Giant cell tumor of the extremity: A review of 349 cases from a single institution

Targeting Bone Tumours with 45S5 Bioactive Glass

Despite advances in treatment modalities, bone tumour therapies still face significant challenges. Severe side effects of conventional approaches, such as chemo- and radiation therapy, result in poor survival rates and high tumour recurrence rates, which are the most common issues that need to be improved upon. The aim of this study was to evaluate the therapeutic properties of 45S5 bioactive glass (BG) for targeting bone tumours. The viability of the cells derived from osteosarcoma, chondrosarcoma, and giant cell tumours was significantly reduced in the presence of 45S5-BG. In contrast, the viability of non-malignant osteoblast-like cells, chondrocytes, and bone marrow-derived stromal cells was not or only slightly affected. While alterations to the particle surface induced by heat treatment, acid etching, or incubation in a simulated body fluid had only minor effects on cytotoxicity, reducing the particle size or sintering the material significantly improved the cytotoxic effect of 45S5-BG. Further, using a chicken chorioallantoic membrane assay, the co-transplantation of 45S5-BG resulted in a significant reduction in tumour formation in vivo. Given the known positive effects of BGs on bone regeneration, our findings suggest that 45S5-BG holds great potential for the development of new and effective bone tumour therapies, with minimal side effects on non-malignant cells and simultaneous contribution to bone healing.

Recurrence and Risk Factors of Giant Cell Tumors in Hand Bones: A Systematic Review

Background

Giant cell tumor of bone (GCTB) is a locally aggressive tumor that may affect the bones of the hand and rarely causes pulmonary metastasis. It exhibits a variable recurrence rate after surgical interventions, which presents challenges in its management. This systematic review aims to delineate recurrence rates and identify risk factors for GCTB in the hand.

Methods

We conducted a systematic literature search in April 2024, following PRISMA guidelines, on PubMed and TDNet for studies reporting postsurgical recurrence of GCTB in the hand. Cohort and case-control studies provided recurrence rates, whereas case reports and series were utilized to identify risk factors, compensating for the sparse data in the primary studies. We used descriptive statistics, χ2 tests, and logistic regression to analyze demographics, lesion characteristics, treatments, and outcomes.

Results

We reviewed 13 cohort and case-control studies involving 244 patients, finding an overall recurrence rate of 19.57%. Curettage was associated with higher recurrence rates compared with other surgical methods. After additional review of case reports, a limited range of motion in patients emerged as a significant protective factor against recurrence, suggesting potential benefits in surgical management and outcome prediction.

Conclusions

The significant recurrence rate associated with curettage highlights the need for alternative surgical strategies in GCTB management of the hand. The protective role of limited ROM underscores the importance of thorough preoperative assessments to optimize surgical approaches and enhance patient outcomes.

The successful control of multiple pulmonary metastasis from giant cell tumor of bone by monthly denosumab administration: A case report

Giant cell tumor of bone (GCTB) is a locally aggressive benign neoplasm that is associated with a large biological spectrum ranging from latent benign to highly recurrent and occasionally metastatic tumor. In this article, we present a case of a 37-year-old woman who presented with fracture at the distal femur due to GCTB. Bone segment resection and reconstruction were done, and histopathology showed tumor features for GCTB. Later, multiple lung metastasis was found 22 months post-operation, which was verified by biopsy. Then systemic denosumab therapy with different intervals (1-month and 2-month) was tried as the treatment. It was clarified that monthly denosumab administration, instead of 2-month interval, was required to control the progression of the unresectable multiple lung metastasis from GCTB, which could be a choice for the future treatment of these patients.

Microwave-assisted intralesional curettage combined with other adjuvant methods for treatment of Campanacci III giant cell tumor of bone in distal radius: a multicenter clinical study

Objective

To compare the clinical outcomes of microwave-assisted intralesional curettage(MAIC) with those of en bloc resection and autogenous fibular reconstruction (EBR-AFR) for treating grade III giant cell tumor of the bone (GCTB) of the distal radius and to elucidate the indications for wrist preservation surgery.

Materials and methods

In this retrospective study, 19 patients with grade III GCTB of the distal radius who underwent surgery at three medical institutions were included and categorized based on their surgical pattern. Seven patients underwent MAIC and internal fixation with bone cement (MAIC group) and 12 underwent EBR-AFR (EBR-AFR group). To evaluate the function of the affected limb postoperatively, wrist range of motion, grip strength, Musculoskeletal Tumor Society (MSTS) scores were recorded.

Results

The follow-up time of the MAIC group was 73.57 ± 28.61 (36-116) months, with no recurrence or lung metastasis. In contrast, the follow-up time of the EBR-AFR group was 55.67 ± 28.74 (36-132) months, with 1 case of local recurrence (8.3%, 1/12) and 1 case of lung metastasis (8.3%, 1/12). The wrist flexion, extension, supination, pronation, grip strength were better in the MAIC group than in the EBR-AFR group. Although there was no statistically significant difference in the MSTS score between the two groups, it is noteworthy that the MAIC group exhibited significantly superior emotional acceptance and hand positioning compared to the EBR-AFR group(p < 0.05).

Conclusion

The functional outcomes of the MAIC group are better. The treatment strategy for grade III GCTB of the distal radius should be determined based on the specific preoperative imaging findings. Nevertheless, MAIC can be the preferred surgical approach for most patients with grade III GCTB of the distal radius, particularly for young patients.

Excision of a Giant Cell Tumor With Bone Grafting and Bone Cementing of the Proximal Humerus: A Case Report

Giant cell tumors (GCTs) of the bone are uncommon neoplasms that predominantly affect the metaphysis of long bones, with proximal humerus involvement being less frequent. We present the case of a 58-year-old male who presented with a two-month history of progressive right shoulder pain and difficulty in raising his arm. Clinical examination revealed a palpable swelling on the lateral aspect of the right arm. Radiological investigations, including X-ray and magnetic resonance imaging (MRI), confirmed the presence of a primary osseous neoplasm involving the proximal humerus, suggestive of a GCT. The patient underwent surgical excision of the tumor with bone grafting and bone cementing of the proximal humerus. Post-operative care included prescribed medications and physiotherapy. This case highlights the successful management of GCTs of the proximal humerus through a multidisciplinary approach, emphasizing the importance of meticulous surgical technique, appropriate reconstruction, and comprehensive post-operative care for optimal patient outcomes.

Current Concepts in the Treatment of Giant Cell Tumor of Bone: An Update

Curettage is recommended for the treatment of Campanacci stages 1-2 giant cell tumor of bone (GCTB) in the extremities, pelvis, sacrum, and spine, without preoperative denosumab treatment. In the distal femur, bone chips and plate fixation are utilized to reduce damage to the subchondral bone and prevent pathological fracture, respectively. For local recurrence, re-curettage may be utilized when feasible. En bloc resection is an option for very aggressive Campanacci stage 3 GCTB in the extremities, pelvis, sacrum, and spine, combined with 1-3 doses of preoperative denosumab treatment. Denosumab monotherapy once every 3 months is currently the standard strategy for inoperable patients and those with metastatic GCTB. However, in case of tumor growth, a possible malignant transformation should be considered. Zoledronic acid appears to be as effective as denosumab; nevertheless, it is a more cost-effective option. Therefore, zoledronic acid may be an alternative treatment option, particularly in developing countries. Surgery is the mainstay treatment for malignant GCTB.

Successful Surgical Management of a Giant Cell Tumor in the Proximal Tibia: A Case Report

Giant cell tumors (GCTs) of the bone present unique challenges in management due to their locally aggressive nature and potential for recurrence. This case report describes the successful surgical management of a GCT located in the proximal tibia of a 28-year-old female. The patient presented with six months of pain and swelling following a traumatic injury to the knee. Diagnostic imaging confirmed the presence of a GCT, leading to preoperative prophylactic embolization to reduce intraoperative bleeding. Surgical excision of the tumor was performed, followed by reconstruction using autologous fibula grafts and plate fixation. Postoperative care included analgesia, antibiotics, and physiotherapy. Regular follow-up demonstrated satisfactory clinical outcomes without evidence of recurrence. This case highlights the importance of a multidisciplinary approach combining surgical expertise, preoperative planning, and postoperative rehabilitation to achieve favorable outcomes in managing GCTs.

Unusual Multiple Recurrences of Soft Tissue Giant Cell Tumors in a Patient Above 60 Years

Primary giant cell tumors of soft tissues (GCT-ST) are rare neoplasms that share histopathological and immunohistochemical characteristics with osseous giant cell tumors. While GCT-ST generally exhibits a benign progression and can affect individuals of various ages, older patients may face a higher risk of recurrence and aggressive disease progression. In this case report, we present the case of a 63-year-old woman who experienced recurrent GCT-ST nine months after the complete excision of an initially localized tumor. Despite the mainstay treatment of GCT-ST being tumor-free margin surgical excision, this case demonstrates the occurrence of recurrences. The etiology of recurrence in GCT-ST remains unclear, highlighting the need for further studies and careful patient follow-up to prevent potential complications such as lung metastasis or widespread metastasis. Thus, this report aims to raise awareness of these tumors and emphasize the importance of diligent patient follow-up to facilitate early identification and management, thereby preventing potential complications such as lung or widespread metastasis.

Management of Recurrent Giant Cell Tumor of Distal Tibia With Intramedullary Hindfoot Fusion Nail and Trabecular Metal Implant Construct

Reconstruction options for giant cell tumors (GCTs) of bone are limited and challenging due to the amount of structural compromise and the high recurrence rates. This is especially true for GCTs of the foot and ankle, as the area is vital for weight bearing and function. The typical treatment for GCTs is currently excision, curettage, and cementation, although that is not always effective. A 36-year-old otherwise healthy female presented with an original diagnosis of a large aneurysmal bone cyst (ABC) of the distal tibia that had recurred despite two previous attempts at treatment with resection and cementation. She was treated with surgical resection of the lesion, reconstruction, and ankle and subtalar joint arthrodesis with a tibiotalocalcaneal intramedullary nail in combination with a trabecular metal cone. The final pathology of the intraoperative samples was consistent with GCT. Postoperatively, she recovered well, and her imaging was consistent with a successful fusion. This case report provides evidence that tibiotalocalcaneal fusion with a unique combination of hindfoot nail and trabecular metal cone construct in a single procedure is a successful option for the treatment of large, recurrent GCT lesions in the distal tibia.

GIANT CELL TUMOR OF BONE: A MULTICENTER EPIDEMIOLOGICAL STUDY IN BRAZIL

Introduction

Giant cell tumor of bone (GCTB) mainly affects young adults' long bone epiphyses, threatening bone strength and joint function. Surgery is the primary treatment, although post-surgery recurrence is significant. This study analyzes patient profiles, treatments, and outcomes for GCTB in Brazil.

Methods

We retrospectively assessed local recurrence, metastasis, and treatment approaches in 643 GCTB patients across 16 Brazilian centers (1989-2021), considering regional differences.

Results

5.1% (n=33) developed pulmonary metastases, 14.3% (n=92) had pathological fractures, and the local recurrence rate was 18.2% (n=114). Higher rates of pulmonary metastases (12.1%) and advanced tumors (Campanacci III, 88.9%) were noted in lower-income North and Northeast regions. The North also had more pathological fractures (33.3%), extensive resections (61.1%), and amputations (27.8%). These regions faced longer surgical delays (36-39 days) than the South and Southeast (27-33 days).

Conclusions

Our findings corroborate international data, underscoring regional disparities in Brazil that may lead to worse outcomes in disadvantaged areas. This highlights the need for improved orthopedic oncology care in Brazil's economically and structurally challenged regions. Level of Evidence III; Retrospective Cohort.

A case report on pulmonary metastasis of giant cell tumor mimicking arteriovenous malformation

Giant cell tumor (GCT) is typically a benign tumor of the skeletal system that mainly presents with bone pain. Pulmonary metastasis is one of the distant presentations of GCT in patients who have previously undergone surgical resection of the tumor. Among the various presentations of pulmonary metastasis in GCT, lesions with arteriovenous malformation (AVM) features are rare and have only been reported in a few cases. In this case report, we present the case of a 29-year-old female patient who had previously undergone surgical resection of a GCT in her right lower extremity 4 years ago. The patient was referred to us with progressive dyspnea, and a lesion resembling an AVM was found during radiologic evaluation using chest computed tomography. Pathologic evaluation of the lesion after biopsy revealed that it was a metastasis of GCT presenting with vascular-like features in the lung. This study reports on a very rare occurrence of GCT pulmonary metastasis with an AVM appearance on imaging, highlighting the clinical importance of atypical presentations of pulmonary metastasis in patients with a history of GCT. Appropriate and timely screening and management of such lesions may prevent adverse outcomes such as massive hemorrhage and deterioration of lung function.

Interferons as Neoadjuvant Chemotherapy for Giant Cell Tumor: A Hospital-Based Prospective Pilot Study

Introduction Neoadjuvant chemotherapy is now considered an effective way to treat Campanacci grade 2 and 3 giant cell tumors (GCTs). Assessment of these drugs is essential clinically, radiologically, and pathologically. This study analyzes the early results of angiogenesis inhibitors (interferons) in the aggressive GCT of bone.

Methodology A prospective pilot study was conducted from January 2021 to July 2022 including eight biopsy-proven GCT patients subjected to interferon therapy. Radiological assessment was done with changes on plain radiograph, computerized tomography scan, and magnetic resonance imaging. Histopathological examination was done by changes in the biopsy and resected segment.

Results Out of the eight patients included in the study, 26% (n = 3) were males and 62% (n = 5) were females, with mean age of the patients being 24.6 ± 8.48 years (range: 22–38). There was significant reduction of the size of swelling (p-value: 0.049), significant reduction in Visual Analog Scale score (p-value: 0.011), significant decrease in swelling size on radiograph (p-value: 0.012), significant marginal sclerosis (p-value: 0.001), significant neocortex formation on radiographs (p-value: 0.001), significant result in and osteoid formation (p-value: 0.001) on histology. Whereas Campanacci grade on plain radiographs, number of viable cells, and number of viable stromal cell were not statistically different in comparison with pretherapy and posttherapy status.

Conclusion Interferon therapy in a GCT has potential beneficiary effect in terms of clinical, radiological, and pathological outcomes. It might prove to be an effective alternative to standard neoadjuvant chemotherapy in the management of aggressive GCT of bones.

Level of Evidence III.

Functional Outcomes of Centralization of the Ulna as a Method of Reconstruction Following Resection of Campanacci Grade 3 Giant Cell Tumor of the Distal Radius

PURPOSE

Wrist reconstruction after distal radial tumor resection poses a challenge to the orthopedic oncologist. We evaluated the functional outcomes of centralization of the ulna with ulnocarpal arthrodesis as a method of reconstruction following resection of distal radius tumors, using impairment measures and patient-reported outcomes.

METHODS

Evaluation of functional outcome was performed using the Musculoskeletal Tumor Society 93 scoring system and Disabilities of the Arm, Shoulder, and Hand questionnaire. We also determined hand grip strength on the affected side, time to radiologic union at the ulnocarpal junction and reduction in wrist circumference. Local complications and oncologic outcomes were recorded.

RESULTS

The study included 26 patients with Campanacci grade 3 giant cell tumor of the distal radius. Mean follow-up period in the study was 32.8 ± 12 months. Mean resection length was 10.3 ± 2.5 cm. Radiologic union at the ulnocarpal junction was achieved in 38.5%, 77% and 96% of the patients by 4, 5, and 6 months respectively. Mean hand grip strength was 74 ± 3.9% of the contralateral side whereas mean reduction in wrist circumference was 16.9 ± 6.4%. A good functional outcome with a mean the Musculoskeletal Tumor Society 93 score of 26 ± 1.4 and mean Disabilities of the Arm, Shoulder, and Hand score of 10.5 ± 6.3 was observed. Fracture of the ulna, hardware loosening, and reflex sympathetic dystrophy were each noted in 1 patient, with an overall complication rate of 10.7% (3/28). No patient had nonunion, infection, or local recurrence.

CONCLUSIONS

This is a simple and effective modality of reconstruction after resection of distal radial tumors. It provides good functional outcome and preservation of good hand grip strength, with low complication rates.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

[Giant cell tumor of bone-an update]

In the past few years, numerous new insights have been gained in the field of giant cell tumor of bone (GCTB). On the one hand, the detection of the highly characteristic histone mutation in the H3F3A gene in GCTB is becoming increasingly important in diagnostics in differentiating GCTB from other giant cell-rich lesions of bone as well as for defining rare variants of GCTB without osteoclastic giant cells. On the other hand, the effects of the H3F3A mutation were shown to have an impact on the epigenetic profile of tumor-driving stromal cells, providing new insights into tumorigenesis of GCTB.

A new joint reconstruction technique in the treatment of giant cell tumors around the knee: Structural allograft and unicompartmental arthroplasty

OBJECTIVE

The long-term prognosis of patients who underwent unicompartmental knee arthroplasty (UKA) with a structural allograft or hemiarticular allograft transplantation to treat giant cell tumors (GCTs) around the knee and the prosthesis survival rate were analyzed.

METHODS

We retrospectively reviewed 73 patients who were diagnosed with GCTs around the knee and underwent surgery to restore joint function from 2000 to 2015. Patients were divided into two groups according to the surgical procedure used for functional knee reconstruction: hemiarticular allograft transplantation or structural allograft and UKA. The Knee Society Score (KSS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) were used to analyze postoperative knee function between the two groups. The Kellgren-Lawrence (K-L) classification system was used to evaluate the progression of osteoarthritis. The incidence of complications and the prosthesis survival rate were also investigated.

RESULTS

Patients who underwent UKA to treat GCT demonstrated significantly improved knee function. The rate of an excellent or good KSS was significantly different between the two groups (p = 0.041 at the 1-year follow-up, p = 0.033 at the last follow-up). The proportion of severe cases according to WOMAC in the two groups was also different (p = 0.030 at the 1-year follow-up, p = 0.021 at the last follow-up). According to the K-L grade of unaffected compartments, UKA better prevented the progression of osteoarthritis (p = 0.034).

CONCLUSIONS

Patients with GCTs around the knee could benefit from UKA. In addition to providing better knee function and range of motion, UKA could also slow the progression of osteoarthritis in the knee joint. This new surgical method could meet the needs of patients wishing to preserve joint integrity and favorable joint function.

Non‑surgical outcomes and risk factors for pulmonary metastasis from giant cell tumor of bone

The present study detailed four factors associated with an increased risk of pulmonary metastasis, age, pathological fracture, local recurrence and mode of treatment. Local recurrence and pathological fracture were independent risk factors for developing metastasis. From January 2016 to December 2021, data from 50 patients diagnosed with giant cell tumor of bone (GCTB) treated in Khon Kaen Hospital, Thailand, were retrospectively analyzed. The risk factors, including age at diagnosis, location of GCTB, clinical presentation, Campanacci stage and no. of local recurrences, for GCTB-induced pulmonary metastasis were evaluated using univariate and multivariable logistic regression analyses. Of the 50 patients analyzed, 9 patients (18%), with a mean age of 46.3 years (range, 18-68 years), developed pulmonary metastasis. No patients died from pulmonary metastasis in the present study. Statistically significant associations were observed between the development of metastasis and both clinical fracture [odds ratio (OR), 6.107; 95% confidence interval (CI), 1.08-34.70] and local recurrence (OR, 6.48; 95% CI, 1.03-40.87). Patients presenting with both a clinical fracture and local tumor recurrence require more rigorous clinical observation due to the significantly elevated risk of disease progression.

Multicentric Giant Cell Tumor of Bone

The typical presentation of giant cell tumor of bone is a solitary lesion involving the meta-epiphyseal region of the long bones. The presence of more than one distinct giant cell tumor in the same patient is rare. This study reports on 7 patients with multicentric giant cell tumor of bone. Clinical and radiologic features were reviewed to evaluate the behavior of multicentric giant cell tumor of bone. Immunohistochemistry and genetic analysis for the H3F3A gene were performed to confirm the diagnosis. The knee was most frequently involved, and most of the lesions were in an ipsilateral extremity. All of the patients received surgical management with curettage or resection. The overall median follow-up was 194 months (interquartile range, 41-336 months). Five of 7 patients had local recurrence (71%), but considering the number of surgically treated lesions, the risk of local recurrence was 33% (5 local recurrences among 15 treated lesions). No lung metastases occurred. Multicentric giant cell tumor of bone tends to exhibit the same aggressive clinical behavior as solitary giant cell tumor of bone. Patients should be monitored for the occurrence of other lesions, especially in the ipsilateral extremity. [Orthopedics. 2023;46(6):e376-e380.].

Comprehensive evaluation and advanced modification of polymethylmethacrylate cement in bone tumor treatment

Bone tumors are invasive diseases with a tendency toward recurrence, disability, and high mortality rates due to their grievous complications. As a commercial polymeric biomaterial, polymethylmethacrylate (PMMA) cement possesses remarkable mechanical properties, injectability, and plasticity and is, therefore, frequently applied in bone tissue engineering. Numerous positive effects in bone tumor treatment have been demonstrated, including biomechanical stabilization, analgesic effects, and tumor recurrence prevention. However, to our knowledge, a comprehensive evaluation of the application of the PMMA cement in bone tumor treatment has not yet been reported. This review comprehensively evaluates the efficiency and complications of the PMMA cement in bone tumor treatment, for the first time, and introduces advanced modification strategies, providing an objective and reliable reference for the application of the PMMA cement in treating bone tumors. We have also summarized the current research on modifications to enhance the anti-tumor efficacy of the PMMA cement, such as drug carriers and magnetic hyperthermia.

Total Knee Arthroplasty for Osteoarthritis Is Uncommon after Intralesional Curettage in Giant Cell Tumor of Bone

Giant cell tumor of bone (GCTB) is most often treated with intralesional curettage; however, periarticular lesions have been shown to increase risk for osteoarthritis. Additionally, the location of these lesions may occasionally preclude a joint-sparing procedure in recurrent tumors. This study sought to investigate rates of secondary arthroplasty in long-term follow-up of knee GCTB. Cases of knee GCTB treated at our institution were reviewed. Rates of recurrence and secondary arthroplasty were recorded, and Kaplan-Meier survival analyses were performed. The records of 40 patients were reviewed. Local recurrence occurred in 25% of patients. The 1-, 5-, and 10-year recurrence-free survival (RFS) probability was 87.4% (95% CI, 77.0-97.7), 72.4% (95% CI, 57.6-87.2), and 72.4% (95% CI, 57.6-87.2), respectively. Function improved after surgery with a mean preoperative MSTS score of 14.9 (standard deviation [SD] 8.4) and mean postoperative MSTS score of 25.1 (SD 5.6) (p <0.001). Three patients had evidence of radiographic osteoarthritis at the last follow-up though they did not require arthroplasty. Arthroplasty was performed as a secondary procedure in six patients. Five patients underwent arthroplasty for recurrent tumors after initial treatment with curettage and one patient underwent patellar arthroplasty for osteoarthritis after initial treatment with an allograft composite arthroplasty. Arthroplasty is performed as a secondary procedure in patients with GCTB at a relatively infrequent rate and more often for cases of recurrent disease than for osteoarthritis. Overall, patients treated for GCTB have improved functional outcomes after surgery than before. Large, multi-institutional studies may be required to assess the incidence of secondary osteoarthritis requiring arthroplasty as this was an infrequent finding in our cohort.

Proximal Tibia Tumour Location and Curettage Are Major Risk Factors of Local Recurrence in Giant Cell Tumour of Bone

Giant cell tumour of bone (GCTB) is one of the most common local aggressive tumourous lesions with a wide variety of biological behaviour. However, there are no clear indicative criteria when choosing the type of procedure and the complication rates remain high, especially in terms of local recurrence. The purpose of the study was to (1) identify the main risk factors for local recurrence, (2) evaluate the recurrence-free survival in dependence on neoadjuvant denosumab use and the type of procedure, and (3) compare the functional outcomes after curettage and en bloc resection. The group included 102 patients with GCTB treated between 2006 and 2020. The mean age of patients was 34.4 years (15-79). The follow-up period was 8.32 years (2-16) on average. Local recurrence occurred in 14 patients (29.8%) who underwent curettage and in 5 patients (10.6%) after en bloc resection. Curettage was shown to be a factor in increasing recurrence rates (OR = 3.64 [95% CI: 1.19-11.15]; p = 0.023). Tibial location was an independent risk factor for local recurrence regardless of the type of surgery (OR = 3.22 [95% CI: 1.09-9.48]; p = 0.026). The recurrence-free survival rate of patients treated with resection and denosumab was higher compared to other treatments at five years postoperatively (p = 0.0307). Functional ability and pain as reported by patients at the latest follow-up were superior after curettage compared to resection for upper and lower extremity (mean difference: -4.00 [95% CI: -6.81 to -1.18]; p < 0.001 and mean difference: -5.36 [95% CI: -3.74 to -6.97]; p < 0.001, respectively). Proximal tibia tumour location and curettage were shown to be major risk factors for local recurrence in GCTB regardless of neoadjuvant denosumab treatment. The recurrence-free survival rate of patients treated with resection and denosumab was higher compared to other treatments. The functional outcome of patients after curettage was better compared to en bloc resection.

The Role of Denosumab in the Treatment of Primary Tumors of Bone

Many hand surgeons treat benign bone tumors without referral to orthopedic oncologists. However, there have been considerable advances in medical therapy for some of these tumors, with which hand surgeons may not be as familiar. This review focuses on the mechanism and uses of denosumab in the treatment of benign tumors of bone. Although the hand surgeon may not be directly prescribing this therapy, they are often the only physician treating the patient for these conditions. As such, awareness regarding the use of this therapy in reducing pain, decreasing tumor volume, and treatment of potential lung metastases is critical to those taking on these cases without the support of an orthopedic oncologist. This article aims to familiarize hand surgeons with denosumab to help promote knowledge of this therapeutic option and the potential role of this medication in the treatment of primary bone tumors in the hand.

Establishment and characterization of two novel patient-derived cell lines from giant cell tumor of bone

Giant cell tumor of bone (GCTB) is a rare bone tumor with osteolytic features, composed of stromal cells with a monotonous appearance, macrophages, and osteoclast-like giant cells. GCTB is commonly associated with a pathogenic mutation in the H3-3A gene. While complete surgical resection is the standard cure for GCTB, it often results in local recurrence and, rarely, metastasis. Thus, an effective multidisciplinary treatment approach is necessary. Although patient-derived cell lines is an essential tool for investigating novel treatment strategies, there are only four GCTB cell lines available in public cell banks. Therefore, this study aimed to establish novel GCTB cell lines and successfully created NCC-GCTB6-C1 and NCC-GCTB7-C1 cell lines from two patients' surgically removed tumor tissues. These cell lines exhibited H3-3A gene mutations, consistent proliferation, and invasive properties. After characterizing their behaviors, we performed high-throughput screening of 214 anti-cancer drugs for NCC-GCTB6-C1 and NCC-GCTB7-C1 and integrated their screening data with those of NCC-GCTB1-C1, NCC-GCTB2-C1, NCC-GCTB3-C1, NCC-GCTB4-C1, and NCC-GCTB5-C1 that we previously established. We identified histone deacetylase inhibitor romidepsin as a possible treatment for GCTB. These findings suggest that NCC-GCTB6-C1 and NCC-GCTB7-C1 could be valuable tools for preclinical and basic research on GCTB.

Treatment of pelvic giant cell tumor by wide resection with patient-specific bone-cutting guide and reconstruction with 3D-printed personalized implant

BACKGROUND

This study reports our experience in the treatment of aggressive pelvic GCT through wide resection assisted with patient-specific bone-cutting guides (PSBCGs) and subsequent reconstruction with 3D-printed personalized implants (3DPIs), aiming to present the operative technique of this method and evaluate its clinical efficacy.

METHODS

We retrospectively analyzed seven patients who underwent wide resection of pelvic GCT followed by reconstruction with 3DPIs from August 2019 to February 2021. There were two males and five females, with a mean age of 43 years. PSBCGs and 3DPIs were prepared using 3D-printing technology. The operational outcomes, local recurrence, radiological results, and any associated complications of this technique were assessed. And the functional outcomes were assessed according to the Musculoskeletal Tumor Society (MSTS) 93 functional score.

RESULTS

The mean follow-up time was 35.3 months (range 28-45 months). There was no intraoperative complication. Negative surgical margins were achieved in all patients. Postoperative pelvic radiographs showed that 3DPIs matched the shape and size of the bone defect. The anterior-posterior, inlet, and outlet pelvic radiograph demonstrated precise reconstruction consistent with the surgical planning. In addition, tomosynthesis-Shimadzu metal artifact reduction technology (T-SMART) showed good osseointegration at an average of three months after surgery (range 2-4 months). There was no local recurrence or tumor metastasis. The average MSTS score was 24.4 (range 23-27) at the last follow-up. Delayed wound healing was observed in one patient, and the wounds healed after debridement. Prosthesis-related complications were not detected during the follow-up, such as aseptic loosening or structure failure.

CONCLUSIONS

The treatment of aggressive pelvic GCTs through wide resection assisted with PSBCGs and subsequent reconstruction with 3DPIs is a feasible method, which provides good clinical results and reasonable functional outcomes.

Reconstruction After En Bloc Resection of a Distal Radius Tumor. An Updated and Concise Review

The distal radius is rarely affected by either primary or metastatic bone cancers. The most frequent tumors of the distal radius are giant cell tumors, which are benign tumors with the propensity to invade. En bloc excision of giant cell tumors of the distal radius achieves a low recurrence rate but compromises the wrist joint, necessitates a significant reconstruction, and has functional consequences. Reconstruction after en bloc resection of a distal radius bone tumor is challenging. Furthermore, orthopedic oncologists disagree on treating such long bone anomalies most effectively. The present article summarizes the various biological and non-biological reconstruction techniques performed after en bloc resection of a distal radius tumor, discusses the advantages and disadvantages of each reconstruction strategy, and summarizes several case studies and case reports.

Current therapies and future prospective for locally aggressive mesenchymal tumors

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

Management of giant cell tumors of the distal radius

Background

The distal radius is the most common location for giant cell tumors (GCT) in the upper extremity. Treatment should balance the goals of maximizing function and minimizing recurrence and other complications. Given the complexity in surgical treatment, various techniques have been described without clear standards of treatment.

Objectives

The purpose of this review is to provide an overview of evaluation of patients presenting with GCT of the distal radius, discuss management, and provide an updated summary on outcomes of treatment options.

Conclusion

Surgical treatment should consider tumor Grade, involvement of the articular surface, and patient-specific factors. Options include intralesional curettage and en bloc resection with reconstruction. Within reconstruction techniques, radiocarpal joint preserving and sparing procedures can be considered. Campanacci Grade 1 tumors can be successfully treated with joint preserving procedures, whereas for Campanacci Grade 3 tumors consideration should be given to joint resection to prevent recurrence. Treatment of Campanacci Grade 2 tumors is debated in the literature. Intralesional curettage and adjuvants can successfully treat cases where the articular surface can be preserved, while en-bloc resection should be used in cases where the articular surface cannot undergo aggressive curettage. A variety of reconstructive techniques are used for cases needing resection, with no clear gold standard. Joint sparing procedures preserve motion at the wrist joint, whereas joint sacrificing procedures preserve grip strength. Choice of reconstructive procedure should be made based on patient-specific factors, considering relative functional outcomes, complications, and recurrence rates.

Giant Cell Tumor of the Distal Fibula Managed by an Autologous Proximal Fibula Graft

A giant cell tumor of the bone is among the most common bone tumors encountered by orthopedic surgeons. These benign and aggressive tumors are most commonly present around the knee joint; however, rare cases may involve the distal fibula. An 18-year-old man presented with a painless swelling of the lateral aspect of the left ankle. Clinical examination, radiologic evaluation, and biopsy confirmed the diagnosis of a giant cell tumor of the distal fibula. The patient was treated with resection of the distal fibula followed by reconstruction using an ipsilateral proximal fibula graft. The post-operative recovery was uneventful, and the patient was doing well on the last visit, one month after the intervention.

Treatment of Recurrent Giant Cell Tumor of Bones: A Systematic Review

The giant cell tumor of bones (GCTB) is a benign bone tumor with high postoperative recurrence potential. No specific treatment protocol has been developed to date in case of tumor recurrence, and the kind of re-operative surgery depends upon the surgeon's preferences. The aim of this systematic review is to determine the second recurrence rate and the respective functional results of the available treatment options applied to recurrent GCTB. Medline/PubMed and Scopus were searched to identify articles published until March 2023. Twelve studies fulfilled the inclusion criteria, comprising 458 patients suffering from recurrent GCTB. The overall incidence of second recurrence was 20.5%, at a mean interval of 28.8 months after the first surgery, and it was more evident after intralesional curettage (IC) surgery than en-bloc resection (EBR) (p = 0.012). In the IC group of patients, the second recurrence rate was lower and the functional outcome was greater when polymethylmethacrylate cement (PMMAc) was used as an adjuvant instead of bone grafting (p < 0.001 for both parameters). Reconstruction of the created bone defect after EBR with a structural allograft provided a better outcome than prosthesis (p = 0.028). According to this systematic review, EBR (first choice) and IC with PMMAc (second choice) are the best treatment options for recurrent GCTB.

Incidence and progression of osteoarthritis following curettage and cementation of giant cell tumor of bone around the knee: long-term follow-up

BACKGROUND

Giant cell tumor of bone (GCTB) is a benign locally aggressive tumor frequently treated with intralesional curettage and cementation. The aim of this study was to investigate the long-term incidence of arthritic changes following curettage and cementation of GCTB around the knee.

MATERIALS AND METHODS

This study was a retrospective review of patients with GCTB around the knee treated with curettage and cementation with a minimum follow-up of 10 years. The functional results were assessed using the Musculoskeletal Tumor Society (MSTS) score. The arthritic changes were classified using the Kellgren-Lawrence (KL) classification system of osteoarthritis.

RESULTS

This study included 119 patients, 54 males and 65 females, with a mean age of 29.4 ± 9.2 years. There were 35 (29.4%) patients with pathological fractures. There were 84 (70.6%) patients with de novo lesions and 35 (29.4%) with recurrent lesions. The mean follow-up period was 13.2 ± 3.16 years. The mean MSTS score was 28.5 ± 1.9. Overall, 25 (21%) patients developed variable degrees of arthritis of KL grade 1 (n = 7), KL grade 2 (n = 11), KL grade 3 (n = 4), and KL grade 4 (n = 3). Ten patients showed progression of arthritis during the follow-up period. Age at presentation, gender, presence of pathological fracture, whether the tumor was de novo or recurrent, and tumor location were not associated with arthritis incidence.

CONCLUSIONS

Curettage and cementation can be used safely to treat GCTB around the knee. Arthritis of the knee is a possible complication, but mild grades are expected in most cases. There was no association between arthritis incidence and age, gender, pathological fractures, tumor location, or recurrent tumors.

LEVEL OF EVIDENCE

Level IV.

Argon Beam Coagulation as an Adjuvant for Extended Curettage for Giant Cell Tumors of the Bone: A Study of 50 Cases

Objective  Extended curettage with adjuvants of giant cell tumors of bone is associated with a lower rate of recurrence of the tumor while preserving the adjacent joint. The present study was conducted to estimate the recurrence rate and functional outcome after using argon beam as an adjuvant for extended curettage. Methods  We selected 50 patients with giant cell tumors, meeting all the inclusion criteria, who underwent extended curettage using high speed burr and argon beam photocoagulation between July 2016 to January 2019. On their follow-up visit, they were assessed for any complaints of pain and signs like tenderness, locally raised temperature, and decreased range of motion of the adjacent joint. Radiologically, the patients were assessed for any increased lucency around the cement mantle and uptake of the subarticular graft. Musculoskeletal Tumor Society Score (MSTS) was administered to the patients, and range of motion of the adjacent joint was compared with the contralateral joint. Results  Recurrence was found in 4 patients, that is, an 8% recurrence rate. Twenty-six out of 28 patients with a tumor in the lower limb had a grade-5 weight bearing status 6 months from the surgery, and their range of motion was comparable to contralateral healthy joint with an average MSTS score of 27 (18-30). Conclusion  Extended curettage of giant cell tumors using argon beam coagulation is associated with low recurrence rates of the tumor and is an effective modality in the treatment of these tumors besides having a functional outcome comparable to the healthy limb.

'Triple clear': a systematic and comprehensive surgical process for Campanacci grades II and III giant cell tumors of the bone, with or without pathological fracture and slight joint invasion

BACKGROUND

In recent years, researchers have proposed a number of adjuvant methods for extended curettage of giant cell tumors of the bone. However, various schemes have significant differences in efficacy and safety. Therefore, this article will describe an empirical expanded curettage protocol, 'triple clear', in detail to show the effect of the efficient surgical protocol.

METHOD

Patients with Campanacci grades II and III primary GCTB who were treated with either SR (n = 39) or TC (n = 41) were included. Various perioperative clinical indicators, including the therapy modality, operation time, Campanacci grade, and filling material were recorded and compared. The pain level was determined by the visual analog scale. Limb function was determined by the Musculoskeletal Tumour Society (MSTS) score. Follow-up time, recurrence rates, reoperation rates, and complication rates were also recorded and compared.

RESULT

The operation time was 135.7 ± 38.4 min in the TC group and 174.2 ± 43.0 min in the SR group (P < 0.05). The recurrence rates were 7.3% in the TC group and 8.3% in the SR group (P = 0.37). The MSTS scores at three months after surgery were 19.8 ± 1.5 in the TC group and 18.8 ± 1.3 in the SR group. The MSTS scores at two years were 26.2 ± 1.2 in the TC group and 24.3 ± 1.4 in the SR group (P < 0.05).

CONCLUSION

TC is recommended for patients with Campanacci grade II-III GCTB and for those with a pathological fracture or slight joint invasion. Bone grafts may be more suitable than bone cement in the long term.

Denosumab salvage therapy in an 11-year-old boy with locally recurrent unresectable giant cell tumor of the lumbar spine after surgery

Giant cell tumors (GCTs) of the bone are locally aggressive primary bone tumors with a benign character. Spinal involvement is rare which accounts for approximately 5% of all primary bone tumors and it is quite rare in the lumbar spine. An 11-year-old boy patient presented with pain of low back and bilateral low extremities. Lumbar CT and MRI revealed a lytic lesion of the L4 vertebra corpus. The patient earned remarkable and timely recovery with 2 surgical interventions and the use of denosumab. Surgical resection for GCTs is still preferable as the initial treatment, denosumab should be utilized after tumor resection whether based on the purpose of prevention or treatment of tumor recurrence.

Custom-Made 3D-Printed Prosthesis after Resection of a Voluminous Giant Cell Tumour Recurrence in Pelvis

Giant-cell tumours are benign aggressive bone lesions that can affect any part of the skeleton. In early stages, curettage is preferred, but in case of local recurrence or voluminous lesions in the periacetabular region, wide resection and reconstruction are recommended. The purpose of this article is to increase clinicians' awareness of the importance of the follow-up of these patients and to describe a case of a voluminous recurrence of a giant-cell tumour in the pelvis. We present a 25-year-old female who underwent internal hemipelvectomy assisted by 3D cutting-guides and reconstruction with a custom-made 3D-printed pelvic prosthesis, hip arthroplasty and ilio-sacral arthrodesis. No postoperative complications occurred and, at long-term follow-up, the patient had a stable and painless hip joint, good bone-implant osteointegration, with an excellent functional outcome. In spite of all available reconstructive techniques, in well-selected patients with voluminous pelvic resections, custom-made 3D-printed implants allow patients to have a good mechanical outcome.

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

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

Outcome of re-operation for local recurrence following pre-operative denosumab administration and curettage for giant cell tumour of bone with difficult joint preservation

PURPOSE

Denosumab enables joint-sparing surgery (curettage) and surgical downstaging in patients with giant cell tumour of bone (GCTB), where joint preservation is not possible. However, denosumab treatment causes osteosclerosis of the lesion, making it difficult to curet the lesion, leaving the tumour behind, and increasing the local recurrence rate. We performed a three-centre retrospective study to investigate the postoperative local re-recurrence rate, joint preservation status, and functional outcomes of locally recurrent lesions after preoperative denosumab treatment and curettage in patients with difficult joint preservation.

METHODS

We included 38 of 142 patients with primary GCTB of the extremities who underwent preoperative denosumab and curettage between 2009 and 2021 with local recurrence. Preoperative denosumab was indicated in patients with minimal residual periarticular and subchondral bones, large extraosseous lesions (Campanacci stage 3), and pathological fractures that made joint preservation difficult.

RESULTS

Local re-recurrence occurred in 6 (15.8%) of the 38 patients. In 29 patients who underwent re-curettage, local re-recurrence occurred in six patients (20.7%); however, in nine patients who underwent en bloc resection, no local re-recurrence was observed. The joint preservation rate was 63.2% (24 of 38 patients), with a median Musculoskeletal Tumor Society score of 28 (interquartile range: 26.8-29.0). The median follow-up period after surgery for local recurrence was 63.5 months (interquartile range: 42.5-82.4).

CONCLUSION

Since the local re-recurrence rate after re-curettage for local recurrence was low, and the joint preservation rate and affected limb function were good, preoperative denosumab administration may be considered in patients who require downstaging to maintain good limb function (joint preservation).

Diffuse Pulmonary Metastases at Presentation of Giant Cell Tumor of Bone: A Case Report and Synthesis of Literature

CASE

We present a 23-year-old man with acute-on-chronic shoulder pain with an aggressive-appearing, destructive lesion of the left proximal humerus and diffuse lung metastases. Biopsy revealed conventional giant cell tumor of bone (GCTB) without sarcomatous differentiation, treated with resection and proximal humerus reconstruction. Without systemic treatment, his pulmonary metastases demonstrated modest spontaneous regression, with no impairment of pulmonary function.

CONCLUSIONS

Although GCTB is known to metastasize to lungs, these deposits most commonly follow local recurrence. We describe a young adult with diffuse pulmonary nodules at initial presentation, although still following an indolent clinical course without the need for additional systemic therapy.

Mid-term results of giant cell tumours with pathologic fractures around the knee: a multicentre retrospective study

OBJECTIVE

The aims of this work are to present a classification of "complex fracture" and "simple fracture", to compare their features, treatments and prognosis in patients with giant cell tumour with pathologic fractures around the knee, and to determine the best surgical method for patients who have giant cell tumour around the knee with different degrees of fracture.

METHODS

Data from 130 patients with pathologic fractures from giant cell tumour around the knee who underwent surgical treatment from March 2000 to November 2015 at 6 institutes around China were collected and analysed. A multicentric study design was used to explore the epidemiological features and to compare differences in the surgical procedures and prognosis of the two fracture groups. The mean age at diagnosis was 37.1 years old (range, 13-77 years). The median follow-up was 126.5 months, ranging from 68 to 370 months.

RESULTS

The general clinical and imaging features of the groups of patients with simple and complex fractures, namely, sex, age, the lesion site, living or working environment, eccentric growth patterns, Campanacci grading system, and duration of symptoms before treatment, showed varying degrees of differences, but with no statistical significance (p > 0.05). The incidence rate of surrounding soft tissue mass was 35.2% (32/91) in the group with simple fractures, whereas it was 87.2% (34/39) in the group with complex fractures, which showed a significant difference (p < 0.05). Wide resection and reconstruction with joint replacement were performed more often in patients with complex fractures (61.5%, 24/39). Intralesional procedures were performed more often in patients with simple fractures (56.0%, 51/91). The difference showed significant differences (p < 0.05). The local recurrence rate was 17.6% (16/91) in the group with simple fractures, whereas it was 10.3% (4/39) in the complex fracture group, showing a significant difference (p < 0.05). A total of 2.3% of patients (n = 3,3/130) developed a skip lesion. The complication rates were 4.6% (4/87) and 14.7% (5/34), respectively, in the two groups with simple or complex fractures, showing a significant difference (p < 0.05). The mean MSTS and TESS scores with simple fractures were 26.6 (range, 13-30) and 84.1 (range, 29-100), respectively, whereas the mean scores in the group with complex fractures were 25.5 (range, 18-30) and 78.3 (range, 30-100), respectively, also showing a significant difference (p < 0.05).

CONCLUSION

Our classification of "simple fracture" and "complex fracture" could guide decisions regarding the best surgical method for lesions in patients who have giant cell tumour around the knee with different degrees of fracture.

Microwave in situ inactivation in the treatment of bone giant cell tumor: a mid-term descriptive study

AIM

To evaluate the mid-term clinical efficacy of microwave in situ inactivation combined with bone grafting or polymethyl methacrylate (PMMA) filling in the treatment of giant cell tumor of bone (GCTB).

METHODS

This is a retrospective, descriptive, and analytical study. A total of 30 GCTB patients received microwave in situ inactivation from January 2012 to January 2020, whose clinical recurrence rate was evaluated at the last follow-up after microwave in situ inactivation surgery. The Musculoskeletal Tumor Society (MSTS) function score was used to evaluate the postoperative clinical panoramic results.

RESULTS

All patients were followed up for 21 to 110 months, with an average of 63.79 months. Distal femur (40%) and proximal tibia (28%) had a higher rate of GCTB incidence. Seventeen percent of tumor patients suffered from associated pathologic fracture. The rate of Campanacci classification stage III was 60%. The average MSTS score was evaluated as 27.53 points overall at the last follow-up. In terms of complications, three, two, two and one cases developed fat liquefaction, controllable tissue rejection reaction, incision infection and degenerative changes around lesion joint, respectively, without in situ recurrences and reoperation as well as distant lung metastasis.

CONCLUSIONS

The method of microwave in situ inactivation combined with bone grafting or PMMA filling is prudently recommended as one of the options for the limb salvage treatment of giant cell tumor of long and periarticular bone.

LEVEL OF EVIDENCE

IV: case series.

Wide resection for giant-cell tumor of the distal radius: which reconstruction? A systematic review of the literature and pooled analysis of 176 cases

Giant-cell tumor (GCT) is often more aggressive when located in the distal radius, and wide resection is then the gold-standard. No single reconstruction protocol is recommended, and the technique depends upon the surgeon's preferences. The aim of the present review was to determine the recurrence rate of GTC of the distal radius after intralesional treatment, to assess the results, advantages and complications of the various surgical techniques, and to draw up a decision-tree for surgical indications. The review of literature was performed in the main healthcare databases, searching for studies that reported results of wide resection and reconstruction of distal radius GCT. Local recurrence rates, metastasis rates, reconstruction techniques and respective results and complications were evaluated and analyzed. Sixteen studies were selected, for a total population of 226 patients; 6.0% and 0.9% experienced local recurrence and lung metastasis, respectively. Arthroplasty with non-vascularized or vascularized ipsilateral fibula were the most common techniques and were associated with the highest satisfaction rates: 86.4% and 88.0%, respectively. Arthroplasty with allograft presented a MusculoSkeletal Tumor Society (MSTS) score of 79.2% and arthroplasty with custom-made prosthesis presented an MSTS score of 81.8%. Arthrodesis was performed in 46 cases, with an MSTS score of 82.7%. Arthroplasty techniques are the most common in literature; they are used in patients who wish to conserve joint motion. Reconstruction with non-vascularized fibula seems to provide the best results, with lower morbidity. Arthrodesis is usually reserved for heavy manual workers or in case of arthroplasty failure.

Outcome of Reoperation for Local Recurrence Following En Bloc Resection for Bone Giant Cell Tumor of the Extremity

En bloc resection is typically performed to treat giant cell tumors of bone (GCTB), particularly when curettage can be challenging owing to extensive bone cortex destruction with soft tissue extension. Few reports have addressed the clinical outcomes after reoperation for local recurrence in patients with GCTB who underwent en bloc resection. In this multicenter retrospective study, we investigated local recurrence, distant metastasis, malignant transformation, mortality, and limb function in patients treated for local recurrence following en bloc resection for GCTB. Among 205 patients who underwent en bloc resection for GCTB of the extremities between 1980 and 2021, we included 29 with local recurrence. En bloc resection was performed for large tumors with soft tissue extension, pathological fractures with joint invasion, complex fractures, and dispensable bones, such as the proximal fibula and distal ulna. Local re-recurrence, distant metastasis, malignant transformation, and mortality rates were 41.4% (12/29), 34.5% (10/29), 6.9% (2/29), and 6.9% (2/29), respectively. The median Musculoskeletal Tumor Society score was 26 (interquartile range, 23–28). The median follow-up period after surgery for local recurrence was 70.1 months (interquartile range, 40.5–123.8 months). Local recurrence following en bloc resection for GCTB could indicate an aggressive GCTB, necessitating careful follow-up.

Giant cell tumor with secondary aneurysmal bone cyst of the left calcaneus

Introduction and importance

Giant cell tumors (GCT) of the feet bones are rare, comprising of <1 % of cases. The lack of well-documented cases and similarity with other tumors under radiologic and histological evaluation makes diagnosis difficult. Current treatment modalities for GCT still result in a relatively high recurrence rate, making the overall management of the case a challenge. We reported a 27-year-old male diagnosed with GCT of the left calcaneus with secondary aneurysmal bone cyst (ABC) treated with curettage and femoral head allograft combined with bone cement application.

Case presentation

A 27-year-old male presented with lump on the left heel since seven months before admission. Physical examination demonstrated solid, palpable mass on the left heel region and limited ankle motion. Magnetic resonance imaging examination demonstrated expansile bone tumor at the left calcaneus with cystic components building fluid levels and hemorrhagic components, suggestive of giant cell tumors with secondary ABC. The patient is diagnosed with giant cell tumor with secondary ABC of the left calcaneus Campanacci grade 2. The patient was managed limb salvage surgery by curettage and subsequent mix of femoral head allograft and bone cement application to fill the defect.

Discussion

Conservative surgery via careful curettage is typically preferred for lower Campanacci grade lesions followed by bone reconstruction. In terms of filling bone defects, it is known that both bone cement and allografts have advantages and disadvantages. We hence decided to perform limb salvage surgery via curettage due to the size of the tumor and bone reconstruction using a mix of femoral head allograft and bone cement to fill the defect.

Conclusion

Curettage and bone allograft with bone cement reconstruction is an option for surgical management of lower Campanacci grade 2 GCT of the calcaneus.

•

A 27-year-old male diagnosed with GCT of the left calcaneus with secondary aneurysmal bone cyst (ABC)

•

GCT of the left calcaneus with secondary aneurysmal bone cyst (ABC) treated with curettage and femoral head allograft combined with bone cement application.

•

Conservative curettage, followed by bone allograft application is effective and safe to manage lower Campanacci grades of giant cell tumors of the calcaneus

Rechallenge of denosumab in advanced giant cell tumor of the bone after atypical femur fracture: A case report and review of literature

Giant cell tumor of the bone (GCTB) is a locally aggressive neoplasm where surgery is often curative. However, it can rarely give rise to distant metastases. Currently, the only available active therapeutic option for unresectable GCTB is denosumab, an anti-RANKL monoclonal antibody that dampens the aggressive osteolysis typically seen in this disease. For advanced/metastatic GCTB, denosumab should be continued lifelong, and although it is usually well tolerated, important questions may arise about the long-term safety of this drug. In fact, uncommon but severe toxicities can occur and eventually lead to denosumab discontinuation, such as atypical fracture of the femur (AFF). The optimal management of treatment-related AFF is a matter of debate, and to date, it is unknown whether reintroduction of denosumab at disease progression is a clinically feasible option, as no reports have been provided so far. Hereinafter, we present a case of a patient with metastatic GCTB who suffered from AFF after several years of denosumab; we describe the clinical features, orthopedic treatment, and oncological outcomes, finally providing the first evidence that denosumab rechallenge after AFF occurrence may be a safe and viable option at GCTB progression.

Updated concepts in treatment of giant cell tumor of bone

PURPOSE OF REVIEW

Giant cell tumors of bone (GCTB) are intermediate, locally aggressive primary bone tumors. For conventional GCTB, surgery remains treatment of choice. For advanced GCTB, a more important role came into play for systemic therapy including denosumab and bisphosphonates over the last decade.

RECENT FINDINGS

In diagnostics, focus has been on H3F3A (G34) driver mutations present in GCTB. The most frequent mutation (G34W) can be detected using immunohistochemistry and is highly specific in differentiating GCTB from other giant cell containing tumors. PD-L1 expression can be used as biological marker to predict higher recurrence risks in GCTB patients.The use of bisphosphonate-loaded bone cement is under investigation in a randomized controlled trial. A new technique consisting of percutaneous microwave ablation and bisphosphonate-loaded polymethylmethacrylate cementoplasty was proposed for unresectable (pelvic) GCTB.Increased experience with use of denosumab raised concern on elevated recurrence rates. However, conclusions of meta-analyses should be interpreted with risk of indication bias in mind. Several small studies are published with short-course denosumab (varying from 3 to 6 doses). One small trial directly compared denosumab and zoledronic acid, with no statistical differences in radiological and clinical outcome, and nonsignificantly higher recurrence rate after denosumab. As bisphosphonates directly target neoplastic stromal cells in GCTB, larger directly comparative trials are still warranted.

SUMMARY

Neoadjuvant denosumab is highly effective for advanced GCTB, and a short-course is advised to facilitate surgery, whereas increased recurrence rates remain of concern. Randomized controlled trials are conducted on bisphosphonate-loaded bone cement and on optimal dose and duration of neoadjuvant denosumab. PD-L1 could be a potential new therapy target in GCTB.

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

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

Establishment and characterization of NCC-GCTB5-C1: a novel cell line of giant cell tumor of bone

Giant cell tumor of bone (GCTB), is a rare intermediate malignant bone tumor with high local infiltrative ability, and is genetically characterized by mutation in the H3-3A gene. Standard treatment is curative surgical tumor resection. GCTB demonstrates both local recurrence and pulmonary metastasis after surgical treatment, and effective systematic chemotherapy is yet to be established. Therefore, development of novel chemotherapies for GCTB is necessary. Although patient-derived tumor cell lines are potent tools for preclinical research, 15 GCTB cell lines have been reported to date, and only four are publicly available. Thus, this study aimed to establish and characterize a novel GCTB cell line for preclinical studies on GCTB. Herein, we described the establishment of a cell line, NCC-GCTB5-C1, from the primary tumor tissue of a patient with GCTB. NCC-GCTB5-C1 was shown to harbor a mutation in the H3-3A gene, which is typical of GCTB; thus, it has useful properties for in vitro studies. We conducted the largest integrated screening analysis of 214 antitumor agents using NCC-GCTB5-C1 along with four GCTB cell lines. Romidepsin (a histone deacetylase inhibitor), camptothecin, and actinomycin D (topoisomerase inhibitors) demonstrated remarkable antitumor effects, suggesting that these antitumor agents are potential therapeutic candidates for GCTB treatment. Therefore, the NCC-GCTB5-C1 cell line could potentially contribute to the elucidation of GCTB pathogenesis and the development of novel GCTB treatments.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

Burden of complications after giant cell tumor surgery. A single-center retrospective study of 192 cases

BACKGROUND

Surgical complications are frequent with giant cell tumor of bone; recurrence is the best known and most widely studies; other causes of failure have been less well investigated. We therefore performed a retrospective study to identify and assess the main reasons for surgical revision.

HYPOTHESIS

Recurrence is the main cause of surgical revision in giant cell tumor of bone, but other complications, such as mechanical issues or infection, are underestimated.

PATIENTS AND METHODS

A single-center retrospective study included 192 patients (included from 2000 to 2016) undergoing first giant cell tumor of bone surgery in a bone tumor reference center. Surgery consisted in curettage for 152 patients (79%) and resection for 40 (21%). The 3 main reconstruction techniques were filling (136 patients; 71%), prosthesis (18 patients; 9%), and fusion (14 patients: 7%). Filling used cement in 9 cases (7%) and bone graft in 127 (93%). Cumulative incidence functions were calculated.

RESULTS

There were 171 revision procedures in 92 patients: 43 for mechanical reasons, 30 for infection, 86 for tumor recurrence, 12 for other causes. Cumulative incidence of revision at 10years was 36% (95% CI: 27-44) for recurrence, 26% (95% CI: 17-36) for mechanical causes, and 13% (95% CI: 9-19) for infection, for overall cumulative incidence of revision of 61% (95% CI: 50-69).

DISCUSSION

Risk of all-cause surgical revision in giant cell tumor of bone was 61% at 10years, with recurrence accounting for only half of cases.

LEVEL OF EVIDENCE

IV.