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Liang HF, Xu H, Zhan MN, Xiao J, Li J, Fei QM. Thoracic giant cell tumor after two total en bloc spondylectomies including one emergency surgery: A case report. World J Clin Cases 2024; 12:2894-2903. [PMID: 38899300 PMCID: PMC11185343 DOI: 10.12998/wjcc.v12.i16.2894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/15/2024] [Accepted: 04/17/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND For patients with acute paraplegia caused by spinal giant cell tumor (GCT) who require emergency decompressive surgery, there is still a lack of relevant reports on surgical options. This study is the first to present the case of an acute paraplegic patient with a thoracic spinal GCT who underwent an emergency total en bloc spondylectomy (TES). Despite tumor recurrence, three-level TES was repeated after denosumab therapy. CASE SUMMARY A 27-year-old female patient who underwent single-level TES in an emergency presented with sudden severe back pain and acute paraplegia due to a thoracic spinal tumor. After emergency TES, the patient's spinal cord function recovered, and permanent paralysis was avoided. The postoperative histopathological examination revealed that the excised neoplasm was a rare GCT. Unfortunately, the tumor recurred 9 months after the first surgery. After 12 months of denosumab therapy, the tumor size was reduced, and tumor calcification. To prevent recurrent tumor progression and provide a possible cure, a three-level TES was performed again. The patient returned to an active lifestyle 1 month after the second surgery, and no recurrence of GCT was found at the last follow-up. CONCLUSION This patient with acute paraplegia underwent TES twice, including once in an emergency, and achieved good therapeutic results. TES in emergency surgery is feasible and safe when conditions permit; however, it may increase the risk of tumor recurrence.
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Affiliation(s)
- Hai-Feng Liang
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
- Department of Orthopaedic Surgery, Shanghai Geriatric Medical Center, Shanghai 201104, China
| | - Hao Xu
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Meng-Na Zhan
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jian Xiao
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Juan Li
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
- Department of Orthopaedic Surgery, Shanghai Geriatric Medical Center, Shanghai 201104, China
| | - Qin-Ming Fei
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
- Department of Orthopaedic Surgery, Zhongshan Hospital Wusong Branch, Fudan University, Shanghai 200940, China
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Adachi Y, Noguchi R, Yoshimatsu Y, Sin Y, Osaki J, Ono T, Iwata S, Akiyama T, Tsuchiya R, Toda Y, Ishihara S, Ogura K, Kobayashi E, Kojima N, Yoshida A, Yokoo H, Kawai A, Kondo T. Establishment and characterization of two novel patient-derived cell lines from giant cell tumor of bone: NCC-GCTB8-C1 and NCC-GCTB9-C1. Hum Cell 2024; 37:874-885. [PMID: 38466561 DOI: 10.1007/s13577-024-01042-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/02/2024] [Indexed: 03/13/2024]
Abstract
Giant cell tumor of bone (GCTB) is a rare osteolytic bone tumor consisting of mononuclear stromal cells, macrophages, and osteoclast-like giant cells. Although GCTB predominantly exhibits benign behavior, the tumor carries a significant risk of high local recurrence. Furthermore, GCTB can occasionally undergo malignant transformation and distal metastasis, making it potentially fatal. The standard treatment is complete surgical resection; nonetheless, an optimal treatment strategy for advanced GCTB remains unestablished, necessitating expanded preclinical research to identify appropriate therapeutic options. However, only one GCTB cell line is publicly available from a cell bank for research use worldwide. The present study reports the establishment of two novel cell lines, NCC-GCTB8-C1 and NCC-GCTB9-C1, derived from the primary tumor tissues of two patients with GCTB. Both cell lines maintained the hallmark mutation in the H3-3A gene, which is associated with tumor formation and development in GCTB. Characterization of these cell lines revealed their steady growth, spheroid-formation capability, and invasive traits. Potential therapeutic agents were identified via extensive drug screening of the two cell lines and seven previously established GCTB cell lines. Among the 214 antitumor agents tested, romidepsin, a histone deacetylase inhibitor, and mitoxantrone, a topoisomerase inhibitor, were identified as potential therapeutic agents against GCTB. Conclusively, the establishment of NCC-GCTB8-C1 and NCC-GCTB9-C1 provides novel and crucial resources that are expected to advance GCTB research and potentially revolutionize treatment strategies.
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Affiliation(s)
- Yuki Adachi
- Division of Rare Cancer Research, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
- Division of Hepato-Biliary-Pancreatic Surgery and Transplant Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1 Midorigaoka Higashi, Asahikawa, Hokkaido, Japan
| | - Rei Noguchi
- Division of Rare Cancer Research, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Yuki Yoshimatsu
- Division of Rare Cancer Research, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
- Department of Patient-Derived Cancer Model, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya, Tochigi, 320-0834, Japan
| | - Yooksil Sin
- Division of Rare Cancer Research, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Julia Osaki
- Division of Rare Cancer Research, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Takuya Ono
- Division of Rare Cancer Research, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Shuhei Iwata
- Division of Rare Cancer Research, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Taro Akiyama
- Division of Rare Cancer Research, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba-shi, 260-8670, Japan
| | - Ryuto Tsuchiya
- Division of Rare Cancer Research, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba-shi, 260-8670, Japan
| | - Yu Toda
- Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Shin Ishihara
- Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Koichi Ogura
- Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Eisuke Kobayashi
- Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Naoki Kojima
- Department of Diagnostic Pathology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Akihiko Yoshida
- Department of Diagnostic Pathology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Hideki Yokoo
- Division of Hepato-Biliary-Pancreatic Surgery and Transplant Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1 Midorigaoka Higashi, Asahikawa, Hokkaido, Japan
| | - Akira Kawai
- Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Tadashi Kondo
- Division of Rare Cancer Research, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
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Elshenawy M, Arabi TZ, Ateya HA, Elhassan T, Ali SS, Othman RK, Alkhatib R, Elshentenawy A, Badran A. The Effectiveness of Denosumab in Middle Eastern Patients With Giant Cell Tumor of the Bone: A Single-Center, Retrospective Study. Cureus 2024; 16:e58292. [PMID: 38752067 PMCID: PMC11094665 DOI: 10.7759/cureus.58292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Giant cell tumor of the bone (GCTB) is an aggressive benign tumor, which constitutes 5% of all primary bone tumors. Denosumab, a receptor activator of nuclear factor κB ligand monoclonal antibody, inhibits osteoclast-induced bone destruction and has demonstrated promising results in patients with GCTB. However, the long-term efficacy of the drug has not been extensively studied, especially in the Middle East. METHODOLOGY In this study, we retrospectively analyzed the five-year progression-free survival (PFS) in patients with GCTB at a single Saudi center. PFS was defined as the time from diagnosis until disease progression, relapse, or death. Events were censored after five years from diagnosis. RESULTS Sixty-two patients with GCTB were included in the study. The median age at diagnosis was 31.16 years, and 38 (61.3%) patients were female. Twenty-nine patients (46.8%) received denosumab during the study period. The median duration of denosumab treatment was 5.06 months, and the median number of cycles was 6. The median PFS was not reached, and the five-year PFS rate was 60.3%. Age, gender, body mass index, performance status at presentation, and tumor location had no impact on five-year PFS. Denosumab treatment prolonged PFS; however, this was not statistically significant compared to non-denosumab patients (P = 0.603). CONCLUSIONS Denosumab does not seem to provide superior long-term outcomes compared to surgery alone. Although our findings are generally consistent with other studies in the literature, larger long-term studies are needed to confirm our findings.
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Affiliation(s)
- Mahmoud Elshenawy
- Department of Medical Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU
- Department of Clinical Oncology and Nuclear Medicine, Menoufiya University, Shebin El Kom, EGY
| | - Tarek Z Arabi
- College of Medicine, Alfaisal University, Riyadh, SAU
| | - Heba A Ateya
- Department of Medical Oncology, Cairo University, Cairo, EGY
| | - Tusneem Elhassan
- Department of Medical Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU
| | - Saad S Ali
- College of Medicine, Alfaisal University, Riyadh, SAU
| | - Rana K Othman
- College of Medicine, Alfaisal University, Riyadh, SAU
| | | | - Ayman Elshentenawy
- Department of Medical Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU
| | - Ahmed Badran
- Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Ain Shams University, Cairo, EGY
- Department of Medical Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU
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He W, Li C, Zhao S, Li Z, Wu J, Li J, Zhou H, Yang Y, Xu Y, Xia H. Integrating coaxial electrospinning and 3D printing technologies for the development of biphasic porous scaffolds enabling spatiotemporal control in tumor ablation and osteochondral regeneration. Bioact Mater 2024; 34:338-353. [PMID: 38274295 PMCID: PMC10809007 DOI: 10.1016/j.bioactmat.2023.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/15/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
The osteochondral defects (OCDs) resulting from the treatment of giant cell tumors of bone (GCTB) often present two challenges for clinicians: tumor residue leading to local recurrence and non-healing of OCDs. Therefore, this study focuses on developing a double-layer PGPC-PGPH scaffold using shell-core structure nanofibers to achieve "spatiotemporal control" for treating OCDs caused by GCTB. It addresses two key challenges: eliminating tumor residue after local excision and stimulating osteochondral regeneration in non-healing OCD cases. With a shell layer of protoporphyrin IX (PpIX)/gelatin (GT) and inner cores containing chondroitin sulfate (CS)/poly(lactic-co-glycolic acid) (PLGA) or hydroxyapatite (HA)/PLGA, coaxial electrospinning technology was used to create shell-core structured PpIX/GT-CS/PLGA and PpIX/GT-HA/PLGA nanofibers. These nanofibers were shattered into nano-scaled short fibers, and then combined with polyethylene oxide and hyaluronan to formulate distinct 3D printing inks. The upper layer consists of PpIX/GT-CS/PLGA ink, and the lower layer is made from PpIX/GT-HA/PLGA ink, allowing for the creation of a double-layer PGPC-PGPH scaffold using 3D printing technique. After GCTB lesion removal, the PGPC-PGPH scaffold is surgically implanted into the OCDs. The sonosensitizer PpIX in the shell layer undergoes sonodynamic therapy to selectively damage GCTB tissue, effectively eradicating residual tumors. Subsequently, the thermal effect of sonodynamic therapy accelerates the shell degradation and release of CS and HA within the core layer, promoting stem cell differentiation into cartilage and bone tissues at the OCD site in the correct anatomical position. This innovative scaffold provides temporal control for anti-tumor treatment followed by tissue repair and spatial control for precise osteochondral regeneration.
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Affiliation(s)
- Wenbao He
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Chunlin Li
- Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shitong Zhao
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Zhendong Li
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jing Wu
- Jinan Clinical Research Centre for Tissue Engineering Skin Regeneration and Wound Repair, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Junjun Li
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haichao Zhou
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yunfeng Yang
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
- Department of Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yong Xu
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Huitang Xia
- Department of Plastic Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, 250014, PR China
- Jinan Clinical Research Centre for Tissue Engineering Skin Regeneration and Wound Repair, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
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Chen X, Ye F, He H, Chen G, Chen Z, Ye E, He B, Yang Y, Zhang J. Denosumab Induces Neoplastic Stromal Cell Apoptosis Via p62 Downregulation Dependent on Autophagy Pathway in Giant Cell Tumour of Bone. Curr Cancer Drug Targets 2024; 24:565-578. [PMID: 37961860 DOI: 10.2174/0115680096265253231022185008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/13/2023] [Accepted: 08/30/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND As the only humanized monoclonal antibody against receptor activator of nuclear factor-κB ligand (RANKL) for giant cell tumour of bone (GCTB) therapy, denosumab has limited antitumour effect on neoplastic stromal cells. Nevertheless, its mechanism of action has not yet been clarified. A previous study has revealed that p62 may play an important role in the antitumour activity of denosumab. OBJECTIVE The study aimed to investigate if the mechanism by which denosumab inhibits GCTB neoplastic stromal cells growth is via p62 modulation and other related mechanisms. METHODS p62 expression before and after denosumab therapy was analysed by RT‒qPCR, western blot, ELISA, and immunohistochemical assays. Two primary neoplastic stromal cells were isolated from fresh GCTB tumour tissue (L cell) and metastatic tissue (M cell). Cell proliferation, migration, apoptosis, and autophagy were investigated in p62 knockdown neoplastic stromal cells transfected by short hairpin RNA lentivirus in vitro. Tumor growth was evaluated in the chick chorioallantoic membrane model in vivo. RESULTS p62 expression was found to be downregulated following denosumab therapy. The patients with a decrease in p62 expression had lower recurrence-free survival rates. The proliferation of M cells was not inhibited by denosumab therapy, but it was restored by p62 knockdown. Moreover, p62 knockdown inhibited tumour growth in vivo. Denosumab induced M cell apoptosis and arrested the cell cycle at the G1/G0 transition and these effects were also enhanced by p62 knockdown. Autophagic flux assays revealed p62 modulation to be dependent on autophagy following denosumab incubation. CONCLUSION Denosumab induced neoplastic stromal cells apoptosis via p62 downregulation dependent on autophagy pathway. The combination of p62 and RANKL knockdown might be a better strategy than RANKL knockdown alone for GCTB targeted therapy.
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Affiliation(s)
- Xianwei Chen
- Department of Orthopaedics, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, China
| | - Fan Ye
- Department of Orthopaedics, The First Affiliated Hospital of Nanyang Medical College, Nangyang, Henan, 473000, China
| | - Hao He
- Department of Orthopaedics, The People's Hospital of Guang'an, Guang'an, Sichuan, 638000, China
| | - Gong Chen
- Department of Orthopaedics, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, China
| | - Zhifu Chen
- Department of Orthopaedics, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, China
| | - En Ye
- Department of Pathology, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, China
| | - Bingjan He
- Department of Orthopaedics, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, China
| | - Yuqi Yang
- Department of Orthopaedics, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, China
| | - Jing Zhang
- Department of Orthopaedics, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, China
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Jha Y, Chaudhary K. Giant Cell Tumour of Bone: A Comprehensive Review of Pathogenesis, Diagnosis, and Treatment. Cureus 2023; 15:e46945. [PMID: 38022126 PMCID: PMC10640696 DOI: 10.7759/cureus.46945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
The benign aggressive tumour known as a giant cell tumour of bone (GCTB) frequently affects the knee bones. Patients suffering from GCTB present with pain, swelling, joint effusion, loss of ability to bear weight on the involved extremity and a restriction in the range of motion of the afflicted joint may also exist, depending on the tumour's size. GCTB makes up 20% of benign skeletal tumours and 5% of all primary bone tumours. Although it has an equal distribution of the sexes, the majority reveal a higher frequency among women. Eighty per cent of GCTB instances were recorded in patients between the ages of 20 and 50 during the third decade. The femur, tibia and radius are where GCTB is most frequently discovered. Lesions can be rated using the Campanacci grading method based on the plain radiograph's results. Plain radiography, CT and MRI are used to diagnose the tumour. Surgery is the only curative treatment which is determined by the Campanacci grade and the tumour's location. Recurrence of GCTB is observed in about 25% of patients, with curettage being associated with rates as high as 50%. We evaluated the GCTB-related articles and summarised the developments in diagnosis, treatment and reducing risk of recurrence.
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Affiliation(s)
- Yash Jha
- Anatomy, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Kirti Chaudhary
- Anatomy, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Hess MC, Kafchinski L, Ransom E. Giant Cell Tumor of the Distal Radius: A Review. Orthop Clin North Am 2023; 54:75-88. [PMID: 36402513 DOI: 10.1016/j.ocl.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Giant cell tumor of the distal radius presents a significant challenge in management due to high risk of recurrence and potential loss of function. Shared decision-making guides management, particularly for more advanced lesions. Intralesional curettage can optimize wrist function but at the cost of a higher recurrence risk. Wide resection decreases local recurrence but has higher complication rates regardless of reconstruction method. No functional difference exists between motion-preserving procedures and arthrodesis; therefore, patients should be clearly informed of the risks and benefits of each treatment option.
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Affiliation(s)
- Matthew C Hess
- Department of Orthopaedic Surgery, University of Alabama-Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
| | - Lisa Kafchinski
- Department of Orthopaedic Surgery, University of Alabama-Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA
| | - Erin Ransom
- Department of Orthopaedic Surgery, University of Alabama-Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA
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