Recurrence after and complications associated with adjuvant treatments for sacral giant cell tumor

Giant cell tumor of femur with single pulmonary metastasis - yet another curative oligometastasis

ABSTRACT

Giant cell tumor of bone (GCT) is a benign tumor of bone that is known to be locally aggressive rarely metastasizing to distant sites, most commonly to the lungs. The reported pulmonary metastasis incidence is 1 - 9%. We report a case of GCT with solitary pulmonary metastasis who had significant clinical benefit and disease control with sequential application of surgical resection of pulmonary metastasis, local external beam radiation therapy (EBRT), and systemic Denosumab. We wish to highlight that even in metastatic GCT, there is significant clinical benefit in aggressive treatment.

The Rare Occurrence of Giant Cell Tumor of the Proximal Tibia With Pathological Fracture in an Elderly Male: A Case Report

Giant cell tumor of the bone (GCTB) is a benign bone tumor that can occasionally progress to malignancy, usually in chronic cases. It is a common benign and aggressive bone tumor that affects patients aged between 20 and 45 years. The most common location is the knee joint. It manifests as a painless or occasionally painful swelling over the affected area. A case of giant cell tumor (GCT) of the proximal tibia in a 72-year-old male is reported here, which was difficult to diagnose as it is rarely found in the geriatric age group. The patient came with a chief complaint of pain and swelling over his left knee for two months with a history of trauma to the knee a couple of times. On clinical examination, the patient had grade 3 tenderness and swelling on the anterolateral aspect of the knee extending toward the proximal tibia. The swelling was well-defined, smooth, firm, and uniform in consistency with dimensions of 15 cm × 12 cm. The swelling was moveable sideways, and the movement of the knee suggested that it was not attached to the underlying bone. As per the age and history of the rapid-growing lesion, we suspected malignancy, but clinical findings were pointing toward benign tumor. X-ray of the affected knee was done, which revealed a soft tissue mass with the involvement of the bone. Magnetic resonance imaging (MRI) of the knee revealed a soft tissue mass with the cortical breach. An open biopsy was done for the confirmation of the diagnosis, which was later reported and confirmed as a giant cell tumor of the proximal tibia. As bone tumor is associated with a cortical breach and pathological fracture, it was classified under Campanacci grade 3, for which an en bloc resection and open reduction and internal fixation with plate osteosynthesis with bone cementing and bone grafting were done followed by knee bending physiotherapy and gradual weight-bearing. Finally, the knee function was improved with pain relief.

Vertebra Plana: A Narrative Clinical and Imaging Overview among Possible Differential Diagnoses

Vertebra plana is a rare radiologic condition characterized by a uniform loss of height of a vertebral body that represents a diagnostic challenge for surgeons. The purpose of this study was to review all possible differential diagnoses that may present with a vertebra plana (VP) described in the current literature. For that purpose, we performed a narrative literature review in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, analyzing 602 articles. Patient demographics, clinical presentation, imaging characteristics and diagnoses were investigated. VP is not a pathognomonic feature of Langerhans cell histiocytosis, but other oncologic and non-oncologic conditions should be considered. The list of differential diagnoses, based on our literature review, can be recalled with the mnemonic HEIGHT OF HOMO: H-Histiocytosis; E-Ewing's sarcoma; I-Infection; G-Giant cell tumor; H-Hematologic neoplasms; T-Tuberculosis; O-Osteogenesis imperfecta; F-Fracture; H-Hemangioma; O-Osteoblastoma; M-Metastasis; O-Osteomyelitis, chronic.

Images of giant cell tumor and chondroblastoma around the knee: retrospective analysis of 99 cases

Background

It is difficult to differentiate giant cell tumors of the bone (GCTB) from chondroblastoma around the knee based on imaging findings. This study analyzed the imaging features of these 2 diseases for better differentiation.

Methods

This retrospective cross-sectional cohort study reviewed data of patients with pathologically confirmed GCTB (n=81; age 15-75 years; median age 33 years) and chondroblastoma (n=18; age 12-34 years; median age 14 years). In all, 18 imaging signs were analyzed.

Results

Patients with chondroblastoma were relatively younger than those with GCTB. On imaging, lesion length was significantly (P<0.00001) smaller in chondroblastoma [range, 15.80-78.30 mm; mean ± standard deviation (SD) 34.15±18.24 mm; 95% confidence interval (CI): 24.05-44.25 mm] than in GCTB [range, 30.10-117.50 mm; mean ± SD 59.73±15.28 mm; 95% CI: 56.24-63.22 mm]. Significantly more (P<0.05) chondroblastoma lesions had calcification (76.5% vs. 1.3%), lobulation (77.8% vs. 32.1%), and swelling range >15 mm (84.6% vs. 41.1%) than did GCTB lesions, whereas significantly more (P<0.05) GCTB lesions were greater than half the host bone diameter (74.1% vs. 16.7%) and had a lesion long axis that was consistent with that of the host bone (98.8% vs. 27.8%). There were no significant differences (P>0.05) between the 2 tumors in the remaining 11 imaging signs.

Conclusions

A narrow zone of transition, intratumor calcification, lobulation, tumor transverse diameter greater than the bone diameter, maximum lesion length, consistency between the tumor and bone long axes, and edema range around the lesion >15 mm are parameters that can be used to differentiate GCTB from chondroblastoma around the knee.

Malignant Brain and Spinal Tumors Originating from Bone or Cartilage

Malignant bone tumors affecting the brain and spine are a rare and exceedingly difficult-to-treat group of diseases. Most commonly consisting of chordoma and chondrosarcoma, these tumors also include giant-cell tumors and osteosarcomas. This chapter will cover the background, epidemiology, genetics, molecular biology, histopathology, radiographic features, clinical manifestations, therapeutic approaches, and clinical management of each entity.

Diagnosis and Treatment of Lumbar Giant Cell Tumor of the Spine: Update on Current Management Strategies

(1) Background: Giant Cell Tumor of the spine remains a difficult tumor to treat. Recent advances in adjuvant therapy such as denosumab and innovations in surgical technique in the last 5 years have given providers new options for treatment after a successful diagnosis of the tumor. (2) Methods: Articles published between 1927 and 2021 were selected from PubMed and Scopus searches using key words “Giant Cell Tumor” AND “Lumbar Spine” AND “Treatment”. Relevant articles were reviewed and selected by the authors. (3) Results: A total of 191 articles were discovered. Complete en bloc spondylectomy remains the most definitive treatment option; however, this surgery is challenging and carries a high rate of complication. New adjuvant therapies including denosumab offer a viable alternative to surgery. (4) En bloc spondylectomy remains the gold standard treatment for Giant Cell Tumor of the spine with the lowest published recurrence rate. The use of (neo)adjuvant denosumab improves recurrence rates. More data are needed to determine if denosumab alone is a viable standalone definitive treatment.

Intralesional nerve-sparing surgery versus non-surgical treatment for giant cell tumor of the sacrum

Background

There is no standard treatment for giant cell tumors of the sacrum. We compared the outcomes and complications in patients with sacral giant cell tumors who underwent intralesional nerve-sparing surgery with or without (neo-) adjuvant therapies versus those who underwent non-surgical treatment (denosumab therapy and/or embolization).

Methods

We retrospectively investigated 15 cases of sacral giant cell tumors treated at two institutions between 2005 and 2020. Nine patients underwent intralesional nerve-sparing surgery with or without (neo-) adjuvant therapies, and six patients received non-surgical treatment. The mean follow-up period was 85 months for the surgical group (range, 25–154 months) and 59 months (range, 17–94 months) for the non-surgical group.

Results

The local recurrence rate was 44% in the surgical group, and the tumor progression rate was 0% in the non-surgical group. There were two surgery-related complications (infection and bladder laceration) and three denosumab-related complications (apical granuloma of the tooth, stress fracture of the sacroiliac joint, and osteonecrosis of the jaw). In the surgical group, the mean modified Biagini score (bowel, bladder, and motor function) was 0.9; in the non-surgical group, it was 0.5. None of the 11 female patients became pregnant or delivered a baby after developing a sacral giant cell tumor.

Conclusions

The cure rate of intralesional nerve-sparing surgery is over 50%. Non-surgical treatment has a similar risk of complications to intralesional nerve-sparing surgery and has better functional outcomes than intralesional nerve-sparing surgery, but patients must remain on therapy over time. Based on our results, the decision on the choice of treatment for sacral giant cell tumors could be discussed between the surgeon and the patient based on the tumor size and location.

What's new in musculoskeletal oncology

We reviewed the recent literature related to primary musculoskeletal tumors and metastatic bone tumors. With regard to primary bone tumors, computer navigation systems and three-dimensional-printed prostheses seem to be new treatment options, especially in challenging anatomical locations, such as the sacrum and pelvis. Regarding the treatment of giant cell tumor of bone, recent studies have suggested that denosumab administration is related to a higher local recurrence rate following curettage, but a lower local recurrence rate following en bloc resection. In addition, there was no difference in the local recurrence rate at five years after surgery between short-term and long-term denosumab therapy. With regard to soft tissue tumors, percutaneous cryoablation appears to be a new treatment option for extra-abdominal desmoid tumors, with encouraging results. Regarding soft tissue sarcomas, a negative surgical margin of < 1 mm is sufficient to control local recurrence. Pexidartinib seems to be a promising systemic therapy for the treatment of tenosynovial giant cell tumors for which surgery is not expected to improve the function of the affected limb. Finally, the life expectancy of patients is the most important factor in determining the optimal surgical procedure for patients with impending or pathological fractures of the long bone due to metastatic bone tumors. Elevated C-reactive protein level was found to be an independent poor prognostic factor at 1 year after surgery for long bone metastases.

New Target for Precision Medicine Treatment of Giant-Cell Tumor of Bone: Sunitinib Is Effective in the Treatment of Neoplastic Stromal Cells with Activated PDGFRβ Signaling

Simple Summary

The purpose of this study was to analyze differential cell signaling in response to denosumab treatment to identify and subsequently inhibit molecular targets in the neoplastic stromal cell population, which poses a risk for tumor recurrence. Using phosphoprotein arrays, a distinct signaling profile was detected in GCTB tissues treated with denosumab, a specific RANKL antibody, which coincided with the RTK profile in derived cell lines. PDGFRβ was selected as a promising receptor target, and its inhibition by the small-molecule inhibitor sunitinib resulted in potent inhibition of cell proliferation in vitro. The addition of sunitinib to denosumab resulted in the disappearance of both multinuclear giant cells and neoplastic stromal cells, as reported here. Thus, sunitinib could become an effective addition to denosumab in the treatment of GCTB with activated PDGFRβ.

Abstract

Giant-cell tumor of bone (GCTB) is an intermediate type of primary bone tumor characterized by locally aggressive growth with metastatic potential. The aim of this study was to identify new druggable targets among the cell signaling molecules involved in GCTB tumorigenesis. Profiles of activated signaling proteins in fresh-frozen tumor samples and tumor-derived cell lines were determined using phosphoprotein arrays. Analysis of the obtained data revealed epidermal growth factor receptor (EGFR) and platelet-derived growth factor receptor beta (PDGFRβ) as potential targets, but only the PDGFR inhibitor sunitinib caused a considerable decrease in stromal cell viability in vitro. Furthermore, in the case of a 17-year-old patient suffering from GCTB, we showed that the addition of sunitinib to the standard treatment of GCTB with the monoclonal antibody denosumab resulted in the complete depletion of multinucleated giant cells and mononuclear stromal cells in the tumor tissue. To summarize, the obtained data showed that a specific receptor tyrosine kinase (RTK) signaling pattern is activated in GCTB cells and plays an important role in the regulation of cell proliferation. Thus, activated RTKs and their downstream signaling pathways represent useful targets for precision treatment with low-molecular-weight inhibitors or with other types of modern biological therapy.

Mid-term results of intralesional extended curettage, cauterization, and polymethylmethacrylate cementation in the treatment of giant cell tumor of bone: A retrospective case series

OBJECTIVE

The aim of this study was to present the mid-term functional outcomes and recurrence rate in patients with giant cell tumor of bone (GCTB) treated by intralesional extended curettage, electrocauterization, and polymethylmethacrylate (PMMA) cementation.

METHODS

In this retrospective observational study, 79 consecutive patients (41 females, 38 males; mean age=39 years; age range=19-62 years) who were diagnosed and treated for GCTB between 2005 and 2017 were identified from hospital medical records. All patients were treated by intralesional extended curettage using high-speed burr, electrocauterization of the cavity, and filling the defect with PMMA. No additional local adjuvants were used. The mean follow-up period was 47 months (range=24-96). The tumors were graded according to the radiological classification system described by Campanacci. Functional outcomes were evaluated using the Musculoskeletal Tumor Society Score (MSTS) preoperatively, one year postoperatively, and at the final follow-up. Postoperative complications and recurrence rates were recorded.

RESULTS

Twenty-nine tumors were located in the distal femur, 23 in the proximal tibia, nine in the distal radius, five in the proximal humerus, five in the pelvis, three in the proximal fibula, two in the distal ulna, two in the distal tibia, and one in the second metatarsal. According to Campanacci classification, 37 tumors were grade III, 32 grade II, and 10 grade I. The mean MSTS score was 46.1% (range 40.2 to 71.4%) preoperatively, 91.7% (range 73.3% to 100%) one year postoperatively, and 86.3 % (range 66.2% to 96,1%) at the final follow-up. The overall complication rate was 7.6%; which included local tumor recurrence in four patients, superficial wound infection in one, and deep wound infection in another. The recurrence rate was 5.1% (4 patients). Recurrent tumors were located at the distal femur in three patients and proximal tibia in one.

CONCLUSION

With satisfactory functional results and low recurrence rates at the mid-term follow-up, GCTB can be treated effectively with intralesional extended curettage, electrocauterization, and PMMA cementation.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Image-Guided Percutaneous Management of Skull and Spine Giant Cell Tumors: Case Report of 2 Challenging Cases Successfully Treated with Doxycycline Sclerotherapy

Background

A giant cell tumor (GCT) of bone is a benign, locally aggressive tumor that is often challenging to treat. When complete resection is not possible, curettage with or without adjuvants is the most common treatment. The high frequency of local recurrence and risk of injury to adjacent structures can limit this surgical approach, especially with skull and spine lesions.

Case Description

We report 2 cases of axial skeleton GCTs, 1 in the skull of a 58-year-old woman in whom operative management failed, who experienced local recurrence, and 1 in the cervical spine of an 8-year-old girl that grew extracompartmentally to surround her brachial plexus. Both patients were referred to us because of the surgically challenging nature of their tumors. After completion of the same percutaneous doxycycline sclerotherapy protocol previously described for aneurysmal bone cysts (ABCs), both patients were considered cured and were able to return to normal activities without loss of pretreatment function. After 4 and 10 years of follow-up, respectively, there has been no tumor recurrence in either patient.

Conclusions

We successfully treated 2 patients with very challenging axial skeleton GCTs using a percutaneous doxycycline sclerotherapy protocol previously shown to have success with ABCs. We believe that this minimally invasive procedure should be considered a potential alternative treatment for GCTs, especially axial skeleton lesions, which may not be easily approached with standard surgical techniques.

Plasma metabolite profiling reveals potential biomarkers of giant cell tumor of bone by using NMR-based metabolic profiles: A cross-sectional study

Giant cell tumor (GCT) of bone is a locally aggressive bone tumor, which accounts for 4% to 5% of all primary bone tumors. At present, the early diagnosis and postoperative recurrence monitoring are still more difficult due to the lack of effective biomarkers in GCT. As an effective tool, metabolomics has played an essential role in the biomarkers research of many tumors. However, there has been no related study of the metabolomics of GCT up to now. The purpose of this study was to identify several key metabolites as potential biomarkers for GCT by using nuclear magnetic resonance (NMR)-based metabolic profiles.Patients with GCT in our hospital were recruited in this study and their plasma was collected as the research sample, and plasma collected from healthy subjects was considered as the control. NMR was then utilized to detect all samples. Furthermore, based on correlation coefficients, variable importance for the projection values and P values of metabolites obtained from multidimensional statistical analysis, the most critical metabolites were selected as potential biomarkers of GCT. Finally, relevant metabolic pathways involved in these potential biomarkers were determined by database retrieval, based on which the metabolic pathways were plotted.Finally, 28 GCT patients and 26 healthy volunteers agreed to participate in the study. In the multidimensional statistical analysis, all results showed that there was obvious difference between the GCT group and the control group. Ultimately, 18 metabolites with significant differences met the selection condition, which were identified as potential biomarkers. Through Kyoto Encyclopedia of Genes and Genomes (KEGG) and Human Metabolome Database (HMD) database searching and literature review, these metabolites were found to be mainly correlated with glucose metabolism, fat metabolism, amino acid metabolism, and intestinal microbial metabolism. These metabolic disorders might, in turn, reflect important pathological processes such as proliferation and migration of tumor cells and immune escape in GCT.Our work showed that these potential biomarkers identified appeared to have early diagnostic and relapse monitoring values for GCT, which deserve to be further investigated. In addition, it also suggested that metabolomics profiling approach is a promising screening tool for the diagnosis and relapse monitoring of GCT patients.

A nonrandomized controlled study of sacral giant cell tumors with preoperative treatment of denosumab

The aim of this nonrandomized controlled study (level 3)was to evaluate whether preoperative denosumab treatment can reduce intraoperative blood loss, facilitate surgical treatment, and improve local control of sacral giant-cell tumor (GCT).Surgical treatment of sacral GCT is very difficult due to extensive bone destruction and complex anatomical structures. The huge intraoperative blood loss may interrupt surgical management and judgment of tumor range. Denosumab can inhibit the differentiation of osteoclast-like giant cells and bone destruction by blocking RANKL-RANK pathway.Study group (preoperative denosumab treatment) and control group (no denosumab treatment) were matched for age, gender, tumor site, staging, and tumor size. In study group, enhanced computed tomography (CT) was performed before and after denosumab treatment. The comparison parameters between 2 groups: CT enhancement rate, intraoperative blood loss, and oncologic outcome.The mean preoperative time of denosumab treatment was 5.2 months in study group. The mean CT enhancement rate of study group was 2.60 before treatment and 1.37 after treatment (P = .012). The posttreatment CT enhancement rate of study group was significantly lower than that of control group (P = .007). The mean intraoperative bleeding of study group and control group was 2166.7 and 5240 mL, respectively (P = .040). The mean operative time of study group and control group was 268.3 and 268.5 minutes, respectively (P = .997). The recurrence rate of study group (66.7%) was significantly higher than that of control group (0%) (P = .046).Preoperative denosumab treatment has the tendency to reduce blood supply and intraoperative bleeding of sacral GCT. But the sclerosis and bony separation can increase the difficulty of tumor curettage and lead to high recurrence rate after denosumab treatment. It is necessary to study the best surgical opportunity after denosumab treatment and precise method to judge tumor range.

Recurrence of Giant Cell Tumor of the Spine after Resection: A Report of 10 Cases

Objective

To review the clinical details and further treatments for recurrent spinal giant cell tumors (SGCT), and to analyze the risk factors of recurrence and shed new light on the treatment options and prognosis of recurrent SGCT.

Methods

A retrospective analysis of recurrent SGCT between April 2003 and January 2014 was performed. A total of 10 patients comprising 3 men and 7 women with a mean age of 28.9 years (range, 21–40 years) were included in the study. All complete clinical data, radiographs, CT, MRI, scans and pathological data were reviewed. The tumor locations and the regions involved were evaluated by CT and MRI. The blood supply of the tumors was evaluated by enhanced CT and MRI. The mean follow‐up was 81.3 months (range, 35.7–172.1 months).

Results

All patients had Enneking stage 3 tumors; 9 (90%) of them had different extents of spinal canal involvement in the primary time period. All patients underwent intralesional resection during their first surgery. Only 1 patient received local adjuvant treatments; no patient underwent selective arterial embolization or used denosumab at that time. Only 1 patient underwent adjuvant radiotherapy postoperatively, and another patient used bisphosphonates. After recurrence, 1 patient was cured using denosumab, and 2 patients' disease was controlled through use of other medical treatments or adjuvant treatments. There were 3 repeated recurrences and 7 repeated surgical procedures were performed in 5 patients. There were 6 intralesional excisions and 1 decompression surgery. The mean relapse‐free time after the first surgery was 32.3 months (range, 10.5–62.6 months). The overall mean relapse‐free time was 40.2 months (range, 10.5–157 months). No distant metastasis was found in our series. At the final follow‐up, 4 patients were disease free, 3 patients' disease was under control, 2 has progressive disease aggravation, while 1 patient died as a result of progression of disease 133.9 months after first surgery.

Conclusion

Intralesional excision for recurrent spinal giant cell tumors is an effective option that may have satisfactory prognosis. However, the excision and the inactivation of the lesion should be carried out carefully and thoroughly without missing any corners. Early diagnosis of recurrence may be associated with better prognosis. Adjuvant treatments perioperatively and systemic medical treatments can decrease recurrence rates and can have therapeutic effects in the recurrent SGCT.

Tumor de células gigantes espinal en niños. Reporte de dos casos. [Spinal giant cell tumor in children. Report of two cases]

El tumor de células gigantes espinal es una neoplasia de estirpe benigna y comportamiento local agresivo, de presentación rara en la población pediátrica. El dolor asociado al compromiso neurológico es la presentación típica en niños. La resección amplia del tumor y la descompresión de los elementos neurales asociada a fusión instrumentada permiten obtener una columna estable, preservar o restaurar la función neural y evitar la recidiva tumoral. Se presentan dos pacientes con tumor de células gigantes espinal en esqueleto inmaduro, sometidos a resección y estabilización mediante artrodesis instrumentada, sin recidiva en el posoperatorio alejado. La presentación clínica, la edad de los pacientes y los resultados quirúrgicos a largo plazo hacen de extremo valor el reporte de estos casos en esqueletos inmaduros.

Total spondylectomy of recurrent giant cell tumors in the cervical spine: Two case reports and review of literature

RATIONALE

Spinal Giant Cell Tumors (SGCTs) are rare, aggressive, and benign tumors. Their presence in the cervical spine is even more exceptional. There are few reports of cervical GCT in the literature, especially recurrent cases. The treatment are challenging to clinically because radical resection is extremely difficult.

PATIENT CONCERNS

In this study, we present the cases of a 25-year-old man and a 41-year-old woman who suffered from recurrent cervical GCT.

INTERVENTIONS

They underwent extensive total spondylectomy of C3-5 and C2-4, respectively, by a combined anterior and posterior approach.

OUTCOMES

Both patients had a satisfactory prognosis after 2 years followe-up, and extensive total spondylectomy provided good disease-free survival rates. Extensive total spondylectomy of cervical recurrent giant cell tumor was successfully achieved combined anterior and posterior approach.

LESSONS

This surgical technique can be an effective option for this pathological condition, which is difficult to manage using other conventional treatment options including repeated curettage and radiotherapy. However, there are insufficient data on long-term subjective outcomes in this type of patient, and larger series studies are needed to determine the efficacy of this approach, especially compared with piecemeal resection techniques.

Giant cell tumor of bone revisited

Giant cell tumor (GCT) of bone is a locally aggressive benign neoplasm that is associated with a large biological spectrum ranging from latent benign to highly recurrent and occasionally metastatic malignant bone tumor. It accounts for 4–10% of all bone tumors and typically affects the meta-epiphyseal region of long bones of young adults. The most common site involved is the distal femur, followed by the distal radius, sacrum, and proximal humerus. Clinical symptoms are nonspecific and may include local pain, swelling, and limited range of motion of the adjacent joint. Radiographs and contrast-enhanced magnetic resonance imaging (MRI) are the imaging modalities of choice for diagnosis. Surgical treatment with curettage is the optimal treatment for local tumor control. A favorable clinical outcome is expected when the tumor is excised to tumor-free margins, however, for periarticular lesions this is usually accompanied with a suboptimal functional outcome. Local adjuvants have been used for improved curettage, in addition to systematic agents such as denosumab, bisphosphonates, or interferon alpha. This article aims to discuss the clinicopathological features, diagnosis, and treatments for GCT of bone.

Giant cell tumour of bone in the denosumab era

Giant cell tumour of bone (GCTB) is an intermediate locally aggressive primary bone tumour, occurring mostly at the meta-epiphysis of long bones. Overexpression of receptor activator of nuclear factor kappa-B ligand (RANKL) by mononuclear neoplastic stromal cells promotes recruitment of numerous reactive multinucleated osteoclast-like giant cells, causing lacunar bone resorption. Preferential treatment is curettage with local adjuvants such as phenol, alcohol or liquid nitrogen. The remaining cavity may be filled with bone graft or polymethylmethacrylate (PMMA) bone cement; benefits of the latter are a lower risk of recurrence, possibility of direct weight bearing and early radiographic detection of recurrences. Reported recurrence rates are comparable for the different local adjuvants (27-31%). Factors increasing the local recurrence risk include soft tissue extension and anatomically difficult localisations such as the sacrum. When joint salvage is impossible, en-bloc resection and endoprosthetic joint replacement may be performed. Local tumour control on the one hand and maintenance of a functional native joint and quality of life on the other hand are the main pillars of surgical treatment for this disease. Current knowledge and development in the fields of imaging, functional biology and systemic therapy are forcing us into a paradigm shift from a purely surgical approach towards a multidisciplinary approach. Systemic therapy with denosumab (RANKL inhibitor) or zoledronic acid (bisphosphonates) blocks, respectively inhibits, bone resorption by osteoclast-like giant cells. After use of zoledronic acid, stabilisation of local and metastatic disease has been reported, although the level of evidence is low. Denosumab is more extensively studied in two prospective trials, and appears effective for the optimisation of surgical treatment. Denosumab should be considered in the standard multidisciplinary treatment of advanced GCTB (e.g. cortical destruction, soft tissue extension, joint involvement or sacral localisation) to facilitate surgery at a later stage, and thereby aiming at immediate local control. Even though several questions concerning optimal treatment dose, duration and interval and drug safety remain unanswered, denosumab is among the most effective drug therapies in oncology.

Long-term administration of bisphosphonate to reduce local recurrence of sacral giant cell tumor after nerve-sparing surgery

OBJECTIVE The objective of this study was to investigate the effect of long-term bisphosphonate treatment on reducing local recurrence of sacral giant cell tumors (GCTs) after nerve-sparing surgery. METHODS Thirty-five consecutive patients with sacral GCTs who received treatment in Shanghai Changzheng Hospital between January 2000 and December 2010 were included in this study. Between January 2007 and December 2010, 19 patients received bisphosphonates following nerve-sparing surgery. Before January 2007, 16 patients received nerve-sparing surgery alone, and these cases were included as the control group. The difference in clinical data between the groups was compared by Student's t-test and 2-tailed chi-square or Fisher's exact test. The postoperative recurrence-free survival (RFS) and overall survival (OS) rates were estimated by the Kaplan-Meier method and compared between the groups by log-rank test. A p value < 0.05 was considered statistically significant. RESULTS All of the patients had relatively good nerve function. The clinical data were homogeneous between the groups. The local recurrence rate was 10.53% (2 of 19) in the bisphosphonate treatment group and 43.75% (7 of 16) in the control group. The log-rank test showed that the 3-year RFS and 3-year OS in the bisphosphonate treatment group were significantly higher than those in the control group (RFS 89.5% vs 56.3%, p = 0.04; OS 100% vs 81.3%, p = 0.05). CONCLUSIONS The long-term use of bisphosphonates after nerve-sparing surgery is a viable option for the treatment of sacral GCTs. This approach could reduce local recurrences while preserving nerve function.

Successful treatment with denosumab in a patient with sacral giant cell tumor of bone refractory to combination therapy with arterial embolization and zoledronic acid: A case report

Giant cell tumor of bone (GCTB) is commonly treated with surgery; however, surgery of GCTB in the sacrum may be challenging due to the associated risk. A conservative approach may be selective arterial embolization or zoledronic acid (ZOL) treatment; however, there are currently no studies investigating the efficacy of combining these two treatments. Denosumab may also be used; however, to the best of our knowledge, there are no reports of a stepwise approach for the use of all three treatments in a single patient. We herein present such a case. A 32-year-old woman diagnosed with sacral GCTB was treated with selective arterial embolization for 3 months. No improvement was observed, and monthly infusions of ZOL were added (administered 2 weeks after each arterial embolization treatment). Ten months after the initiation of ZOL, there was still no improvement. The therapy was changed to denosumab 120 mg, injected subcutaneously once a month. By the third dose, the buttock pain had decreased and the patient became ambulatory. At 5 and 10 months, computed tomography scans revealed bone sclerosis gradually appearing around the sacrum. By 1 year, needle biopsy detected no neoplastic cells. At that point, the patient discontinued treatment, as there was hepatic function impairment due to a history of hepatitis B. Despite treatment discontinuation, the patient exhibited no further symptoms, there were no signs of progression on radiography, and surgery was not required. Our patient experienced treatment failure with selective arterial embolization. The combination of ZOL with selective arterial embolization also did not improve the patient's condition. Denosumab was found to be superior to both treatments, achieving tumor remission. The patient remains symptom- and disease-free. Further studies are required, but our results suggest that patients with unresectable GCTB who fail to respond to selective arterial embolization may benefit from denosumab treatment, but not from combination therapy with selective arterial embolization and ZOL.

Benign Tumors of the Spine: Has New Chemotherapy and Interventional Radiology Changed the Treatment Paradigm?

STUDY DESIGN

Clinically based systematic review.

OBJECTIVE

To determine the role of (A) medical treatment and (B) interventional radiology as either adjuvant or stand-alone treatment in primary benign bone tumors of the spine.

METHODS

A multidisciplinary panel of spine surgeons, radiation oncologists, and medical oncologists elaborated specific focused questions regarding aneurysmal bone cyst, giant cell tumor, and osteoid osteoma. Denosumab, bisphosphonate, interferon, bone marrow aspirate, doxycycline, thermal ablation, and selective arterial embolization were identified as areas of interest for the article. A systematic review was performed through MEDLINE and EMBASE. Recommendations based on the literature review and clinical expertise were issued using the GRADE system.

RESULTS

The overall quality of the literature is very low with few multicenter prospective studies. For giant cell tumor, combination with Denosumab identified 14 pertinent articles with four multicenter prospective studies. Nine studies were found on bisphosphonates and six for selective arterial embolization. The search on aneurysmal bone cyst and selective arterial embolization revealed 12 articles. Combination with Denosumab, Doxycycline, and bone marrow aspirate identified four, two, and three relevant articles respectively. Eleven focused articles were selected on the role of thermal ablation in osteoid osteoma.

CONCLUSION

Alternative and adjuvant therapy for primary benign bone tumors have emerged. Their ability to complement or replace surgery is now being scrutinized and they may impact significantly the algorithm of treatment of these tumors. Most of the data are still emerging and further research is desirable. Close collaboration between the different specialists managing these pathologies is crucial.

LEVEL OF EVIDENCE

N/A.

Wide resection versus curettage with adjuvant therapy for giant cell tumour of bone

PURPOSE

To determine the association between type of surgery (wide resection versus curettage with adjuvant therapy) and outcome in patients with giant cell tumour (GCT) of bone.

METHODS

Records of 30 male and 52 female consecutive patients aged 10 to 62 years who underwent wide resection (n=57) or curettage with adjuvant therapy (n=25) for primary GCT of bone were reviewed. The surgical decision was based on patient age, tumour location, functional demand, and patient preference. The median tumour size was 8.5 cm. Tumours were classified as stage 1 (n=4), stage 2 (n=60), and stage 3 (n=18), and 25%, 68.3%, and 83.3% of them were treated with wide resection, respectively. Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) score; the maximum score was 30.

RESULTS

The wide resection and curettage with adjuvant therapy groups were comparable in terms of patient age, gender, tumour size, location, symptoms, tumour stage, type of biopsy, and MSTS score. The MSTS score was excellent in 50.2% of patients, good in 38.7% of patients, and fair and poor in the remaining patients. The MSTS score was not associated with tumour stage or type of surgery. Four patients in the wide resection group had metastasis to the lung. They also had lower haemoglobin level (10.6 vs. 12.7 g/dl, p=0.020) and higher percentage of stage-3 tumour (100% vs. 17.9%, p=0.001) but had no recurrence (0% vs. 6.4%, p=0.774), compared with those without metastatsis. All died from massive haemoptysis and respiratory failure. Eight patients died; their haemoglobin level was lower than that of patients who were still living (11.2 vs. 12.7 g/dl, p=0.032). Mortality was associated with metastasis (100% vs 5.2%, p<0.001) but not recurrence or complication. Two patients in each group had recurrence; recurrence was not associated with type of surgery.

CONCLUSION

There was no association between type of surgery and tumour recurrence, metastasis, or outcome. Curettage with adjuvant therapy was more commonly performed for stage 1 and 2 tumours, whereas wide resection was more for stage 3 tumours. Metastasis was associated with stage 3 tumour and mortality but not recurrence.

Interest of Denosumab for the Treatment of Giant-cells Tumors and Aneurysmal Bone Cysts of the Spine. About Nine Cases

STUDY DESIGN

A prospective cohort study.

OBJECTIVE

The aim of this study was to evaluate the interest of denosumab in the treatment of spinal giant-cells tumors (GCTs) and aneurysmal bone cysts (ABCs).

SUMMARY OF BACKGROUND DATA

To treat GCTs and ABCs, surgical resection remains the best treatment to limit local recurrence (LR) but constitutes an aggressive treatment with potential morbidity. Denosumab, a human antibody anti-RankL, inhibiting the differentiation of osteoclasts, could be an alternative treatment to avoid aggressive surgery.

METHODS

Patients suffering from GCTs and ABCs of the spine were included. Patients received a monthly subcutaneous injection of denosumab (120 mg) during a minimum of 6 months either as a neoadjuvant or as an adjuvant therapy. In association with denosumab, an osteosynthesis was added in case of vertebral fracture and a laminectomy in case of spinal cord compression. Clinical and computed tomography (CT)-scan outcomes were analyzed.

RESULTS

Eight GCTs and one ABC were included. The mean age was 35 years (range: 22-55 yr). Five patients had neurologic deficit. All patients were operated: six osteosynthesis, one "en bloc" resection, four curettages, and two of them associated with an osteosynthesis. Average duration of denosumab therapy was 12.9 months (range: 3.2-24 months). Among them, four patients began denosumab 6 months at least before the surgery. With a mean follow-up of 19.3 months (range: 3.2-52.4 months), back pain and neurologic deficit improved for all patients. Systematic CT-scan at 6 months showed decrease of tumor size and bone consolidation. Regarding patients treated by neoadjuvant denosumab treatment, intraoperative histologic analysis showed an absence of giant cells and a maximum of 10% of alive tumor cells.

CONCLUSION

Denosumab allows bone formation and tumor regression with a maximum efficacy after 6 months of treatment without widely substituting surgery. Long-term results are mandatory to confirm the interest of denosumab and to evaluate LR when stopping denosumab.

LEVEL OF EVIDENCE

3.

Management of spinal giant cell tumors

BACKGROUND CONTEXT

Spinal giant cell tumors (SGCT) remain challenging tumors to treat. Although advancements in surgical techniques and adjuvant therapies have provided new options for treatment, evidence-based algorithms are lacking.

PURPOSE

This study aims to review the peer-reviewed literature that addresses current treatment options and management of SGCT, to produce an evidence-based treatment algorithm.

STUDY DESIGN/SETTING

A systematic review was performed.

METHODS

Articles published between January 1, 1970 and March 31, 2015 were selected from PubMed and EMBASE searches using keywords "giant cell tumor" AND "spine" AND "treatment." Relevant articles were selected by the authors and reviewed.

RESULTS

A total of 515 studies were identified, of which 81 studies were included. Complete surgical resections of SCGT resulted in the lowest recurrence rates. However, morbidity of en bloc resections is high and in some cases, surgery is not possible. Intralesional resection can be coupled with adjuvant therapies, but evidence-based algorithms for use of adjuvants remain elusive. Several recent advancements in adjuvant therapy may hold promise for decreasing SGCT recurrence, specifically stereotactic radiotherapy, selective arterial embolization, and medical therapy using denosumab and interferon.

CONCLUSIONS

Complete surgical resection of SGCT should be the goal when possible, particularly if neurologic impairment is present. Denosumab holds promise as an adjuvant and perhaps stand-alone therapy for SGCT. Spinal giant cell tumors should be approached as a case-by-case problem, as each presents unique challenges. Collaboration of spine surgeons, radiation oncologists, and medical oncologists is the best practice for treating these difficult tumors.

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

A giant-cell tumor of the bone (GCTB) is a benign but locally aggressive bone tumor. Recently, the receptor activator of nuclear factor κB (RANK) ligand inhibitor, denosumab, has demonstrated activity against giant-cell tumors. The current study reports a case of a sacral GCTB with lung metastasis. A 19-year-old male patient presented with right buttock pain and right lower leg pain, and a sacral GCTB was diagnosed based on the histological analysis of a biopsy specimen. The patient was successfully treated with neoadjuvant denosumab therapy, which allowed curettage. In addition, the pulmonary nodule reduced in size following denosumab administration, and surgical resection was performed. Since the operation, the patient has been managed with the continued use of denosumab with no sign of recurrence. Microscopic findings from the surgical specimen following denosumab treatment revealed that the giant cells had disappeared and woven bone had formed. The specimen from the pulmonary nodule exhibited similar findings to the surgical specimen. It was reported that denosumab treatment was able to reduce the number of giant cells and RANK-positive stromal cells, and cause the formation of new bone in the primary lesion. The present study reports the first case to demonstrate the efficiency of denosumab in treating pulmonary metastasis of GCTB.

Denosumab, a Potential Alternative to the Surgical Treatment of Distal Radius Giant Cell Tumor of Bone: Case Report

Juxta-articular giant cell tumors can pose major surgical challenges. Aggressive distal radius giant cell tumors often require complex reconstructive procedures that are associated with numerous complications. We present a case of a 25-year old man with a Campanacci grade 3 giant cell tumor of the distal radius that was successfully treated with denosumab without complex reconstructive procedures. At 3.5-year follow-up and 1-year drug free period, the patient remained asymptomatic without histologic evidence of recurrent tumor. With denosumab therapy, patients can potentially avoid surgery and achieve a successful outcome.

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.

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.

Giant cell tumors of the sacrum--a nationwide study on midterm results in 26 patients after intralesional excision

PURPOSE

Evaluation of recurrences, complications and function at mid-term follow-up after curettage for sacral giant cell tumor (GCT).

METHODS

We retrospectively studied all 26 patients treated for sacral GCT in the Netherlands (from 1990 to 2010). Median follow-up was 98 (6-229) months. All patients underwent intralesional excision, 21 with local adjuvants, 5 radiotherapy, 3 IFN-α, 1 bisphosphonates. Functional outcome was assessed using Musculoskeletal Tumor Society (MSTS) score. Statistics were performed with Kaplan-Meier, Cox regression, log rank and Mann-Whitney U.

RESULTS

Recurrence rate was 14/26 after median 13 (3-139) months and was highest after isolated curettage (4/5). Soft tissue masses >10 cm increased recurrence risk (HR = 3.3, 95 % CI = 0.81-13, p = 0.09). Complications were reported in 12/26 patients. MSTS was superior in patients without complications (27 vs. 21; p = 0.024).

CONCLUSION

Recurrence rate for sacral GCT was highest after isolated curettage, indicating that (local) adjuvant treatment is desired to obtain immediate local control. Complications were common and impaired function.

Utility of the omentum in sacral reconstruction following total sacrectomy due to recurrent and irradiated giant cell tumour of the spine

Reconstruction of the lumbosacral region after surgical excision of irradiated and recurrent spinal giant cell tumours remains a challenging problem. In this case report, we describe the use of the pedicled omentum flap in reconstruction of an irradiated and infected wide sacral defect of a 19-year-old male patient. The patient had radiotherapy and subsequent wide surgical resection after recurrence of the tumour. A myocutaneous flap from the gluteal area had failed previously. Local flap options could not be used because of the recent radiotherapy to the gluteal area. Since the patient had a laparotomy for tumour resection and a colostomy, abdominal muscles were not considered reliable for reconstructive procedures. A pedicled omentum flap was chosen as a reconstructive option because of its rich blood supply, large surface area, and angiogenic capacity. This report aims to describe the use of the pedicled omentum flap for reconstruction of the lumbosacral area following surgical resection of a spinal tumour, when gluteal and abdominal flap options for reconstruction are jeopardised.

RANKL, denosumab, and giant cell tumor of bone

PURPOSE OF REVIEW

Giant cell tumor (GCT) of bone is a benign, osteolytic neoplasm of bone. The receptor activator of NF-KB ligand (RANKL) pathway has recently been shown to play a key role in the pathogenesis of GCT.

RECENT FINDINGS

Treatment for refractory, recurrent, or metastatic GCT remains challenging. The recent development of a monoclonal antibody to RANKL, denosumab, offers promise in the management of these patients. A recent phase 2 study suggested denosumab offers disease and symptom control for patients with advanced or refractory disease. In this population, denosumab appears to be well tolerated. There are key questions which remain to be addressed, including patient selection, optimal scheduling, use as an adjuvant, and application to other giant cell-rich disorders.

SUMMARY

Denosumab offers a new treatment option for a subset of patients with previously untreatable GCT. The role of denosumab in curative treatment is the subject of ongoing studies.

Infections in surgery of primary tumors of the sacrum

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To evaluate the risk of infection, related treatment, and outcome after surgery of the 2 most common primary sacral tumors.

SUMMARY OF BACKGROUND DATA

Rarity of sacral tumors has limited the number of population-based studies. Treatment depends on malignancy or local aggressiveness: wide resection is indicated for malignant lesions, intralesional surgery for benign.

METHODS

We studied 82 patients with sacral chordomas (55 cases) or giant cell tumor (GCT) (27 cases) treated between 1976 and 2005. All patients had IV antibiotic therapy with amikacin and teicoplanin. Surgery of chordoma was resection; surgery of GCT was intralesional excision. Infections were classified as immediate postoperative, early (within 6 months), and late (more than 6 months from surgery). Mean follow-up was 9.5 years (range: 3-27 years). Some factors possibly influencing the risk of infection were statistically analyzed by Kaplan Meier curves and log-rank test.

RESULTS

No deep infections were observed in the GCT series. Three patients with sacral chordoma died for postoperative complications and were excluded from this analysis. Of the remaining 52 patients with chordoma, 23/52 had deep wound infection (44%) that required 1 or more surgical debridements combined with antibiotics, according to cultures. In 16 patients (70%), infection occurred within 4 weeks postoperatively, and in 7 within 6 months. Most frequent bacteria were Enterococcus (23%), Escherichia coli (20%), and Pseudomonas aeruginosa (18%). In 74% of cases, infection was multimicrobial. Level of resection, previous intralesional treatment elsewhere, tumor volume, and age did not statistically influence risk of infection.

CONCLUSION

Type of surgery was the prominent factor related to a major risk of infection. Operating procedure time correlated as well. Resections of sacral chordoma imply a high risk of deep infection, while intralesional excision of GCT does not. All infections healed with surgical debridements and antibiotic therapy.

Orthopaedic research in italy: state of the art

The most significant results in experimental and clinical orthopaedic research in Italy within the last three years have been primarily in major congenital diseases, bone tumors, regenerative medicine, joint replacements, spine, tendons and ligaments. The data presented in the following discussion is comparable with leading international results, highlighting Italian orthopaedic research excellemce as well as its shortcomings.

Giant cell bone tumor of the thoracic spine presenting in late pregnancy

BACKGROUND

We report a case of a large giant cell tumor of the thoracic spine presenting with spinal cord compression during pregnancy.

CASE

A 24-year-old woman presented at term with lower back pain, bilateral lower extremity weakness, numbness, and bowel and bladder incontinence. Magnetic resonance imaging revealed a spinal soft tissue mass compressing the spinal cord. The patient delivered a healthy girl by cesarean then underwent a T8-T9 laminectomy, posterior spinal decompression, and instrument fusion. Two days later, she had a thoracotomy, corpectomy of the vertebral body, and anterior tumor debulking. Ultimately, the patient was discharged to inpatient rehabilitation with improved lower extremity strength and returned bowel and bladder function.

CONCLUSION

Obstetricians should be vigilant regarding progressive neurologic symptoms during pregnancy.

Selective arterial embolisation for bone tumours: experience of 454 cases

PURPOSE

The authors present the experience of a single institution with selective arterial embolisation for primary and metastatic bone tumours.

MATERIALS AND METHODS

A total of 365 patients were treated with 454 embolisation procedures from December 2002 to April 2010. Embolisation was the primary treatment for benign bone tumours, adjuvant treatment to surgery for benign and malignant bone tumours and palliative treatment for bone sarcomas and metastases. Indications for repeat embolisation included pain or imaging evidence of progressive disease: 105 patients had repeat embolisation at the same location at an interval of 1-3 months; 260 patients had one embolisation, 78 had two and 29 had three or more. In all patients, N-2-butyl cyanoacrylate (NBCA) in 33% lipiodol was the embolic agent used.

RESULTS

A total of 419 of the 454 embolisations (93%) were technically successful. In 35 cases, embolisation was not feasible because of poor lesion vascularisation (21 patients with bone metastases and two with aneurysmal bone cysts), origin of the Adamkiewicz artery in the embolisation field (four patients with bone metastases and one with aneurysmal bone cyst), atheromatosis and arteriosclerosis (five patients with bone metastases) and anatomical and technical problems such as small-calibre vessels, many branches and acute vessel angles (two patients with bone metastases). A clinical response was achieved in 406 of the 419 procedures (97%), and no response in 13 procedures in patients with pelvis and sacrum tumours. Complications included postembolisation syndrome in 81 patients (22%), transient paraesthesias in 41 (11%), skin breakdown and subcutaneous necrosis at the shoulder and pelvis in five (1.4%) and paresis of the sciatic nerve in one (0.3%).

CONCLUSIONS

We recommend embolisation as primary or palliative treatment or an adjunct to surgery for tumours of variable histology. Strict adherence to the principles of transcatheter embolisation is important. Arteries feeding the tumour and collaterals must be evaluated carefully and catheterised superselectively to protect the normal tissues. NBCA is considered the most appropriate embolic agent for small-vessel occlusion without major complications.