Giant cell tumor of the thoracic spine completely removed by total spondylectomy after neoadjuvant denosumab therapy

Thoracic giant cell tumor after two total en bloc spondylectomies including one emergency surgery: A case report

BACKGROUND

For patients with acute paraplegia caused by spinal giant cell tumor (GCT) who require emergency decompressive surgery, there is still a lack of relevant reports on surgical options. This study is the first to present the case of an acute paraplegic patient with a thoracic spinal GCT who underwent an emergency total en bloc spondylectomy (TES). Despite tumor recurrence, three-level TES was repeated after denosumab therapy.

CASE SUMMARY

A 27-year-old female patient who underwent single-level TES in an emergency presented with sudden severe back pain and acute paraplegia due to a thoracic spinal tumor. After emergency TES, the patient's spinal cord function recovered, and permanent paralysis was avoided. The postoperative histopathological examination revealed that the excised neoplasm was a rare GCT. Unfortunately, the tumor recurred 9 months after the first surgery. After 12 months of denosumab therapy, the tumor size was reduced, and tumor calcification. To prevent recurrent tumor progression and provide a possible cure, a three-level TES was performed again. The patient returned to an active lifestyle 1 month after the second surgery, and no recurrence of GCT was found at the last follow-up.

CONCLUSION

This patient with acute paraplegia underwent TES twice, including once in an emergency, and achieved good therapeutic results. TES in emergency surgery is feasible and safe when conditions permit; however, it may increase the risk of tumor recurrence.

The efficacy and safety of short-course neoadjuvant denosumab for en bloc spondylectomy in spinal giant cell tumor of bone: a preliminary report

PURPOSE

This study aimed to investigate whether short course of neoadjuvant denosumab treatment for spinal GCTB could (1) Induce radiological and histological response? (2) Facilitate en bloc resection? (3) Achieve satisfactory oncological and functional outcomes?

METHODS

The clinical information of ten consecutive patients between 2018 and 2022 with spinal GCTB treated with short course of neoadjuvant denosumab (≤ 5 doses) and en bloc spondylectomy was retrospectively reviewed. The radiological and histological response, operative data, oncological and functional outcomes were analyzed.

RESULTS

The mean doses of neoadjuvant denosumab were 4.2 (range 3-5 doses). After neoadjuvant denosumab, there were 9 cases showing new ossification and 5 cases with reappearance of cortical integrity. The values of Hounsfield units (HU) of the soft tissue component were increased by > 50% in 7 cases. The signal intensity (SI) ratios of tumor/muscle in T2WI of plain MRI were decreased by > 10% in 60% of the cases. Shrinkage of soft tissue mass by > 10% was observed in 4 cases. The mean duration of operation was 575 ± 174 min, and the mean estimated blood loss (EBL) was 2790 ± 1934 ml. No obvious adhesion to dura mater or major vessels was encounter intraoperatively. There is no tumor collapse or breakage during surgery. Multinucleated giant cells were decreased in 6 cases (60%) with the remaining 4 cases showing absence of multinucleated giant cells. Mononuclear stromal cells existed in most of the cases (8 cases, 80%). New bone formation was noticed in 8 cases (80%). No patient had a worsening of neurologic function after surgery. No tumor recurrence was noticed within the mean follow-up of 24 ± 20 months.

CONCLUSION

Short-term neoadjuvant denosumab could yield radiological and histological responses and might facilitate en bloc spondylectomy by hardening the tumor and causing less adhesion to segmental vessels, major vessels and nerve roots, which was beneficial to achieve the optimal oncological and functional outcomes.

Revisiting En Bloc Resection Versus Piecemeal Resection for the Treatment of Giant Cell Tumor of the Spine

OBJECTIVE

Surgery for spinal giant cell tumors (GCTs) is challenging because these tumors often exhibit a poor clinical course owing to their locally aggressive features. This study aimed to investigate the prognostic factors of GCT recurrence in the spine by focusing on surgical factors.

METHODS

We retrospectively reviewed patients who underwent surgery for spinal GCTs between January 2005 and December 2016. Using the Kaplan-Meier method, surgical variables were evaluated for disease-free survival (DFS). Since tumor violation may occur at the pedicle during en bloc resection of the spine, it was further analyzed as a separate variable. Multivariate Cox proportional hazard regression analysis was performed for other clinical and radiographic variables. A total of 28 patients (male:female = 8:20) were included. The mean follow-up period was 90.5 months (range, 15-184 months).

RESULTS

Among the 28 patients, gross total resection (GTR) was the most important factor for DFS (P = 0.001). Any form of tumor violation was also correlated with DFS (P = 0.049); however, use of en bloc resection technique did not show a significant DFS gain compared to piecemeal resection (P = 0.218). In the patient group that achieved GTR, the mode of resection was not a significant factor for DFS (P = 0.959). In the multivariate analysis, the extent of resection was the only significant variable that affected DFS (P = 0.016).

CONCLUSIONS

Conflicting results on tumor violation from univariate and multivariate analyses suggest that GTR without tumor violation should be the treatment goal for spinal GCTs. However, when tumor violation is unavoidable, it would be important to prioritize GTR over adhering to en bloc resection.

Complications and prognosis of primary thoracic and lumbar giant cell tumors treated by total tumor resection

BACKGROUND

Spinal giant cell tumor (SGCT) is a relatively rare primary tumor. En bloc resection is the preferred surgical procedure for it due to its aggressiveness, meanwhile leading to more complications. We reported the characteristics of perioperative complications and local control of total tumor resection including en bloc resection and piecemeal resection for primary thoracic and lumbar spinal giant cell tumors in a single center over 10 years.

METHODS

This is a retrospective cross-sectional and cohort study. Forty-one consecutive patients with SGCTs who underwent total tumor resection from 2010 to 2020 at our institution and were followed up for at least 24 months were reviewed. Surgery data, complication characteristics and local tumor control were collected and compared by different surgical procedure.

RESULTS

Forty-one patients were included, consisting of 18 males and 23 females, with a mean age of 34.2 years. Thirty-one had thoracic vertebra lesions, and 10 had lumbar vertebra lesions. Thirty-five patients were primary cases, and 6 patients were recurrent cases. Eighteen patients were treated by total en bloc spondylectomy (TES), 12 patients underwent en bloc resection according to WBB surgical system, and 11 patients underwent piecemeal resection. The average surgical time was 498 min, and the mean estimated blood loss was 2145 ml. A total of 58 complications were recorded, and 30 patients (73.2%) had at least one perioperative complication. All patients were followed up after surgery for at least 2 years. A total of 6 cases had postoperative internal fixation failure, and 4 cases presented local tumor recurrence (9.8%).

CONCLUSIONS

Although the surgical technique is difficult and accompanied by a high rate of perioperative complications, en bloc resection can achieve favorable local control in SGCT. When it is too difficult to complete en bloc resection, thoroughly piecemeal resection without residual is also acceptable, given the relatively low recurrence rate.

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

STUDY DESIGN

Retrospective study.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Simple Summary

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

Abstract

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

Total en bloc spondylectomy is worth doing in complete paralysis spinal giant cell tumor, a minimum 1-year follow-up

OBJECTIVE

To investigate the neurological recovery of Frankel A spinal giant cell tumor (GCT) patients after they had received a Total En Bloc Spondylectomy (TES).

MATERIALS AND METHODS

We retrospectively recorded data of three patients (two females) with mobile spine GCT (T6, T10, and L2) Enneking stage III with complete paralysis before surgery, who had undergone TES in our institute from January 2018 to September 2020. The duration of neurologic recovery to Frankel E was the primary outcome. The intra-operative blood loss, operative time, operative-related complications, and the local recurrence were the secondary outcomes.

RESULTS

The duration of suffering from Frankel A to TES surgery was 2 months for the T6 patient, 3 weeks for the T10 patient, and 1 month for the L2 patient. Three patients had achieved full neurological recovery to Frankel E within 6 months after TES (T6 for 5 months, T10 for 3 months, and L2 for 3 months). The average blood loss was 2833.33 ml and the mean operative time was 400 min. Up until the last follow-up (13-25 months), no evidence of local recurrences had been found in any of the three patients.

CONCLUSION

Frankel A spinal GCT patients can achieve full neurological recovery after TES, if the procedure is performed within 3 months after complete paraplegia. TES can effectively control any local recurrences.

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.

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.

Multiprofessional Management of Giant Cell Tumors in the Cervical Spine: A Systematic Review

BACKGROUND

Giant cell tumors of the bone (GCTB) are rare bone tumors, especially in the cervical spine. Generally considered benign, local aggressiveness and metastatic growth have been described. Surgical concepts for GCTB are challenged by complex neurovascular anatomy. Specific clinical management guidelines are nonexistent. This systematic review aims to compile existing evidence on the treatment of GCTB of the cervical spine.

METHODS

Four electronic databases were searched: Medline, Embase, Web of Science, and Cochrane Library. All clinical studies reporting the treatment of GCTB in the human cervical spine in English language were found eligible for review.

RESULTS

Seven studies were included in the synthesis including a total number of 54 patients. Of those patients, 46 (85%) were treated for naive nonrecurrent GCTB. Only 1 study is considered a cohort study; all other studies were case reports. Generally, intralesional procedures were performed in 13 (24%) cases. Subtotal resections were reported for 11 (20%) patients. Twenty-eight (52%) patients were surgically treated with piecemeal resection, en-bloc resection, or spondylectomy. Thirty-six (67%) patients underwent adjuvant radiotherapy. A combination of radiotherapy and chemotherapy was reported in 2 (4%) cases. Bisphosphonates were prescribed for 9 (17%) patients. Inconsistent reporting of outcome data did not allow for comparative analyses.

CONCLUSIONS

Best available evidence suggests that the most aggressive surgical approach should be the main goal of any GCTB surgery. No specific adjuvant or neoadjuvant treatment can be recommended as superior due to a lack of comparative data. Therapeutic approaches need to be planned thoroughly on an individual basis.

The most appropriate titanium mesh cage size for anterior spinal reconstruction after single-level lumbar total en bloc spondylectomy: a finite element analysis and cadaveric validation study

Purpose

There is little information available regarding the cage diameter that can provide the most rigid construct reconstruction after total en bloc spondylectomy (TES). The aim of this study was thus to determine the most appropriate titanium mesh cage diameter for reconstruction after spondylectomy.

Methods

A finite element model of the single level lumbar TES was created. Six models of titanium mesh cage with diameters of 1/3, 1/2, 2/3, 3/4, 4/5 of the caudad adjacent vertebra, and 1/1 of the cephalad vertebra were tested for construct stiffness. The peak von Mises stress (MPa) at the failure point and the site of failure were measured as outcomes. A cadaveric validation study also conducted to validate the finite element model.

Results

For axial loading, the maximum stress points were at the titanium mesh cage, with maximum stress of 44,598 MPa, 23,505 MPa, 23,778 MPa, and 16,598 MPa, 10,172 MPa, 10,805 MPa in the 1/3, 1/2, 2/3, 3/4, 4/5, and 1/1 diameter model, respectively. For torsional load, the maximum stress point in each of the cages was identified at the rod area of the spondylectomy site, with maximum stress of 390.9 MPa (failed at 4459 cycles), 141.35 MPa, 70.098 MPa, and 88.972 MPa, 42.249 MPa, 15.827 MPa, respectively. A cadaveric validation study results were coincided with the finite element model results.

Conclusion

The most appropriate mesh cage diameter for reconstruction is 1/1 the diameter of the lower endplate of the adjacent cephalad vertebra, due to its ability to withstand both axial and torsional stress. According to the difficulty of large size cage insertion, a cage diameter of more than half of the upper endplate of the caudad vertebrae is acceptable in term of withstand stress. A cage diameter of 1/3 is unacceptable for reconstruction after total en bloc spondylectomy.

Denosumab Therapy for Giant-cell Tumor of the Lumbar Spine: A Case Report and Immunohistochemical Examination

Introduction

Denosumab, a monoclonal antibody that inhibits the receptor activator of nuclear factor-kappa (RANK) ligand, has been reported to reduce tumor size and progression, promote bone mineralization reconstruction, and increase bone density in patients with giant-cell tumor of bone (GCTB). However, information regarding the histopathological findings of spinal GCTB following denosumab therapy and the time course of the treatment is limited.

Case Report

We report the case of a 58-year-old woman with progressive low back pain for 3 months before admission. Radiological and histological examinations revealed L4 GCTB. The patients received 10 courses of denosumab, and the tumor was subsequently resected. The therapy resulted in reduction of tumor mass and replacement of the lesions with bone tissue, particularly at the extravertebral and intracanal mass lesions. Histological examination of resected vertebra revealed a notable decrease in the number of RANK-positive and cyclooxygenase-2-positive cells. However, few RANK-positive cells were present around the woven bone.

Conclusion

Denosumab therapy for spinal GCTB is effective for reducing the tumor stage, surgical complications, and neurological impairment progression; however, it does not lead to total elimination of GCT cells, and careful consideration is needed in terms of the surgical procedure and post-operative denosumab therapy.

Denosumab in the treatment of giant cell tumor of the spine. Preliminary report, review of the literature and protocol proposal

BACKGROUND

The interest on the role of Denosumab in the treatment strategy of giant cell tumor of the spine is growing. En bloc resection is considered the Enneking appropriate treatment, but morbidity and functional loss are sometimes unacceptable. Denosumab could play a role as a stand-alone treatment, but also as preoperative treatment or as postoperative after intralesional surgery.

MATERIALS AND METHODS

A cohort of 10 out of 12 cases of spinal GCT consecutively treated with Denosumab are analyzed and discussed compared to the cases reported in the literature. A staging of the radiological effect of the treatment is proposed.

RESULTS

The stand-alone and postoperative treatments are still running (12 to 88 months). One therapy was stopped after 15 months, once a satisfactory local effect was achieved, but the treatment had to be restarted 2 months later due to the recurrence of the erosive images. The new treatment was successful. At 1-year follow-up after the gross total excision followed by postoperative Denosumab treatment, no evidence of local recurrence was found. The preoperative treatment duration ranged from 3 to 24 months. No local recurrence followed the en bloc resections.

CONCLUSIONS

Denosumab alone is effective in relieving pain, increasing the ossification and sometimes reducing the tumor volume. It can be considered an excellent solution in spine GCTs whose surgical treatment cannot be Enneking appropriate or is associated with unacceptable morbidity or loss of functions. It is still impossible to state when to safely stop the treatment. Denosumab also plays a role as preoperative protocol. These slides can be retrieved under Electronic Supplementary Material.

Endothelin-1 Activates the Notch Signaling Pathway and Promotes Tumorigenesis in Giant Cell Tumor of the Spine

STUDY DESIGN

Experimental study.

OBJECTIVE

To examine the role of endothelin-1 (ET-1) and the Notch signaling pathway in giant cell tumor (GCT) of the spine.

SUMMARY OF BACKGROUND DATA

Previously published studies have shown that the Notch signaling pathway has a role in tumor invasion and that ET-1 is involved in tumor invasion and angiogenesis. However, the roles of both Notch signaling and ET-1 in GCT of the spine remain unknown.

METHODS

Expression of ET-1 in tissue samples from patients with spinal GCT, and adjacent normal tissue, were analyzed by immunohistochemistry and western blot. GCT stromal cells (GCTSCs) were isolated and ET-1 expression was demonstrated by immunofluorescence. Cell viability and cell migration of GCTSCs and human vascular endothelial cells following ET-1 treatment were assessed using the cell counting kit-8 assay and a transwell assay. Receptor activator of nuclear factor kappa-B ligand (RANKL) and osteoprotegerin (OPG) mRNA expression was determined following ET-1 treatment of GCTSCs using quantitative real-time polymerase chain reaction. In GCTSCs treated with ET-1 and the ET-1 signaling antagonist, BQ-123, levels of cyclin D1, vascular endothelial growth factor, matrix metalloproteinase-2 and -9 (MMP-2 and MMP-9), Jagged1, Hes1, Hey2, and Notch intracellular domain were examined by western blot.

RESULTS

Compared with normal adjacent tissue, ET-1 was highly expressed in GCT tissue. In GCTSCs studied in vitro, treatment with ET-1 significantly increased GCTSC and human vascular endothelial cells growth and migration and increased the expression of RANKL and OPG, meanwhile the ratio of RANKL/OPG was increased, in GCTSCs, it upregulated the production of cyclin D1, vascular endothelial growth factor, MMP-2, MMP-9, Jagged1, Hes1, Hey2, and Notch intracellular domain expression in a dose-dependent manner. Treatment with BQ-123 reversed these effects.

CONCLUSION

In GCT of the spine, ET-1 showed increased expression. In cultured GCTSCs, ET-1 treatment activated the Notch signaling pathway.

LEVEL OF EVIDENCE

2.

Three-Level Lumbar En Bloc Spondylectomy with Three-Dimensional-Printed Vertebrae Reconstruction for Recurrent Giant Cell Tumor

BACKGROUND

Primary malignancies involving the mobile spine often require total en bloc spondylectomy with complex mechanical reconstruction, which can be augmented with novel application of the 3-dimensional (3D)-printing technique.

CASE DESCRIPTION

A 51-year-old man presented with a 12-month history of progressive thigh pain and lower limb motor function loss, 36 months after T12-L4 instrumentation and fusion for giant cell tumor (GCT) of the L2 vertebrae before referral. The patient subsequently underwent successful curative management of recurrent GCT through denosumab treatment, L1-L3 total en bloc spondylectomy (TES), and a novel lumbopelvic reconstruction method with a 3D-printed lumbar vertebrae and screw-rod system.

CONCLUSIONS

To our knowledge, this is the first reported case of multilevel lumbar TES for GCT reconstructed using a 3D-printed vertebrae. Although TES-specifically in the lumbosacral spine-remains challenging due to its unique anatomy and increased risk of neurologic insult, it is an effective option for curative management of GCTs.

Giant cell tumor of the eleventh thoracic vertebra in a pediatric patient: an interesting case report and comprehensive literature review

INTRODUCTION

Giant cell tumors of the mobile spinal column are very rare tumors, especially in the pediatric age group. Although they are benign tumors, they have locally aggressive growth pattern and high risk of recurrence.

CASE PRESENTATION

We report a 15-year-old female patient with thoracic giant cell tumor who underwent percutaneous vertebroplasty and had cement extravasation into the spinal canal. Because of the deterioration of the patient's neurological condition, total enbloc spondylectomy and cement excision were performed. She underwent instrumentation and fusion procedures in order to prevent spinal instability.

CONCLUSION

The main purpose of the treatment is gross total resection of the giant cell tumor. However, adjuvant methods such as denosumab should be added to the treatment protocol in patients who are older than 2 years old and can not undergo gross total resection due to tumor size and anatomic localization.

Total Spondylectomy for Upper Thoracic Spine Giant Cell Tumor: A Case Report

Introduction

Giant cell tumors (GCT) are benign lesions that are generally locally aggressive tumors with occasional malignant behavior. These tumors are most frequently encountered in long bones; however, they also occur rarely in the spine. GCT of the spine are rare pathological entities, and spinal involvement shows a sacral predilection, with only a few cases involving the supra-sacral segment (mobile spine). Only a few cases of thoracic spinal GCT are reported in the literature; these tumors are particularly uncommon in the thoracic segment.

Presentation of Case

A 29-year-old man presented with a complaint of neck pain over the previous six months that radiated to his left hand. GCT of the upper thoracic spine was diagnosed, which was surgically managed using a 2-stage approach involving total resection of the tumor followed by spondylectomy and multilevel spinal fixation.

Discussion

Accurate diagnosis of vertebral column lesions, and choosing an optimum management plan are crucial. In the majority of cases, En-bloc resection of GCTs is not feasible ought to the close contact of the lesion with the spinal cord. Larger studies are encouraged to ascertain the efficacy of variable management approaches, particularly compared with piecemeal resection techniques.

Conclusion

Spinal GCT are a unique group of tumors with an uncommon and unexpected presentation. Although surgery is the mainstay of treatment for spinal GCT, the management of this tumor can be challenging. No clear management algorithm has been established, and the tumor displays an unpredictable course. Therefore, each case needs tailored treatment.

Total spondylectomy for Enneking stage III giant cell tumor of the mobile spine

PURPOSE

We reported the surgical outcomes of total en bloc spondylectomy (TES) with intralesional T-saw transpedicular osteotomy in patients with Enneking stage III spinal giant cell tumors (GCTs).

METHODS

The medical records and imaging and pathological studies of 25 consecutive patients with Enneking stage III spinal GCTs undergoing surgery at our institution who were followed for at least 2 years were retrospectively reviewed.

RESULTS

Eight men and 17 women (mean age: 34.2 years, range 16-51 years, at the time of surgery) were included. Six patients underwent previous tumor excision at another hospital, and one patient had a history of denosumab treatment. The GCTs were at the cervical, thoracic, and lumbar levels in three, nine, and 13 patients, respectively. TES was performed in 13 patients; 12 required intralesional pediculotomy. The remaining patients underwent total piecemeal spondylectomy with further intralesional tumor resection. During a mean follow-up of 99.2 months (range 24-216), two patients who underwent total piecemeal spondylectomy had local tumor recurrence, but no patients who underwent TES with intralesional pediculotomy had recurrence. The 2- and 10-year recurrence-free survival rates of patients treated with total piecemeal spondylectomy were 91.7% and 78.6%, respectively, while those of patients treated with TES were both 100%.

CONCLUSIONS

TES with intralesional pediculotomy had a good surgical outcome even in patients with Enneking stage III spinal GCT, suggesting that minimal intralesional procedures could radically cure spinal GCTs. These slides can be retrieved under Electronic Supplementary Material.