L4 and L5 spondylectomy for en bloc resection of giant cell tumor and review of the literature

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

STUDY DESIGN

Retrospective study.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Free Vascularized Fibula Graft with Femoral Allograft Sleeve for Lumbar Spine Defects After Spondylectomy of Malignant Tumors: A Case Report

CASE

We present a 65-year-old man with an L4 conventional chordoma. Total en bloc spondylectomy (TES) of the involved vertebral bodies and surrounding soft tissues with reconstruction of the spine using a free vascularized fibula autograft (FVFG) is a proven technique, limiting complications and recurrence. However, graft fracture has occurred only in the lumbar spine in our institutional cases. We used a technique in our patient to ensure extra stability and support, with the addition of a femoral allograft sleeve encasing the FVFG.

CONCLUSIONS

Our technique for the reconstruction of the lumbar spine after TES of primary malignant spinal disease using a femoral allograft sleeve encasing the FVFG is viable to consider.

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

BACKGROUND

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

CASE DESCRIPTION

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

CONCLUSIONS

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

Successful total en bloc spondylectomy of the L3 vertebra with a paravertebral giant cell tumor following preoperative treatment with denosumab: a case report

BACKGROUND

Giant cell tumor is known to be a benign neoplasm that arises most commonly in the long bones, while cases in the spine are rare. Recently, denosumab, a monoclonal antibody that inhibits receptor activator of nuclear factor-kappa β ligand, has been used to treat patients with giant cell tumor. However, there are few reports of total en bloc spondylectomy being used for paravertebral giant cell tumor lesions following denosumab therapy.

CASE PRESENTATION

Our patient was a 20-year-old Japanese woman with a 4-month history of lower back pain. A spinal computed tomography scan and magnetic resonance imaging of her lumbar spine revealed an osteolytic lesion involving the L3 vertebral body, and the tumor extended toward the left side of the paravertebral soft tissue and into the left pedicle. The lesion was diagnosed as a giant cell tumor by needle biopsy. Denosumab treatment calcified the paravertebral giant cell tumor lesion and the tumor vertebral body was removed completely by total en bloc spondylectomy.

CONCLUSION

This case report describes a patient with a paravertebral giant cell tumor who was successfully treated by preoperative denosumab injection followed by total en bloc spondylectomy.

Total En Bloc Spondylectomy for Solitary Metastatic Tumors of the Fourth Lumbar Spine in a Posterior-Only Approach

BACKGROUND

Total en bloc spondylectomy (TES) significantly decreases the rate of local recurrence and provides long-term survival in patients with malignant tumor of the spine. This procedure can be performed through a posterior-only approach. However, TES for lower lumbar spine through a posterior-only approach is technically challenging.

METHODS

We retrospectively reviewed 9 patients with solitary metastatic tumors of the fourth lumbar spine who underwent TES in a posterior-only approach from June 2012 to December 2015. This series included 5 female and 4 male patients, with a mean age of 54.1 years. Endpoints included length of surgery, estimated blood loss, visual analogue scale for pain, instrumentation failure, perioperative complications, local control rate, and overall survival.

RESULTS

All patients underwent TES and circumferential reconstruction of the involved level. Average operative time and estimated blood loss were 282 minutes and 2421 mL, respectively. The mean follow-up time was 41.2 months. We encountered nerve roots stretches in all patients during the surgeries. Three patients experienced acute lower-extremity neurologic dysfunction, but the symptoms were significantly alleviated in 4 weeks postoperatively and fully resolved within 6 months. Five patients showed no evidence of disease at the latest follow-up. Three patients died of metastasis and systemic failure. One patient developed new metastases and was alive with disease. Titanium mesh cage subsidence was observed in 3 patients, but no implant failures or related clinical symptoms were found.

CONCLUSIONS

TES for the fourth lumbar spine in a posterior-only approach is feasible. Although the surgery is challenging, long-term oncologic and neurologic outcomes are satisfying.

Surgical approach selection for total spondylectomy for the treatment of giant cell tumors in the lumbar spine: A retrospective analysis of 12 patients from a single center

AIM

To describe the selection of the surgical approach used for total spondylectomy in the treatment of giant cell tumors of the lumbar spine.

METHODS

This retrospective study included 12 patients with giant cell tumors of the lumbar spine who underwent total spondylectomy. The effect of the Weinstein-Boriani-Biagini surgical staging and tumor location on the approach selected was evaluated.

RESULTS

Two tumors were treated using the posterior approach: one located in L1, extending into layers A∼D and involving sectors 2∼6, and the other located in L4, extending into layers B∼D and involving sectors 4∼11. Four tumors (one each located in L1, L2, L3, and L4) were treated by a combined posterior and anterolateral approach as the tumors involved sectors 5∼6 or 7∼8. Six tumors were treated using a combined posterior and anterior approach, two tumors located in L4, extending into layers A∼D and involving sectors 1∼12, and associated with a soft tissue mass extending into layer A and involving sectors 5∼8; and four tumors located in L5. Complications were observed in 9 of the 12 patients.

CONCLUSIONS

A posterior approach is the obvious strategy for tumors located in L1∼L4 and extending into layers B∼D or A and involving sectors 1∼3 or 10∼12. For tumors invading beyond layer A and involving sectors 1∼12, including those with a soft tissue mass extending from layer A, with involvement of sectors 4∼9, a posterior approach combined with an anterolateral or anterior approach is required. For L5 tumors, a combined posterior and anterior approach is needed.

Surgical Outcomes in Patients with High Spinal Instability Neoplasm Score Secondary to Spinal Giant Cell Tumors

Study Design Retrospective review. Objective To describe the surgical outcomes in patients with high preoperative Spinal Instability Neoplastic Score (SINS) secondary to spinal giant cell tumors (GCT) and evaluate the impact of en bloc versus intralesional resection and preoperative embolization on postoperative outcomes. Methods A retrospective analysis was performed on 14 patients with GCTs of the spine who underwent surgical treatment prior to the use of denosumab. A univariate analysis was performed comparing the patient demographics, perioperative characteristics, and surgical outcomes between patients who underwent en bloc marginal (n = 6) compared with those who had intralesional (n = 8) resection. Results Six patients underwent en bloc resections and eight underwent intralesional resection. Preoperative embolization was performed in eight patients. All patients were alive at last follow-up, with a mean follow-up length of 43 months. Patients who underwent en bloc resection had longer average operative times (p = 0.0251), higher rates of early (p = 0.0182) and late (p = 0.0389) complications, and a higher rate of surgical revision (p = 0.0120). There was a 25% (2/8 patients) local recurrence rate for intralesional resection and a 0% (0/6 patients) local recurrence rate for en bloc resection (p = 0.0929). Conclusions Surgical excision of spinal GCTs causing significant instability, assessed by SINS, is associated with high intraoperative blood loss despite embolization and independent of resection method. En bloc resection requires a longer operative duration and is associated with a higher risk of complications when compared with intralesional resection. However, the increased morbidity associated with en bloc resection may be justified as it may minimize the risk of local recurrence.

Spondylectomy for Giant Cell Tumor After Denosumab Therapy

STUDY DESIGN

A case report.

OBJECTIVE

To report a case of the lumbar giant cell tumor (GCT) utilizing a new clinical treatment modality (denosumab therapy), which showed a massive tumor reduction combined with the L4 spondylectomy.

SUMMARY OF BACKGROUND DATA

There are some controversies about spinal GCT treatments. Denosumab has provided good clinical results in terms of tumor shrinkage, and local control in a short-time follow-up clinical study phase 2, although for spinal lesions, it has not been described. Nonetheless, "en bloc" spondylectomy has been accepted as being the best treatments modalities in terms of oncological control.

METHODS

A case study with follow-up examination and series radiological assessments 6 months after therapy started, followed by a complex spine surgery.

RESULTS

The denosumab therapy showed on the lumbar computed tomography scans follow-up 6 months later, a marked tumor regression around 90% associated to vertebral body calcification, facilitating a successful L4 spondylectomy with an anterior and posterior reconstruction. The patient recovered without neurological deficits.

CONCLUSION

A new therapeutic modality for spinal GCT is available and showing striking clinical results; however, it is necessary for well-designed studies to answer the real role of denosumab therapy avoiding or facilitating complex spine surgeries as spondylectomies for spinal GCT.

LEVEL OF EVIDENCE

5.