-cell tumor of bone, anti-RANKL therapy

Giant-cell tumor of bone (GCTB) is a rare osteolytic tumor of the bone. Although classified as a benign tumor, GCTB is characterized by local aggressiveness and risk of local recurrence. In addition, GTCB can in some cases lead to the development of so-called 'benign' chest metastases. Surgical resection by intralesional curettage with high-speed burring and polymethylmethacrylate cement is the standard treatment for resectable tumors. In cases of metastatic or unresectable disease (when planned surgical procedure is impossible or would result in severe morbidity), medical treatments such as cytotoxic chemotherapy or interferon-α have limited efficacy. Bisphosphonates have been proposed as a therapeutic option to reduce osteoclast activity. In bone, various pathological states may result from an imbalance in the RANK (receptor activator of nuclear factor kappa-B)/RANKL (receptor activator of nuclear factor kappa-B ligand)/OPG (osteoprotegerin) pathway. Involvement of the RANKL pathway in pathogenesis of GCTB was first proposed in 2000. Denosumab is a fully human monoclonal antibody that binds and inhibits RANKL, thereby preventing the activation of the RANK pathway. As it showed the possibility to counteract osteoclast activation in GCTB and prevent the known physiopathological role of RANKL, denosumab has been under evaluation in the clinic as a treatment for GCTB since 2005. Results of a first Phase II trial demonstrate the therapeutic potential of denosumab to inhibit progressive bone destruction and metastatic progression in patients with unsalvageable giant-cell tumor (GCT), and have also provided key insights into the biology of GCT. Denosumab is currently a therapeutic option for patients with unresectable GCTB but its place in the global therapeutic strategy has not yet been defined.

Soft tissue extension increases the risk of local recurrence after curettage with adjuvants for giant-cell tumor of the long bones

BACKGROUND AND PURPOSE

Risk factors for local recurrence of giant-cell tumor of bone (GCTB) have mostly been studied in heterogeneous treatment groups, including resection and intralesional treatment. The aim of the study was the identification of individual risk factors after curettage with adjuvants in GCTB.

METHODS

Of 147 patients treated for primary GCTB between 1981 and 2009, 93 patients were included in this retrospective single-center study. All patients were treated with curettage and polymethylmethacrylate (PMMA) with (n = 75) or without (n = 18) phenol. Mean follow-up was 8 (2-24) years. Recurrence-free survival was assessed for treatment modalities. Age, sex, tumor location, soft tissue extension, and pathological fractures were scored for every patient and included in a Cox regression analysis.

RESULTS

The recurrence rate after the first procedure was 25/93. Recurrence-free survival for PMMA and phenol and for PMMA alone was similar. Eventually, local control was achieved using 1 or multiple intralesional procedures in 85 patients. Resection was required in 8 patients. A higher risk of local recurrence was found for soft tissue extension (HR = 5, 95% CI: 2-12), but not for age below 30, sex, location (distal radius vs. other), or pathological fracture.

INTERPRETATION

Curettage with adjuvants is a feasible first-choice treatment option for GCTB, with good oncological outcome and joint preservation. Soft tissue extension strongly increased the risk of local recurrence, whereas age, sex, location, and pathological fractures did not.

Modern interpretation of giant cell tumor of bone: predominantly osteoclastogenic stromal tumor

Owing to striking features of numerous multinucleated cells and bone destruction, giant cell tumor (GCT) of bone, often called as osteoclastoma, has drawn major attractions from orthopaedic surgeons, pathologists, and radiologists. The name GCT or osteoclastoma gives a false impression of a tumor comprising of proliferating osteoclasts or osteoclast precursors. The underlying mechanisms for excessive osteoclastogenesis are intriguing and GCT has served as an exciting disease model representing a paradigm of osteoclastogenesis for bone biologists. The modern interpretation of GCT is predominantly osteoclastogenic stromal cell tumors of mesenchymal origin. A diverse array of inflammatory cytokines and chemokines disrupts osteoblastic differentiation and promotes the formation of excessive multi-nucleated osteoclastic cells. Pro-osteoclastogenic cytokines such as receptor activator of nuclear factor kappa-B ligand (RANKL), interleukin (IL)-6, and tumor necrosis factor (TNF) as well as monocyte-recruiting chemokines such as stromal cell-derived factor-1 (SDF-1) and monocyte chemoattractant protein (MCP)-1 participate in unfavorable osteoclastogenesis and bone destruction. This model represents a self-sufficient osteoclastogenic paracrine loop in a localized area. Consistent with this paradigm, a recombinant RANK-Fc protein and bisphosphonates are currently being tried for GCT treatment in addition to surgical excision and conventional topical adjuvant therapies.

Giant cell tumor expanded into the thoracic cavity with spinal involvement

This article describes a case of a giant cell tumor that expanded into the thoracic cavity and through the spinal canal into the vertebrae. A 36-year-old man presented with a 6-month history of back pain and dyspnea. Plain chest radiographs showed a huge mass accompanied by right pleural effusion. The mass involved the 12th thoracic spine, and the spinal cord was severely compressed. The tumor was resected with a 2-stage procedure. As a first stage to separate the tumor from the anterior vital structures under direct vision, thoracic surgeons performed a right thoracotomy with chest wall reconstruction from the 8th to 11th ribs. The right lung and inferior vena cava were gently retracted, and the tumor was carefully detached from these structures. We were not able to separate the tumor from the right diaphragm due to severe invasion; therefore, we performed partial resection of the right diaphragm with the tumor. After excision of the anterior part of the tumor, the thoracic wall was reconstructed with the right eighth rib and Marlex mesh. When the patient's general condition improved 2 weeks later, spondylectomy by posterior approach was performed. We achieved excision of a giant cell tumor that had expanded into the thoracic cavity and through the spinal canal into the vertebrae. The patient had achieved full rehabilitation with no neurological or respiratory abnormalities at 7 years postoperatively.

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

BACKGROUND

There are no recent reports of giant cell tumors of bone in a large series of Chinese people. The present study was designed to review the epidemiological characteristics and outcomes of surgical management in a large series of Chinese patients with giant cell tumor of an extremity, treated at a single institution.

METHODS

The records and images of 621 patients in whom a benign giant cell tumor in an extremity was treated between 1989 and 2009 were reviewed retrospectively. There were 359 male and 262 female patients. The mean age at diagnosis was 31.4 years (range, eleven to seventy-one years). Sixty-six percent of the giant cell tumors were localized around the knee. Surgical treatments primarily included curettage, extensive curettage, and resection. The median duration of follow-up was forty-nine months (range, eighteen to 256 months).

RESULTS

Giant cell tumor accounted for 13.7% of all primary bone tumors treated at our institution. Multivariate Cox regression analysis indicated that the only variable that contributed to recurrence-free survival was the type of surgical treatment. The local recurrence rate after extensive curettage was 8.6%, which was significantly lower than the 56.1% recurrence rate after curettage alone. Bone-grafting did not affect local tumor control after extensive curettage; the local recurrence rate was 11.1% if bone graft was used. Recurrent giant cell tumor can be treated by further curettage or resection, with acceptable re-recurrence rates of 6.7% and 9.3% respectively. The Musculoskeletal Tumor Society Score for patients treated with extensive curettage was 92.6%, which was significantly higher than that for patients treated with resection. Twenty-one (3.4%) of the 621 patients developed benign pulmonary metastasis, with a favorable outcome, and three patients presented with multifocal giant cell tumors.

CONCLUSIONS

The incidence of giant cell tumor in the Chinese population may be higher than that in Western countries, and it has a male predilection. The results of the present study suggest that extensive curettage provides favorable local control and satisfactory functional outcomes.

[Giant cell tumours in a pyramidal bone: a clinical case and a review of the literature]

Giant cell tumours (GCT) of the bone are benign, but locally invasive tumours. We present a new case of carpus GCT, involving the triquetrum. The diagnosis required a prior biopsy before doing the block resection. This treatment is the best option to avoid recurrences. We review the literature on this particular lesion in the carpus bone.

Giant cell tumor of bone: are we stratifying results appropriately?

BACKGROUND

There is no consensus as to which surgical approach to the treatment of giant cell tumor of bone is most appropriate or which patients are at a higher risk for recurrence or metastasis.

QUESTIONS/PURPOSES

Therefore, we asked: (1) Are there subsets of patients who are associated with a more recalcitrant disease course? And (2) are surgeons appropriately stratifying patients by identifying risk factors for increased local recurrence and pulmonary metastases?

METHODS

We retrospectively reviewed the records of 230 patients with giant cell tumor of bone treated from 1980 to 2010, stratifying them by primary versus recurrent disease and by surgical treatment. From the records, we determined local recurrence, metastatic disease, and complications of treatment. The median follow up was 47 months (range, 0.1-312 months).

RESULTS

Overall incidence of local recurrence was 10% and pulmonary metastasis was 2%. When stratified by surgical treatment, the incidence of local recurrence among patients undergoing intralesional curettage (12%) was greater than in those undergoing resection (2%). The incidence of local recurrence among primary tumors, independent of treatment, was 9%, whereas the incidence of local recurrence after treatment of recurrent lesions was 16%. The incidence of pulmonary metastases was similar, regardless of treatment or whether primary or recurrent.

CONCLUSIONS

Our observations suggest there are subsets of patients with giant cell tumor of bone who are at higher risk of recurrence and should be clinically followed more closely. This should allow surgeons to provide patients with more informed expectations.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Epidermal growth factor receptor signalling contributes to osteoblastic stromal cell proliferation, osteoclastogenesis and disease progression in giant cell tumour of bone

AIMS

Epidermal growth factor receptor (EGFR) is implicated in bone remodelling. The aim was to determine whether EGFR protein expression contributes to the aggressiveness and recurrence potential of giant cell tumour of bone (GCTB), an osteolytic primary bone tumour that can exhibit markedly variable clinical behaviour.

METHODS AND RESULTS

Immunohistochemical analysis on tissue microarrays (TMA) of 231 primary, 97 recurrent, 17 metastatic and 26 malignant GCTBs was performed using TMA analysis software and whole digital slides allowing validated scoring. EGFR expression was restricted to neoplastic stromal cells and was significantly more frequent in recurrent (71 of 92; 77%) than in non-recurrent GCTBs (86 of 162; 53%) (P = 0.002); and in clinicoradiologically aggressive (31 of 43; 72%) than latent (27 of 54; 50%) cases (P = 0.034). Detecting phosphotyrosine epitopes pY1068 and -pY1173 indicated active EGFR signalling, and finding EGFR ligands EGF and transforming growth factor-α restricted to cells of the monocytic lineage suggested paracrine EGFR activation in stromal cells. In functional studies EGF supported proliferation of GCTB stromal cells, and the addition of EGF and macrophage-colony stimulating factor promoted osteoclastogenesis.

CONCLUSION

In GCTB, EGFR signalling in neoplastic stromal cells may contribute to disease progression through promoting stromal cell proliferation and osteoclastogenesis.

Giant cell tumors of the axial skeleton

Background. We report on 19 cases of giant cell tumor of bone (GCT) affecting the spine or sacrum and evaluate the outcome of different treatment modalities. Methods. Nineteen patients with GCT of the spine (n = 6) or sacrum (n = 13) have been included in this study. The mean followup was 51.6 months. Ten sacral GCT were treated by intralesional procedures of which 4 also received embolization, and 3 with irradiation only. All spinal GCT were surgically treated. Results. Two (15.4%) patients with sacral and 4 (66.7%) with spinal tumors had a local recurrence, two of the letter developed pulmonary metastases. One local recurrence of the spine was successfully treated by serial arterial embolization, a procedure previously described only for sacral tumors. At last followup, 9 patients had no evidence of disease, 8 had stable disease, 1 had progressive disease, 1 died due to disease. Six patients had neurological deficits. Conclusions. GCT of the axial skeleton have a high local recurrence rate. Neurological deficits are common. En-bloc spondylectomy combined with embolization is the treatment of choice. In case of inoperability, serial arterial embolization seems to be an alternative not only for sacral but also for spinal tumors.

Similar local control between phenol- and ethanol-treated giant cell tumors of bone

BACKGROUND

Giant cell tumors (GCTs) of bone often are treated with curettage, adjuvant therapy, and cementation. Phenol is a commonly used adjuvant associated with local control rates ranging from 9% to 25%. However, it is corrosive to the eyes, skin, and respiratory tract. Ethanol is readily available and does not cause chemical burns on contact, but it is unclear whether ethanol can achieve similar local control rates as phenol for treating GCTs.

QUESTIONS/PURPOSES

We evaluated (1) the recurrence rate and recurrence-free Kaplan-Meier survival function, (2) Musculoskeletal Tumor Society (MSTS) functional score (1993 version), and (3) complications of two groups of patients with GCTs treated with extensive curettage, local adjuvant therapy with phenol or ethanol, and cement reconstruction, to determine if ethanol was a reasonable alternative to phenol.

PATIENTS AND METHODS

We retrospectively reviewed all 26 patients with GCTs in the long bones of extremities treated with curettage, high-speed burring, phenolization, and cementation between May 1995 and November 2001, and 35 patients treated with the same protocol, except phenol was replaced with 95% ethanol, between November 2001 and November 2007. The recurrence rates, Kaplan-Meier recurrence-free survival curves, and MSTS functional scores of these two treatment groups were compared with Fisher's exact test, Tarone-Ware test, and Mann-Whitney U test, respectively. The minimum followup was 36 months (mean, 58 months; range, 36-156 months).

RESULTS

Local recurrence rates were similar in the two groups: 11% in the ethanol group and 12% in the phenol group. The survival curves (using local recurrence as an endpoint) of the two groups were similar. The mean MSTS functional score was 27.3 (91%) for the ethanol group and 26.9 (90%) for the phenol group.

CONCLUSIONS

Ethanol is a reasonable alternative to phenol when adjuvant therapy is considered in the treatment of GCTs of long bones.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Calcitonin use in giant cell bone tumors

INTRODUCTION

As osteoclast, giant cell tumors express calcitonin receptors. The aim of this paper is to assess treatment using salmon calcitonin after curettage.

MATERIAL AND METHODS

We retrospectively reviewed 25 patients with giant cell tumor of the appendicular skeleton treated with a single protocol of calcitonin administration following curettage in order to assess the effectiveness of calcitonin in reducing the rate of local recurrence.

RESULTS

The mean duration follow-up was 68 months. Thirteen patients (52%) had local recurrence. Eight of them were treated successfully after repeated curettage and calcitonin. Four patients had bone resection and one patient had curettage and cement filling. All patients with cavity left empty had ossified and the functional score as assessed by the MSTS score was 28.02/30.

CONCLUSION

This study suggests that the use of calcitonin as adjuvant is not effective and that filling agents are not required after curettage of giant cell tumors.

LEVEL OF EVIDENCE

Level 4.