Features of grade 3 giant cell tumors of the distal radius associated with successful intralesional treatment

Evaluating Extended Curettage and Adjuvant Therapy Against Wide Resection and Reconstruction in the Management of Distal Radius Giant Cell Tumors: A Systematic Review and Meta-analysis

BACKGROUND

The management of distal radius giant cell tumors (GCTs) remains challenging, and the optimal approach is still a matter of debate. This systematic review and meta-analysis aimed to compare the outcomes of extended curettage and wide resection, the mainstays of treatment.

METHODS

Medline (via PubMed), Cochrane Library, Web of Science, Google Scholar, ClinicalTrials.gov, and Embase databases were searched for comparative studies that assessed extended curettage with adjuvant therapy and wide resection with reconstruction in patients with GCTs of the distal radius up to April 2023. Data were collected and analyzed on rates of local recurrence, metastasis, overall complications, and functional outcomes. The Newcastle-Ottawa scale was used to appraise the risk of bias within each study.

RESULTS

Fifteen studies (n = 373 patients) were included and analyzed. Patients who underwent curettage were more likely to develop recurrence (risk ratio [RR] = 3.02 [95% confidence interval; CI, 1.87-4.89], P < .01), showed fewer complications (RR = 0.32 [95% CI, 0.21-0.49], P < .01), and showed greater improvement in Visual Analog Scale and lower Disabilities of the Arm, Shoulder, and Hand scores (P < .00001) than those who underwent wide resection. No significant difference was found regarding metastasis (RR = 1.03 [95% CI, 0.38-2.78], P = .95).

CONCLUSIONS

Regarding the surgical approach to GCT of the distal radius, curettage with adjuvant therapy was associated with a higher likelihood of recurrence compared with wide resection with reconstruction. Nevertheless, the curettage approach resulted in significantly lower rates of operative complications, decreased pain scores, and better functional outcomes in comparison to the resection group.

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.

Wrist Reconstruction Using Free Vascularized Fibular Head Graft Following Intralesional Excision for Campanacci Grade 3 Giant Cell Tumors Involving the Articular Surface of the Distal Radius

Reconstruction with a free vascularized fibular head graft after en bloc excision of a Campanacci grade 3 giant cell tumor of bone in the distal radius can effectively control local recurrence. However, it leads to the loss of wrist movement, subsequent radiocarpal subluxation, and an osteoarthritic change. Another treatment option for grade 3 lesions is intralesional excision and cementation, which preserves wrist movement but does not restore the articular surface. We report a case of wrist reconstruction using a free vascularized fibular head graft after the intralesional excision of a Campanacci grade 3 giant cell tumor of bone with invasion of the articular surface of the distal radius. In patients with this type of a lesion, wrist reconstruction using a free vascularized fibular head graft after intralesional excision can help prevent local tumor recurrence, restore the articular surface, and maintain movements of the wrist joint.

Curettage versus wide resection followed by arthrodesis/arthroplasty for distal radius Giant cell tumours: A meta-analysis of treatment and reconstruction methods

Purpose

Primary aim of this review was to compare the two treatment modalities-curettage and wide excision (WE)- of Giant cell tumours of distal radius along with the methods of reconstruction viz. arthrodesis (AD) and arthroplasty (AP), and determine which had a better outcome.

Methods

PubMed and Cochrane library databases were systematically searched using a well-defined search strategy by two independent reviewers. Inclusion/exclusion criteria were predetermined using the PICO format. MINORS tool was used to evaluate study quality. Recurrence rate (RR) was the chief oncological determinant whereas range of motion, grip strength, disability of arm, shoulder and hand (DASH) and musculoskeletal tumour society (MSTS) scores and complication rates were the functional outcome measures used.

Results

For the first part, a total of 11 articles (284 patients) were analysed. The second half- AP versus AD-included four studies (71 patients). Quantitative analysis revealed a significantly higher RR (Odds ratio (OR) 8.6 [95% CI, 3.4, 21.75]) with curettage. WE, on the other hand, was associated with a higher complication rate (OR 0.3[ 95% CI, 0.14, 0.62]) and lower grip strength (Standard Mean Difference (SMD) 18.08[95% CI, 13.78, 22.37]). Complication rates were also significantly higher with wrist AP (OR 6.36[ 95% CI, 1.72, 23.52]). Remaining functional parameters failed to show any significant difference between either group.

Conclusion

WE is the preferred surgical strategy in terms of lower RR and functionally equivalent results. In terms of the choice of reconstruction following WE, there is a trend towards higher patient satisfaction after wrist AD.

Global Prevalence and Risk of Local Recurrence following Cryosurgery of Giant Cell Tumour of Bone: A Meta-Analysis

Simple Summary

Giant cell tumours are benign but locally aggressive and can potentially metastasise to the lungs. Reducing the risk of local recurrence while maintaining limb function and minimising adverse consequences is the best therapeutic strategy in treating giant cell tumours. Based on our observation through this meta-analysis, cryosurgery is one of the viable treatment options that can provide good oncologic and functional outcomes with minimal complication rates.

Abstract

The challenge in the surgical treatment of giant cell tumours of bone is the relatively high recurrence rate after curettage alone. The use of a local adjuvant following curettage, on the other hand, has lowered the rate of recurrence. This systematic review and meta-analysis aimed to investigate the prevalence and risk of local recurrence of giant cell tumours of the bone after cryosurgery and the subsequent complications. Web of Science, Scopus, ScienceDirect, PubMed, and Google Scholar were searched to identify articles published until 13 October 2021. A random-effects model was used to examine the pooled prevalence and risk ratio (RR) of local recurrence in patients with giant cell tumours after cryosurgery with 95% confidence intervals (CIs). This study was registered with PROSPERO (CRD42020211620). A total of 1376 articles were identified, of which 38 studies (n = 1373, 46.2% male) were included in the meta-analysis. Following cryosurgery, the pooled prevalence of local recurrence in giant cell tumours was estimated as 13.5% [95% CI: 9.3–17.8, I² = 63%], where European subjects exhibited the highest prevalence (24.2%). Compared to other local adjuvants. The RR of local recurrence following cryosurgery was 0.85 (95% CI: 0.63–1.17, I² = 15%), which was not statistically significant compared to other local adjuvants. We found 3.9% fracture, 4.0% infection, 2.1% nerve injury, and 1.5% skin necrosis as the common complications. Based on the sensitivity analyses, this study is robust and reliable. This meta-analysis estimated a low prevalence of local recurrence of giant cell tumours with low complications following cryosurgery. Thus, it can be one of the adjuvant options for treating giant cell tumours.

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.

Management of giant cell tumors of the distal radius: a systematic review and meta-analysis

PURPOSE

The treatment of giant cell tumors (GCT) of the distal radius remains challenging, with no consensus on the optimal surgical management. Surgical management remains the mainstay of treatment with options including intralesional curettage and en-bloc resection with reconstruction. The objective of this systematic review and meta-analysis was to evaluate and compare the outcomes of these two procedures.

METHODS

Using OVID-Medline and Embase databases, a systematic literature search was performed. Comparative studies, assessing intralesional curettage and en-bloc resection in patients with GCTs of the distal radius, were included. Data regarding rates of local recurrence, metastasis, overall complications, and functional outcomes, were collected and analyzed. The ROBINS-I tool was utilized for risk of bias appraisal within each study outcome.

RESULTS

Thirteen studies (n = 373 patients) reporting on 191 intralesional curettage procedures and 182 en-bloc resections were included in the analysis. The average age of participants was 31.9 (SD ± 2.4) years and average follow-up was 7.1 (SD ± 3.6) years. Patients that underwent intralesional curettage were more likely to develop local recurrence (Risk Ratio (RR) 3.3, 95% CI, [2.1, 5.4], p < 0.00001) when compared to patients that underwent en-bloc resection. In Campanacci grade 3 lesions, the risk for local recurrence was 5.9 (95% CI, [2.2, 16.3], p = 0.0006) times higher in patients that received intralesional curettage. Patients that underwent intralesional curettage showed an 84% reduction in the relative risk of developing overall complications compared to en-bloc resection (95% CI, [0.1, 0.4], p < 0.00001), and a larger decrease in Visual Analog Scale and lower Disabilities of the Arm, Shoulder, and Hand (DASH) scores (p < 0.00001). Risk ratio for developing a local recurrence, with PMMA versus bone graft following an intralesional procedure was not significant (RR 1.2, 95% CI, [0.6, 2.6], p = 0.62).

CONCLUSIONS

In the surgical management of GCT of the distal radius, intralesional curettage increased local recurrence compared to en-bloc resection with reconstruction, particularly in grade 3 tumors. However, it led to significantly fewer operative complications, lower pain scores, and improved functional outcomes compared to en-bloc resection. Both treatment options remain relevant in the contemporary management of GCTs of the distal radius. Surgical decision making should include both patient and tumor factors when determining the optimal treatment strategy for these patients. LEVEL 3 EVIDENCE: Meta-analysis of Level 3 studies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Vascularized Ulnar Transposition and Ulno-scapholunate Fusion for Reconstructing Campanacci Grade 3 Giant Cell Tumor of Distal Radius: Technique and a Series of 5 Cases

Campanacci grade 3 distal radius giant cell tumors are difficult to treat and just doing a curettage and bone grafting is insufficient. These lesions are associated with a high chance of recurrence. We are presenting our technique and series of 5 patients who underwent enbloc excision and ulna transposition with ulno-scapholunate fusion. Between 2014 and 2017 5 patients underwent en bloc excision of Campanacci grade 3 giant cell tumor of the distal radius, ulna transposition and ulno carpal fusion. These patients were regularly followed for evidence of union, range of motion, grip strength, and to look for recurrence of tumor. All 5 patients were Campanacci grade 3 tumors. The average duration of symptoms was 5 months (1 to 9 mo). The average duration of follow-up was 33 months (24 to 48 mo). The average time for ulno-scapholuante fusion was 8 weeks (6 to 10 wk) and the average time to radio ulnar fusion was 14.5 weeks (12 to 16 wk). The average arc of wrist flexion and extension was 34 degrees. The average grip strength was 58.2% of the contralateral side (48% to 69%). In conclusion vascularized ulnar transposition with partial wrist fusion for a Camapanacci grade 3 giant cell tumor is an alternate procedure in the management of these difficult tumors.

Denosumab for Bone Giant Cell Tumor of the Distal Radius

There are conflicting reports regarding the outcome and effect of denosumab for distal radius giant cell tumor of bone (GCTB). The authors performed this study to evaluate the behavior of distal radius GCTB in relation to the type of treatment and the administration of denosumab. The files of 72 patients with distal radius GCTB treated from 1984 to 2018 were reviewed. Fourteen patients were administered denosumab. Surgical treatment consisted of curettage (25 patients) or resection (47 patients) and allograft or vascularized fibular head graft reconstruction. Median follow-up was 63.1 months (interquartile range [IQR], 35.5-107.1 months). The authors evaluated local recurrences, metastasis, function, and complications. The local recurrence rate was 30.6% at a median of 14.0 months (IQR, 10-19 months), with no difference between curettage and resection. The local recurrence rate was significantly higher in the patients who received denosumab. The metastasis rate was 9.7% at a median of 41.0 months (IQR, 15-114 months), with no difference regarding denosumab administration. Function was significantly better in patients after curettage. The complication rate was 25%; vascularized fibular graft reconstruction was associated with fewer complications. This study found that denosumab increases the risk of local recurrence after curettage, function is better after curettage, and vascularized fibular graft is the optimal reconstruction after resection of distal radius GCTB. [Orthopedics. 2020;43(5):284-291.].

Giant Cell Tumors of the Upper Extremity: Predictors of Recurrence

PURPOSE

Giant cell tumors (GCT) of the distal radius are thought to be more aggressive than in other locations. Therefore, the aim of this study was to investigate factors associated with recurrence of GCTs in the upper extremity.

METHODS

We retrospectively identified 82 patients who underwent primary surgical treatment for an upper extremity GCT. Tumors were located in the radius (n = 47), humerus (n = 17), ulna (n = 9), and hand (n = 9). Treatment consisted of either wide resection or amputation or intralesional resection with or without adjuvants. A multivariable logistic regression was performed including tumor grade, type of surgery, and tumor location, from which the percentage of contribution to the model of each variable was calculated.

RESULTS

The recurrence rate after intralesional resection was 48%; after wide resection or amputation, it was 12%. Two patients developed a pulmonary metastasis (2.4%). In multivariable analysis, intralesional resection was independently associated with recurrence. Intralesional resection had a 77% contribution to predict recurrence and the distal radius location had a 16% contribution in the predictive model.

CONCLUSIONS

As expected, intralesional resection was the strongest independent predictor of recurrence after surgical treatment for GCT. The distal radius location contributed to the prediction of giant cell tumor recurrence to a lesser extent.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Extended intralesional curettage preferred over resection-arthrodesis for giant cell tumour of the distal radius

BACKGROUND

Distal radius giant cell tumour (GCT) is known to be associated with distinct management difficulties, including high rates of local recurrence and lung metastases compared to other anatomic locations. Multiple treatment options exist, each with different outcomes and complications.

QUESTIONS/PURPOSES

To compare oncological and functional outcomes and complications following treatment of patients with distal radius GCT by extended intralesional curettage (EIC) or resection-arthrodesis.

METHODS

Patients operated on for distal radius GCT were identified from prospectively collected databases at four Canadian musculoskeletal oncology specialty centres. There were 57 patients with a mean age of 35.4 years (range 17-57). Thirteen tumours were Campanacci grade 2, and 40 were Grade 3 (4 unknown). Twenty patients presented with an associated pathologic fracture. There were 34 patients treated by EIC and 23 by en bloc resection and wrist arthrodesis. All resections were performed for grade 3 tumours. The mean follow-up was 86 months (range 1-280).

RESULTS

There were a total of 11 (19%) local recurrences: 10 of 34 (29%) in the EIC group compared to only 1 of 23 (4%) in the resection-arthrodesis group (p = 0.028). For the 10 patients with local recurrence following initial treatment by EIC, 7 underwent repeat EIC, while 3 required resection-arthrodesis. The one local recurrence following initial resection was managed with repeat resection-arthrodesis. Six of the 11 local recurrences followed treatment of Campanacci grade 3 tumours, while 4 were in grade 2 lesions and in one case of recurrence the grade was unknown. There were no post-operative complications after EIC, whereas 7 patients (30%) had post-operative complications following resection-arthrodesis including 4 infections, one malunion, one non-union and one fracture (p = 0.001). The mean post-operative Musculoskeletal Tumor Society score was 33.5 in the curettage group compared to 27 in the resection group (p = 0.001). The mean Toronto Extremity Salvage Score was 98.3% following curettage compared to 91.5% after resection (p = 0.006). No patients experienced lung metastasis or death.

CONCLUSIONS

EIC is an effective alternative to wide resection-arthrodesis following treatment of distal radius GCT, with the advantage of preserving the distal radius and wrist joint function, but with a higher risk of local recurrence. Most local recurrences following initial treatment by EIC could be managed with iterative curettage and joint preservation. Wide excision and arthrodesis were associated with a significantly lower risk of tumour recurrence but was technically challenging and associated with more frequent post-operative complications. EIC was associated with better functional scores. Resection should be reserved for the most severe grade 3 tumours and recurrent and complex cases not amenable to treatment with EIC and joint salvage.

LEVEL OF EVIDENCE

III, retrospective comparative trial.

Giant Cell Tumor of Distal Radius After Open Reduction Internal Fixation for Distal Radius Fracture

Case:

A 77-year-old woman presented with volar wrist pain 1.5 years after undergoing distal radius volar locked plating for fracture. Radiographs and CT were notable only for plate prominence, and she was admitted for removal of hardware. Intraoperatively, a large cavitary bone lesion was found. Histopathology demonstrated a giant cell tumor of the bone. Definitive management consisted of wide en bloc resection and osteoarticular allograft reconstruction, which achieved local control and an acceptable clinical result.

Conclusion:

Although not previously described, a giant cell tumor of the bone may develop after fracture. Metal artifact in an area of previous internal fixation can make recognition challenging, but dual-energy CT can be used to decrease this artifact. Local control can be achieved with wide excision and reconstruction.

Vascularized Iliac Bone Lining in Downgraded Treatment of Campanacci Grade III Giant Cell Tumor of the Distal Radius

It is commonly accepted that wide en bloc resection followed by reconstruction is essential in progressive lesions (Campanacci grade III) for local control of possible recurrence. However, specific grade III can be downgraded and treated with intralesional curettage to preserve better wrist function, without increasing the recurrency rates. In this report, Grade III giant cell tumor of the distal radius was successfully treated using vascularized osseous graft from the inner lip of the iliac bone in addition to downgrading strategy.

Treatment of giant cell tumor of distal radius with limited soft tissue invasion: Curettage and cementing versus wide excision

BACKGROUND

Intralesional curettage and adjuvant versus wide en bloc excision (WEE) as the best treatment method of giant cell tumor (GCT) of distal radius with limited soft tissue extension is a controversial topic.

METHODS

Prospectively, 13 patients who had GCT of distal radius with perforation of either volar or dorsal cortex of the bone and soft tissue extension which was confined to one plane were enrolled in the study. Six patients treated with ICC and seven cases cured by WEE technique and proximal fibular arthroplasty. The results were evaluated based on recurrence, range of motion of the wrist joint, rotation of the forearm, grip and pinch power.

RESULTS

The mean age of the patients treated with ICC and WEE techniques were 32.7 (range: 23-43) and 34.5 (range: 28-44), respectively. Mean follow-up period was 72 months (range: 28-148). Local recurrence was seen in 4 of 6 patients (66.7%) underwent ICC technique but in none of the 7 subjects treated with WEE technique (P value = 0.021). The overall range of flexion/extension and supination/pronation in the WEE group were 83% and 92% of the ICC group, respectively. Both of pinch and grip power were 14% less in the WEE group compared to the ICC group.

CONCLUSIONS

In GCT lesion of distal radius even with limited soft tissue extension, WEE and proximal fibular arthroplasty may be a more reasonable suggestion when the patient seeks a one-shot surgery.

Epidemiological and Clinical Features of Primary Giant Cell Tumors of the Distal Radium: A Multicenter Retrospective Study in China

Giant cell tumors of the distal radius are challenging for surgeons because they are associated with high recurrence rates and poor functional outcomes. Between June 2005 and October 2015, patients with primary giant cell tumors of the distal radius were recruited from seven orthopedic centers in China. The patients’ clinical features and demographic characteristics were obtained from medical records and reviewed retrospectively. Overall, 48 cases of giant cell tumors of the distal radius were assessed in this study. These patients were more likely to be between 20 and 40 years of age, to have a Campanacci grade of III, and to undergo a surgical style of resection. The prevalence of pathological fractures was 12.5% overall (20.0% in men and 4.3% in women). The prevalence of local recurrence was 30.0% overall (38.1% in men and 21.1% in women) during the average follow-up period of 62.5 months, with a pulmonary metastasis rate of 5.0%. Giant cell tumors of the distal radius were predominant in men and were more likely to recur locally than around the knee. These findings suggest that it is crucial to evaluate the optimal surgical approach for balancing local recurrence control and functional outcomes to reduce the disease burden.

Does Wrist Arthrodesis With Structural Iliac Crest Bone Graft After Wide Resection of Distal Radius Giant Cell Tumor Result in Satisfactory Function and Local Control?

BACKGROUND

Many techniques have been described for reconstruction after distal radius resection for giant cell tumor with none being clearly superior. The favored technique at our institution is total wrist fusion with autogenous nonvascularized structural iliac crest bone graft because it is structurally robust, avoids the complications associated with obtaining autologous fibula graft, and is useful in areas where bone banks are not available. However, the success of arthrodesis and the functional outcomes with this approach, to our knowledge, have only been limitedly reported.

QUESTIONS/PURPOSES

(1) What is the success of union of these grafts and how long does it take? (2) How effective is the technique in achieving tumor control? (3) What complications occur with this type of arthrodesis? (4) What are the functional results of wrist arthrodesis by this technique for treating giant cell tumor of the distal radius?

METHODS

Between 2005 and 2013, 48 patients were treated for biopsy-confirmed Campanacci Grade III giant cell tumor of the distal radius. Of those, 39 (81% [39 of 48]) were treated with wrist arthrodesis using autogenous nonvascularized iliac crest bone graft. Of those, 27 (69% [27 of 39]) were available for followup at a minimum of 24 months (mean, 45 months; range, 24-103 months). During that period, the general indications for this approach were Campanacci Grade III and estimated resection length of 8 cm or less. Followup included clinical and radiographic assessment and functional assessment using the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Musculoskeletal Tumor Society (MSTS) score, grip strength, and range of motion at every followup by the treating surgeon and his team. All functional results were from the latest followup of each patient.

RESULTS

Union of the distal junction occurred at a mean of 4 months (± 2 months) and union of the proximal junction occurred at a mean of 9 months (± 5 months). Accounting for competing events, at 12 months, the rate of proximal junction union was 56% (95% confidence interval [CI], 35%-72%), whereas it was 67% (95% CI, 45%-82%) at 18 months. In total, 11 of the 27 patients (41%) underwent repeat surgery on the distal radius, including eight patients (30%) who had complications and three (11%) who had local recurrence. The mean DASH score was 9 (± 7) (value range, 0-100, with lower scores representing better function), and the mean MSTS 1987 score was 29 (± 1) (value range, 0-30, with higher scores representing better function) as well as 96% (± 4%) of mean MSTS 1993 score (value range, 0%-100%, with higher scores representing better function). The mean grip strength was 51% (± 23%) of the uninvolved side, whereas the mean arc of forearm rotation was 113° (± 49°).

CONCLUSIONS

Reconstruction of defects after resection of giant cell tumor of the distal radius with autogenous structural iliac crest bone graft is a facile technique that can be used to achieve favorable functional results with complications and recurrences comparable to those of other reported techniques. We cannot show that this technique is superior to other options, but it seems to be a reasonable option to consider when other reconstruction options such as allografts are not available.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Giant cell tumor of distal radius treated with ulnar translocation and wrist arthrodesis

INTRODUCTION

The aim is to analyze the functional outcomes of patients of giant cell tumor (GCT) of distal radius treated with ulnar translocation and wrist arthrodesis.

METHODS

Study included 25 patients of aggressive GCT of distal radius, resected and reconstructed using ulnar translocation and wrist arthrodesis. The ulna-carpal radius fixation was performed with plate and screws. The patients were followed to bony union and minimum follow-up was 1 year.

RESULT

Twenty-two patients were of Campanacci grade 3 and three patients were of Campanacci grade2. The mean follow-up was of 23 months (12-36). All patients had an excellent range of pronation and supination. The mean Musculoskeletal Tumor Society score was 24 (range 22-28). Grip strength of affected hand compared to the contra lateral hand was found good in 17 cases and average in 7 cases. The mean bone union time at ulna to radius junction was at 6.5 (5-8) months and ulna to carpal junction at 4.5 (4-6) months. The complications were surgical site infection (one case), recurrence (one case) and failure of union (one case), and ulna graft fracture with implant failure in (two cases).

CONCLUSION

Reconstruction of distal end of radius using ulnar translocation and wrist arthrodesis provides excellent functional outcomes with preservation of rotational movement of forearm and hand function. Reconstruction of the distal radius by ulnar translocation without complete detachment from surrounding soft tissues functions like vascularized graft without use of microvascular techniques.

Clinical effects of three surgical approaches for a giant cell tumor of the distal radius and ulna

The aim of the present study was to assess the curative effects of three surgical approaches for a giant cell tumor (GCT) of the distal radius and ulna. A total of 27 patients with GCT on distal radius and ulnas (7 and 20, respectively), confirmed by biopsy, were treated with individualized treatment regimens, according to the Campanacci's grade system: i) Curettage plus inactivated tumor bed and allogeneic bone graft/bone cement augmentation for Campanacci's grade I GCT of the distal radius and ulna (Group A); ii) simple en bloc resection for Campanacci's grade II and III GCT of the distal ulna (Group B); iii) en bloc resection and reconstruction with non-vascularized fibular autograft/allogeneic bone graft for Campanacci's II and III GCT of the distal radius (Group C). Postoperative recurrence and complications were recorded. The Musculoskeletal Tumor Society Score was used to assess functional results. The mean follow-up time was 25 months (range, 9-125 months). A total of 3 patients exhibited tumor recurrence at 9, 11 and 15 months following surgery (1 case succumbed to pulmonary metastasis at 27 months). Overall, the incidence of the postoperative recurrence of the GCT of the distal ulna and radius were 14.3 (1/7) and 10% (2/20), respectively, with a statistical P-value of 0.762. No statistically significant difference was observed regarding the incidence of the postoperative recurrence, postoperative complications and MSTS results among the three surgical approaches for the GCT on distal ulna and radius (all P>0.05). However, statistically significant differences were noted when the incidence of the postoperative recurrence of curettage (Group A) was compared with that of en bloc resection (Groups B and C) (P=0.024). In conclusion, in order to achieve the best clinical effects for patients with GCT on distal radius and ulna, individualized treatment regimens must be designed according to the different Campanacci's grades and tumor locations.

Advantages of Pressurized-Spray Cryosurgery in Giant Cell Tumors of the Bone

BACKGROUND

Giant Cell Tumor is considered a benign, local and aggressive tumor. Although considered a benign bone tumor, it is still the subject of discussion and research because of the associated local bone destruction, as well as high rates of recurrence and distant metastases. Options are being developed for both surgical techniques and adjuvant therapies.

AIMS

The present study evaluated the administration of cryotherapy via a pressurized-spray technique in giant cell tumors of the bone.

STUDY DESIGN

Cross-sectional study.

METHODS

The study included 40 patients who were treated with extensive curettage and cryotherapy at various locations during the period from February 2006 to December 2013. Informed consent forms were obtained from the participants and ethics committee approval was taken from the local ethics committee of Ondokuz Mayıs University. The pressurized-spray technique was performed using liquid nitrogen. The patients were evaluated with respect to age, gender, radiological appearance, treatment modality, duration of follow-up, skin problems and recurrence.

RESULTS

Twenty-one patients were female; 19 were male. The average age of the patients was 33 years (range: 16-72 years), and the average duration of follow-up was 43 months (range: 12-80 months). The average time from the onset of the complaints to the diagnosis was 6 months (range: 2-12 months). Based on the Campanacci classification: 9 patients were Grade I; 25 patients were Grade II; six patients were Grade III. The lesion was located in the femur in 14 patients, in the tibia in 11 patients, in the radius in 5 patients, in the pelvis in 4 patients, in the fibula in 3 patients, in the metatarsal in 2 patients and in the phalanges of the hand in one patient. One patient had postoperative early fracture. None of the patients had skin problems and infection. Three (7.5%) of the patients had recurrence.

CONCLUSION

It was found that cryotherapy was highly effective in the lesions, especially those located in the femur and tibia and remained insufficient in the lesions expanded outside the cortex. Wound healing problems, infection and fracture risk are lower with this technique.

Is intralesional treatment of giant cell tumor of the distal radius comparable to resection with respect to local control and functional outcome?

BACKGROUND

A giant cell tumor is a benign locally aggressive tumor commonly seen in the distal radius with reported recurrence rates higher than tumors at other sites. The dilemma for the treating surgeon is deciding whether intralesional treatment is adequate compared with resection of the primary tumor for oncologic and functional outcomes. More information would be helpful to guide shared decision-making.

QUESTIONS/PURPOSES

We asked: (1) How will validated functional scores, ROM, and strength differ between resection versus intralesional excision for a giant cell tumor of the distal radius? (2) How will recurrence rate and reoperation differ between these types of treatments? (3) What are the complications resulting in reoperation after intralesional excision and resection procedures? (4) Is there a difference in functional outcome in treating a primary versus recurrent giant cell tumor with a resection arthrodesis?

METHODS

Between 1985 and 2008, 39 patients (39 wrists) were treated for primary giant cell tumor of the distal radius at two academic centers. Twenty patients underwent primary intralesional excision, typically in cases where bony architecture and cortical thickness were preserved, 15 underwent resection with radiocarpal arthrodesis, and four had resection with osteoarticular allograft. Resection regardless of reconstruction type was favored in cases with marked cortical expansion. A specific evaluation for purposes of the study with radiographs, ROM, grip strength, and pain and functional scores was performed at a minimum of 1 year for 21 patients (54%) and an additional 11 patients (28%) were available only by phone. We also assessed reoperations for recurrence and other complications via chart review.

RESULTS

With the numbers available, there were no differences in pain or functional scores or grip strength between groups; however, there was greater supination in the intralesional excision group (p=0.037). Tumors recurred in six of 17 wrists after intralesional excision and none of the 15 after en bloc resection (p=0.030). There was no relationship between tumor grade and recurrence. There were 12 reoperations in eight of 17 patients in the intralesional excision group but only one of 11 patients (p=0.049) who underwent resection arthrodesis with distal radius allograft had a reoperation. There were no differences in functional scores whether resection arthrodesis was performed as the primary procedure or to treat recurrence after intralesional excision.

CONCLUSIONS

Resection for giant cell tumor of the distal radius with distal radius allograft arthrodesis showed a lower recurrence rate, lower reoperation rate, and no apparent differences in functional outcome compared with joint salvage with intralesional excision. Because an arthrodesis for recurrence after intralesional procedures seems to function well, we believe that intralesional excision is reasonable to consider for initial treatment, but the patient should be informed about the relative benefits and risks of both options during the shared decision-making process. Because arthrodesis after recurrence functions similar to the initial resection and arthrodesis, an initial treatment with curettage remains a viable, and likely the standard, mode of treatment for most giant cell tumors of the distal radius unless there is extensive bone loss.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Targeting the giant cell tumor stromal cell: functional characterization and a novel therapeutic strategy

Giant cell tumor of bone (GCTB) is a benign, locally destructive neoplasm, with tumors comprised of mesenchymal fibroblast-like stromal cells; monocytic, mononuclear cells of myeloid lineage; and the characteristic osteoclast-like, multinucleated giant cells. Hampering the study of the complex interaction of its constituent cell types is the propensity of longstanding, repeatedly passaged cell cultures to undergo phenotypic alteration and loss of osteoclast-inducing capacities. In this study, we employed a novel, single-step technique to purify freshly harvested stromal cells using a CD14-negative selection column. Using 9 freshly harvested GCTB specimens and the purified stromal cell component, we performed analyses for markers of osteoblast lineage and analyzed the capacity of the stromal cells to undergo osteoblastic differentiation and induce osteoclastogenesis in co-cultures with monocytic cells. Successful purification of the CD14-negative stromal cells was confirmed via flow cytometric analysis and immunocytochemistry. Osteogenic media upregulated the expression of osteocalcin, suggesting an osteoblastic lineage of the GCTB stromal cells. The effects of the Wnt pathway agonist, SB415286, and recombinant human bone morphogenetic protein (BMP)-2 on osteoblastogenesis varied among samples. Notably, osteogenic media and SB415286 reversed the receptor activator of NF-κB ligand (RANKL)/osteoprotegerin (OPG) expression ratio resulting in diminished osteoclastogenic capacity. Recombinant human BMP2 had the opposite effect, resulting in enhanced and sustained support of osteoclastogenesis. Targeting the giant cell tumor stromal cell may be an effective adjunct to existing anti-resorptive strategies.

A Systematic Review and Meta-Analysis of En-Bloc vs Intralesional Resection for Giant Cell Tumor of Bone of the Distal Radius

Introduction:

Surgical management of Giant Cell Tumor of Bone of the distal radius (GCTDR) remains controversial due to risk of local recurrence (LR) offset by functional limitations which result from en-bloc resection. This study aims to determine the oncologic and functional outcomes of wide excision (WE) vs intralesional curettage (IC) of GCTDR.

Methods:

A complete search of the applicable literature was done. Included studies reported on patients from the same cohort who were surgically treated for GCTDR with WE or IC. Two reviewers independently assessed all papers. The primary outcome measure was LR.

Results:

One-hundred-forty-one patients from six studies were included: 60 treated with WE, and 81 with IC. Five WE patients (8%) suffered LR whereas 25 IC patients (31%) did. The odds of LR were three times less in the WE group vs the IC group. MSTS1993 scores, where available, were on average 'good' with WE and 'excellent' with IC.

Conclusions:

Within statistical limitations the data support an attempt, where feasible, at wrist joint preservation and superior function with IC. Intralesional curettage is reasonable when the functional benefit outweighs the risk of recurrence as is the case in many cases of GCT of the distal radius.

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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