En Bloc Resection Versus Intralesional Surgery in the Treatment of Giant Cell Tumor of the Spine

En-bloc resection for spinal giant cell tumors: superior outcomes-a comprehensive meta-analysis and trial sequential analysis

Spinal giant cell tumors (GCTs) management primarily involves surgical resection; however, the optimal surgical approach continues to be a subject of debate. This study aims to comprehensively compare the efficacy of en-bloc resection with that of control resection techniques, specifically intralesional curettage and piecemeal resection, in the treatment of spinal GCTs. A comprehensive search of English databases, including the Cochrane Library, Embase, PubMed, Scopus, and Web of Science, as well as Chinese databases such as the National Knowledge Infrastructure (CNKI), Chongqing VIP (VIP), and Wan Fang, was conducted up to January 2024. This search identified twelve studies encompassing 492 participants. The meta-analysis indicated that en-bloc resection significantly reduces recurrence rates (OR = 0.27, 95% CI: 0.15-0.47, P < 0.00001) and mortality (OR = 0.16, 95% CI: 0.03-0.88, P = 0.04) when compared to control resection techniques. Notably, en-bloc resection demonstrated superior performance over control methods in both 1-year and 5-year relapse-free survival (RFS) rates (P = 0.001 and P < 0.00001, respectively), as well as in overall RFS (HR = 0.27, 95% CI: 0.08-0.91; P = 0.04). Despite its advantages, en-bloc excision was associated with a higher overall complication rate (P = 0.01). Furthermore, trial sequential analysis (TSA) suggests that the current sample size is inadequate to draw definitive conclusions, thereby underscoring the necessity for further investigations. En-bloc resection shows significant advantages over control resection techniques in reducing recurrence rates, mortality, and improving RFS. However, the higher complication rates and TSA findings stress the need for more high-quality studies to verify the benefits and safety of en-bloc resection in spinal GCT treatment.

The Effect of Denosumab on Pain and Radiological Improvement in Giant Cell Tumours of the Spine in the Acute Setting

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

The current recommended treatment for Giant Cell Tumour (GCT) of the spine is en bloc excision. Denosumab is a monoclonal antibody reducing osteoclast activity that shows promising results when used as a neo - adjuvant treatment. However, the current literature remains limited. The purpose of this study was to assess the effect of denosumab on tumour characteristics and symptom relief in the acute phase of treatment of spinal GCT.

METHODS

We performed a retrospective review of 16 patients treated with denosumab as neo-adjuvant and stand - alone treatment. MRI and PET tumour characteristics were taken before and after treatment and patients were interviewed for subjective pain responses.

RESULTS

Following treatment, all patients showed improvement of pain, of which 68.7% of patients were pain free with 43.75% noting improvement within 48 hours. Mean relative volumetric reduction in tumour volume was 37.3% (P < .001). Eight patients showed high grade of Bilsky classification (Epidural spinal cord compression scale - ESCC) with seven of them showing significant improvement to low grade of ESCC (P = .016). Median baseline PET Standardised Uptake Value (SUV)max was 14.57 and post treatment was 4.8 (P < .001).

CONCLUSIONS

This study provides necessary insight to the limited literature on the use of denosumab for spinal GCT in the acute phase. The clinical and radiographic responses observed demonstrate the critical role that neo-adjuvant denosumab has by reducing the tumour burden around critical adjacent neurovascular structures before eventual resection, significant pain improvement even with presence of fractured vertebra.

Japanese orthopaedic association (JOA) clinical practice guideline on the management of primary malignant bone tumors - Secondary publication

BACKGROUND

In Japan, there are currently no general guidelines for the treatment of primary malignant bone tumors. Therefore, the Japanese Orthopaedic Association established a committee to develop guidelines for the appropriate diagnosis and treatment of primary malignant bone tumors for medical professionals in clinical practice.

METHODS

The guidelines were developed in accordance with "Minds Clinical Practice Guideline Development Handbook 2014″ and "Minds Clinical Practice Guideline Development Manual 2017". The Japanese Orthopaedic Association's Bone and Soft Tissue Tumor Committee established guideline development and systematic review committees, drawing members from orthopedic specialists leading the diagnosis and treatment of bone and soft tissue tumors. Pediatricians, radiologists, and diagnostic pathologists were added to both committees because of the importance of multidisciplinary treatment. Based on the diagnosis and treatment algorithm for primary malignant bone tumors, important decision-making points were selected, and clinical questions (CQ) were determined. The strength of recommendation was rated on two levels and the strength of evidence was rated on four levels. The recommendations published were selected based on agreement by 70% or more of the voters.

RESULTS

The guideline development committee examined the important clinical issues in the clinical algorithm and selected 22 CQs. The systematic review committee reviewed the evidence concerning each CQ and a clinical value judgment was added by experts. Eventually, 25 questions were published and the text of each recommendation was determined.

CONCLUSION

Since primary malignant bone tumors are rare, there is a dearth of strong evidence based on randomized controlled trials, and recommendations cannot be applied to all the patients. In clinical practice, appropriate treatment of patients with primary malignant bone tumors should be based on the histopathological diagnosis and degree of progression of each case, using these guidelines as a reference.

Efficacy and safety of en-bloc resection versus debulking for spinal tumor: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to consolidate the existing evidence regarding the comparison between en-bloc resection surgery and debulking surgery for spinal tumors, including both primary and metastatic tumors.

MATERIALS AND METHODS

The databases of PubMed, Embase, Cochrane database, Web of Science, Scopus, Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP Database (VIP), and Wan Fang Database was carried out and included all studies that directly compared en-bloc resection surgery with debulking surgery for spinal tumors in patients through March 2024. The primary outcomes included recurrence rate, postoperative metastasis rate, mortality rate, overall survival (OS), recurrence-free survival (RFS), complication, and so on. The statistical analysis was conducted using Review Manager 5.3.

RESULTS

We systematically reviewed 868 articles and included 27 studies involving 1135 patients who underwent either en-bloc resection surgery (37.89%) or debulking surgery (62.11%). Our meta-analysis demonstrated significant advantages of en-bloc resection over debulking surgery. Specifically, the en-bloc resection group had a lower recurrence rate (OR = 0.19, 95%CI: 0.13-0.28, P < 0.00001), lower postoperative metastasis rate (P = 0.002), and lower mortality rate (P < 0.00001). Additionally, en-bloc resection could improve OS and RFS (HR = 0.45, 95%CI: 0.32-0.62, P < 0.00001 and HR = 0.37, 95%CI: 0.17-0.80, P = 0.01, respectively). However, en-bloc resection required longer operative times and was associated with a higher overall complication rate compared to debulking surgery (P = 0.0005 and P < 0.00001, respectively).

CONCLUSION

The current evidence indicates that en-bloc surgical resection can effectively control tumor recurrence and mortality, as well as improve RFS and OS for patients with spinal tumors. However, it is crucial not to overlook the potential risks of perioperative complications. Ultimately, these findings should undergo additional validation through multi-center, double-blind, and large-scale randomized controlled trials (RCTs).

The risk of neurological deterioration while using neoadjuvant denosumab on patients with giant cell tumor of the spine presenting with epidural disease: a meta-analysis of the literature

BACKGROUND CONTEXT

Giant cell tumor (GCT) of bone is most commonly a benign but locally aggressive primary bone tumor. Spinal GCTs account for 2.7% to 6.5% of all GCTs in bone. En bloc resection, which is the preferred treatment for GCT of the spine, may not always be feasible due to the location, extent of the tumor, and/or the patient's comorbidities. Neoadjuvant denosumab has recently been shown to be effective in downstaging GCT, decreasing the size and extent of GCTs. However, the risk of neurologic deterioration is of major concern for patients with epidural spinal cord compression due to spinal GCT. We experienced this concern when a patient presented to our institution with a midthoracic spinal GCT with progressive epidural disease. The patient was not a good surgical candidate due to severe cardiac disease and uncontrolled diabetes. In considering nonoperative management for this patient, we asked ourselves the following question: What is the risk that this patient will develop neurologic deterioration if we do not urgently operate and opt to treat him with denosumab instead?

PURPOSE

The purpose of this study was to assess the literature to (1) determine the risk of neurological deterioration in patients receiving neoadjuvant denosumab for the treatment of spinal GCT and (2) to evaluate the secondary outcomes including radiographic features, surgical/technical complexity, and histological features after treatment.

STUDY DESIGN/SETTING

Meta-analysis of the literature.

PATIENT SAMPLE

Surgical cases of spinal GCT that (1) presented with type III Campanacci lesions, (2) had epidural disease classified as Bilsky type 1B or above and (3) received neoadjuvant denosumab therapy.

OUTCOME MEASURES

The primary outcome measure of interest was neurologic status during denosumab treatment. Secondary outcome measures of interest included radiographic features, surgical/technical complexity, histological features, tumor recurrence, and metastasis.

METHODS

Using predetermined inclusion and exclusion criteria, PubMed and Embase electronic databases were searched in August 2022 for articles reporting spinal GCTs treated with neoadjuvant denosumab and surgery. Keywords used were "Spine" AND "Giant Cell Tumor" AND "Denosumab."

RESULTS

A total of 428 articles were identified and screened. A total of 22 patients from 12 studies were included for review. 17 patients were female (17/22, 77%), mean age was 32 years (18-62 years) and average follow-up was 21 months. Most GCTs occurred in the thoracic and thoracolumbar spine (11 patients, 50%), followed by 36% in the lumbar spine and 14% in the cervical spine. Almost half of the patients had neurological deficits at presentation (10/22 patients, 45%), and more than 60% had Bilsky 2 or 3 epidural spinal cord compression. None of the patients deteriorated neurologically, irrespective of their neurological status at presentation (p-value=.02, CI -2.58 to -0.18). There were no local recurrences reported. One patient was found to have lung nodules postoperatively. More than 90% of cases had decreased overall tumor size and increased bone formation. Surgical dissection was facilitated in more than 85% of those who had documented surgical procedures. Four patients (18%) underwent initial spinal stabilization followed by neoadjuvant denosumab and then surgical excision of the GCT. Regarding the histologic analyses, denosumab eradicated the giant cells in 95% of cases. However, residual Receptor Activator of Nuclear Factor Kappa B Ligand (RANKL)-positive stromal cells were noted, in 27% (6 cases).

CONCLUSIONS

Neoadjuvant denosumab was a safe and effective means of treating spinal GCTs prior to surgery. Neurologic status remained stable or improved in all cases included in our review, irrespective of the presenting neurologic status. The most appropriate dosage and duration of denosumab therapy is yet to be determined. We recommend future well-designed studies to further evaluate the use of neoadjuvant denosumab for patients with spinal GCT.

Two-step osteotomy/discectomy through cannulated screw (TOCS) technique for en bloc resection of spine tumor: surgical technique and preliminary results

PURPOSE

We have developed a novel technique for osteotomy/discectomy during en bloc resection of spine tumors named two-step osteotomy/discectomy through cannulated screw (TOCS). This study aims at describing the procedure of TOCS technique and assessing its efficiency and safety.

METHODS

We retrospectively reviewed fourteen patients who underwent en bloc resection for spine tumors using TOCS technique in our center between August 2018 and September 2022. The technique was based on a specially designed "slotted" cannulated screw which was a cannulated screw with a longitudinal slot to provide the accessibility of T-saw. During osteotomy/discectomy, the "slotted" cannulated screw was inserted obliquely along the plane between the dura and the posterior wall of spine in light of the planned osteotomy/discectomy plane under routine fluoroscopic imaging guidance. The T-saw was introduced through the screw, and the osteotomy/discectomy was performed sequentially in two steps under the guidance of the screw by turning the slot away and toward the dura. The intra-/perioperative complication, neurological function (determined by Frankel grading), surgical margin (determined by a pathologist using AJCC R system), follow-up details were documented.

RESULTS

The mean duration of surgery was 599.3 (360-890) min with a mean volume of intra-operative hemorrhage of 2021.4 (800-5000) mL. The intra-/perioperative complications were found in four patients (28.6%). R0 and R1 resections were achieved in nine and five patients, respectively. There was no R2 resection. After a mean follow-up period of 30.6 (10-67) months, all patients were alive except one patient died ten months after surgery due to unrelated cause. No recurrence and implant failure were found. Thirteen patients (92.9%) exhibited completely normal neurological function same as their preoperative neurological status.

CONCLUSION

Using TOCS technique can facilitate a precise, complete and safe osteotomy/discectomy procedure during en bloc resection for spine tumor without the aid of intra-operative navigation.

En-bloc spondylectomy in the lumbar spine: indications, results and complications in a series of 47 patients affected by primary malignant bone tumors

INTRODUCTION

Wide Surgery is the reference treatment for malignant and aggressive benign primary bone tumors in the spine. When located in the lumbar spine, En-Bloc Spondylectomy (EBS) remains a complex challenge. Moreover, surgery is complicated by the presence of the diaphragm in the thoracolumbar junction and the hinderance of the iliac wings at the lumbosacral levels. Therefore, EBS in the lumbar spine frequently requires combined approaches. The purpose of this study is to describe clinical presentation, tumor characteristics and results of a series of 47 consecutive patients affected by malignant primary bone tumors of the lumbar spine who underwent EBS.

MATERIALS AND METHODS

47 patients were reviewed. Complications were distinguished in early and late whether they occurred before or after 30 days from surgery. Overall survival (OS), disease-free survival (DFS) and local recurrence-free survival (LRFS) were calculated by the Kaplan-Meier product-limit method from surgery until relapse or death.

RESULTS

27 patients presented to observation after a first intralesional approach in a non-specialized center. Chordoma was the most represented histotype. Vertebrectomies were: 23 one-level, 10 two-level, 12 three-level and 2 four-level. Reconstructions were always carried out with screws and rods. The main postoperative complication was blood loss, while hardware failure was the main long-term complication. The 5-year LRFS was 75.5%, the 5-year DFS was 54.3%, and 5-year OS was 63.6%.

CONCLUSIONS

The surgical margin obtained during the index surgery was statistically associated with Local Recurrence, DFS and OS, underlining the importance of treating patients in reference centers.

Does Preoperative Bilsky Score Predict Outcome Following Surgical Resection of Primary Tumors of the Spine?

OBJECTIVE

In patients undergoing surgery for primary bone tumors of the spine, we sought to compare Bilsky score 0-1 versus 2-3 in: 1) preoperative presentation, 2) perioperative variables, and 3) long-term outcomes.

METHODS

A single-center, retrospective cohort study was undertaken of patients undergoing surgery for extradural, primary bone tumors of the spine between January 2010 and January 2021. The primary exposure variable was Bilsky score, dichotomized as 0-1 versus 2-3. Survival analysis was performed to assess local recurrence (LR) and overall survival (OS).

RESULTS

Of 38 patients undergoing resection of primary spinal tumors, 19 (50.0%) patients presented with Bilsky 0-1 and 19 (50.0%) Bilsky 2-3 grades. The most common diagnosis was chondrosarcoma (33.3%), followed by chordoma (16.7%). There were 15 (62.5%) malignant tumors. Preoperatively, there was no significant difference in demographics, Karnofsky Performance Scale (KPS) (P > 0.999), or motor deficit (P > 0.999). Perioperatively, no difference was found in operative time (P = 0.954), blood loss (P = 0.416), length of stay (P = 0.641), neurologic deficit (P > 0.999), or discharge disposition (P = 0.256). No difference was found in Enneking resection status (69.2% vs. 54.5%, P = 0.675). Long-term, no differences were found regarding reoperation (P = 0.327), neurologic deficit (P > 0.999), postoperative KPS (P = 0.605) and modified McCormick Scale (MMS) (P = 0.870). No difference was observed in KPS (P = 0.418) and MMS (P = 0.870) at last follow-up. However, patients with Bilsky 2-3 had shorter time to LR (1715.0 vs. 513.0 ± 633.4 days, log-rank; P = 0.002) and shorter OS (2025.0 ± 1165.3 vs. 794.0 ± 952.6 days, log-rank; P = 0.002).

CONCLUSIONS

Bilsky 2-3 lesions were associated with shorter time to LR and shorter OS. Patients harboring primary spinal tumors with higher grade Bilsky score appear to be at a higher risk for worse outcomes.

Customized 3-dimensional-printed Vertebral Implants for Spinal Reconstruction After Tumor Resection: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To examine the outcomes of customized 3-dimensional (3D) printed implants for spinal reconstruction after tumor resection.

SUMMARY OF BACKGROUND DATA

Various techniques exist for spinal reconstruction after tumor resection. Currently, there is no consensus regarding the utility of customized 3D-printed implants for spinal reconstruction after tumor resection.

MATERIALS AND METHODS

A systematic review was registered with PROSPERO and performed according to "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guidelines. All level I-V evidence studies reporting the use of 3D-printed implants for spinal reconstruction after tumor resection were included.

RESULTS

Eleven studies (65 patients; mean age, 40.9 ± 18.1 y) were included. Eleven patients (16.9%) underwent intralesional resections with positive margins and 54 patients (83.1%) underwent en bloc spondylectomy with negative margins. All patients underwent vertebral reconstruction with 3D-printed titanium implants. Tumor involvement was in the cervical spine in 21 patients (32.3%), thoracic spine in 29 patients (44.6%), thoracolumbar junction in 2 patients (3.1%), and lumbar spine in 13 patients (20.0%). Ten studies with 62 patients reported perioperative outcomes radiologic/oncologic status at final follow-up. At the mean final follow-up of 18.5 ± 9.8 months, 47 patients (75.8%) had no evidence of disease, 9 patients (14.5%) were alive with recurrence, and 6 patients (9.7%) had died of disease. One patient who underwent C3-C5 en bloc spondylectomy had an asymptomatic subsidence of 2.7 mm at the final follow-up. Twenty patients that underwent thoracic and/or lumbar reconstruction had a mean subsidence of 3.8 ± 4.7 mm at the final follow-up; however, only 1 patient had a symptomatic subsidence that required revision surgery. Eleven patients (17.7%) had one or more major complications.

CONCLUSION

There is some evidence to suggest that using customized 3D-printed titanium or titanium alloy implants is an effective technique for spinal reconstruction after tumor resection. There is a high incidence of asymptomatic subsidence and major complications that are similar to other methods of reconstruction.

LEVEL OF EVIDENCE

Level V, systematic review of level I-V studies.

The Role of En Bloc Resection in the Modern Era for Primary Spine Tumors

STUDY DESIGN

A literature review.

OBJECTIVE

The aim of this review is to provide an overview of benign and malignant primary spine tumors and a balanced analysis of the benefits and limitations of (and alternatives to) surgical treatment with en bloc resection.

SUMMARY OF BACKGROUND DATA

Primary spine tumors are rare but have the potential to cause severe morbidity, either from the disease itself or as a result of treatment. The prognosis, goals, and treatment options vary significantly with the specific disease entity. Appropriate initial management is critical; inappropriate surgery before definitive treatment can lead to recurrence and may render the patient incurable, as salvage options are often inferior.

METHODS

We performed a comprehensive search of the PubMed database for articles relevant to primary spine neoplasms and en bloc spine surgery. Institutional review board approval was not needed.

RESULTS

Although Enneking-appropriate en bloc surgery can be highly morbid, it often provides the greatest chance for local control and/or patient survival. However, there is growing data to support modern radiotherapy as a feasible and less morbid approach to certain primary neoplasms that historically were considered radioresistant.

CONCLUSIONS

Choosing the optimal approach to primary spine tumors is complex. A comprehensive and up-to-date assessment of the evidence is required to guide patient care and to balance the often-competing goals of prolonging life and preserving quality of life.

Surgical Strategy for Recurrent Giant Cell Tumor in the Thoracolumbar Spine

OBJECTIVE

Recurrent giant cell tumor (RGCT) of the spine represents a clinical challenge for surgeons, and the treatment strategy remains controversial. This study aims to describe the long-term follow-up outcomes and compare the efficacy of en bloc spondylectomy versus piecemeal spondylectomy in treating RGCT of the thoracolumbar spine.

METHODS

A total of 32 patients with RGCT of the thoracolumbar spine treated from June 2012 to June 2019 were retrospectively reviewed. A total of 15 patients received total en bloc spondylectomy (TES) with wide or marginal margin while 17 patients received total piecemeal spondylectomy (TPS) with intralesional margin. Postoperative Eastern Cooperative Oncology Group Performance Score (ECOG-PS), Frankel classification and recurrence-free survival (RFS) were evaluated after surgery. Survival curves were estimated by the Kaplan-Meier method and differences were analyzed with the log-rank test. Multivariate analysis was performed with Cox regression to identify the independent prognostic factors affecting RFS.

RESULTS

During a median follow-up of 41.9 ± 17.5 months, all patients with compromised neurologic functions exhibit significant improvement, with the mean ECOG-PS decreasing from 1.5 ± 1.3 to 0.13 ± 0.3 (p < 0.05). Among the 17 patients treated with TPS, eight patients developed local recurrence after a median time of 15.9 ± 6.4 months and four patients died from progressive disease. On the other hand, local recurrence were well managed with TES, since only one out of 15 patients experienced local relapse and all patients are alive with satisfied function at the latest follow-up. The median RFS for patients receiving TES and TPS are 75.0 months (95% CI: 67.5-82.5 m) and 38.3 months (95% CI: 27.3-49.3 m) respectively (p = 0.008). Multivariate analysis shows that the Ki67 index (p = 0.016), resection mode (p = 0.022), and denosumab (p = 0.039) are independent risk factors affecting RFS.

CONCLUSIONS

TES with wide/marginal margin should be offered to patients with RGCT whenever feasible, given its long-term benefits in local control and symptom alleviation. Additionally, patients with lower Ki67 index and application of denosumab tend to have a better prognosis.

The efficacy and safety of short-course neoadjuvant denosumab for en bloc spondylectomy in spinal giant cell tumor of bone: a preliminary report

PURPOSE

This study aimed to investigate whether short course of neoadjuvant denosumab treatment for spinal GCTB could (1) Induce radiological and histological response? (2) Facilitate en bloc resection? (3) Achieve satisfactory oncological and functional outcomes?

METHODS

The clinical information of ten consecutive patients between 2018 and 2022 with spinal GCTB treated with short course of neoadjuvant denosumab (≤ 5 doses) and en bloc spondylectomy was retrospectively reviewed. The radiological and histological response, operative data, oncological and functional outcomes were analyzed.

RESULTS

The mean doses of neoadjuvant denosumab were 4.2 (range 3-5 doses). After neoadjuvant denosumab, there were 9 cases showing new ossification and 5 cases with reappearance of cortical integrity. The values of Hounsfield units (HU) of the soft tissue component were increased by > 50% in 7 cases. The signal intensity (SI) ratios of tumor/muscle in T2WI of plain MRI were decreased by > 10% in 60% of the cases. Shrinkage of soft tissue mass by > 10% was observed in 4 cases. The mean duration of operation was 575 ± 174 min, and the mean estimated blood loss (EBL) was 2790 ± 1934 ml. No obvious adhesion to dura mater or major vessels was encounter intraoperatively. There is no tumor collapse or breakage during surgery. Multinucleated giant cells were decreased in 6 cases (60%) with the remaining 4 cases showing absence of multinucleated giant cells. Mononuclear stromal cells existed in most of the cases (8 cases, 80%). New bone formation was noticed in 8 cases (80%). No patient had a worsening of neurologic function after surgery. No tumor recurrence was noticed within the mean follow-up of 24 ± 20 months.

CONCLUSION

Short-term neoadjuvant denosumab could yield radiological and histological responses and might facilitate en bloc spondylectomy by hardening the tumor and causing less adhesion to segmental vessels, major vessels and nerve roots, which was beneficial to achieve the optimal oncological and functional outcomes.

Revisiting En Bloc Resection Versus Piecemeal Resection for the Treatment of Giant Cell Tumor of the Spine

OBJECTIVE

Surgery for spinal giant cell tumors (GCTs) is challenging because these tumors often exhibit a poor clinical course owing to their locally aggressive features. This study aimed to investigate the prognostic factors of GCT recurrence in the spine by focusing on surgical factors.

METHODS

We retrospectively reviewed patients who underwent surgery for spinal GCTs between January 2005 and December 2016. Using the Kaplan-Meier method, surgical variables were evaluated for disease-free survival (DFS). Since tumor violation may occur at the pedicle during en bloc resection of the spine, it was further analyzed as a separate variable. Multivariate Cox proportional hazard regression analysis was performed for other clinical and radiographic variables. A total of 28 patients (male:female = 8:20) were included. The mean follow-up period was 90.5 months (range, 15-184 months).

RESULTS

Among the 28 patients, gross total resection (GTR) was the most important factor for DFS (P = 0.001). Any form of tumor violation was also correlated with DFS (P = 0.049); however, use of en bloc resection technique did not show a significant DFS gain compared to piecemeal resection (P = 0.218). In the patient group that achieved GTR, the mode of resection was not a significant factor for DFS (P = 0.959). In the multivariate analysis, the extent of resection was the only significant variable that affected DFS (P = 0.016).

CONCLUSIONS

Conflicting results on tumor violation from univariate and multivariate analyses suggest that GTR without tumor violation should be the treatment goal for spinal GCTs. However, when tumor violation is unavoidable, it would be important to prioritize GTR over adhering to en bloc resection.

The Role of 3D Printing in Treatment Planning of Spine and Sacral Tumors

Three-dimensional (3D) printing technology has proven to have many advantages in spine and sacrum surgery. 3D printing allows the manufacturing of life-size patient-specific anatomic and pathologic models to improve preoperative understanding of patient anatomy and pathology. Additionally, virtual surgical planning using medical computer-aided design software has enabled surgeons to create patient-specific surgical plans and simulate procedures in a virtual environment. This has resulted in reduced operative times, decreased complications, and improved patient outcomes. Combined with new surgical techniques, 3D-printed custom medical devices and instruments using titanium and biocompatible resins and polyamides have allowed innovative reconstructions.

An improved total en bloc spondylectomy for L5 vertebral giant cell tumor through a single-stage posterior approach

PURPOSE

Although total en bloc spondylectomy (TES) is strongly recommended for spinal giant cell tumor (GCT), it is extremely difficult to excise a L5 neoplasm intactly through the single-stage posterior approach. Given the risk of neurological and vascular injury, intralesional curettage (IC) is usually recommended for the treatment of L5 GCT. In this study, we presented our experience with the use of an improved TES to treat L5 GCT through the single-stage posterior approach.

METHODS

This study included 20 patients with L5 GCT who received surgical treatment in our department between September 2010 and April 2021. Of them, seven patients received improved TES without iliac osteotomy, and the other 13 patients received IC (n = 8), sagittal en bloc resection (n = 1), TES with iliac osteotomy (n = 3), and TES with radicotomy (n = 1) as control.

RESULTS

The mean operative time was 331.43 ± 92.95 min for improved TES group and 365.77 ± 85.17 min for the control group (p = 0.415), with the mean blood loss of 1142.86 ± 340.87 ml vs. 1969.23 ± 563.30 ml (p = 0.002). Postoperative treatment included bisphosphonates in nine patients and denosumab in 12 patients including one patient who changed from bisphosphonates to denosumab. Three patients who received IC experienced local recurrence, and no relapse was observed in improved TES group.

CONCLUSION

Single-stage posterior TES for L5 GCT was previously considered impossible. In this study, we presented our experience with the use of an improved surgical technique for L5 TES through the single-stage posterior approach, which has proved to be superior to the conventional procedures in terms of blood loss control and complication and recurrence rates.

LEVEL OF EVIDENCE

IV.

Complications and prognosis of primary thoracic and lumbar giant cell tumors treated by total tumor resection

BACKGROUND

Spinal giant cell tumor (SGCT) is a relatively rare primary tumor. En bloc resection is the preferred surgical procedure for it due to its aggressiveness, meanwhile leading to more complications. We reported the characteristics of perioperative complications and local control of total tumor resection including en bloc resection and piecemeal resection for primary thoracic and lumbar spinal giant cell tumors in a single center over 10 years.

METHODS

This is a retrospective cross-sectional and cohort study. Forty-one consecutive patients with SGCTs who underwent total tumor resection from 2010 to 2020 at our institution and were followed up for at least 24 months were reviewed. Surgery data, complication characteristics and local tumor control were collected and compared by different surgical procedure.

RESULTS

Forty-one patients were included, consisting of 18 males and 23 females, with a mean age of 34.2 years. Thirty-one had thoracic vertebra lesions, and 10 had lumbar vertebra lesions. Thirty-five patients were primary cases, and 6 patients were recurrent cases. Eighteen patients were treated by total en bloc spondylectomy (TES), 12 patients underwent en bloc resection according to WBB surgical system, and 11 patients underwent piecemeal resection. The average surgical time was 498 min, and the mean estimated blood loss was 2145 ml. A total of 58 complications were recorded, and 30 patients (73.2%) had at least one perioperative complication. All patients were followed up after surgery for at least 2 years. A total of 6 cases had postoperative internal fixation failure, and 4 cases presented local tumor recurrence (9.8%).

CONCLUSIONS

Although the surgical technique is difficult and accompanied by a high rate of perioperative complications, en bloc resection can achieve favorable local control in SGCT. When it is too difficult to complete en bloc resection, thoroughly piecemeal resection without residual is also acceptable, given the relatively low recurrence rate.

Spinal tumours: recommendations of the Polish Society of Spine Surgery, the Polish Society of Oncology, the Polish Society of Neurosurgeons, the Polish Society of Oncologic Surgery, the Polish Society of Oncologic Radiotherapy, and the Polish Society of Orthopaedics and Traumatology

PURPOSE

The purpose of these recommendations is to spread the available evidence for evaluating and managing spinal tumours among clinicians who encounter such entities.

METHODS

The recommendations were developed by members of the Development Recommendations Group representing seven stakeholder scientific societies and organizations of specialists involved in various forms of care for patients with spinal tumours in Poland. The recommendations are based on data yielded from systematic reviews of the literature identified through electronic database searches. The strength of the recommendations was graded according to the North American Spine Society's grades of recommendation for summaries or reviews of studies.

RESULTS

The recommendation group developed 89 level A-C recommendations and a supplementary list of institutions able to manage primary malignant spinal tumours, namely, spinal sarcomas, at the expert level. This list, further called an appendix, helps clinicians who encounter spinal tumours refer patients with suspected spinal sarcoma or chordoma for pathological diagnosis, surgery and radiosurgery. The list constitutes a basis of the network of expertise for the management of primary malignant spinal tumours and should be understood as a communication network of specialists involved in the care of primary spinal malignancies.

CONCLUSION

The developed recommendations together with the national network of expertise should optimize the management of patients with spinal tumours, especially rare malignancies, and optimize their referral and allocation within the Polish national health service system.

Outcomes of Surgical Treatment for Extradural Benign Primary Spinal Tumors in Patients Younger than 25 Years: An Ambispective International Multicenter Study

Extradural primary spinal tumors were retrospectively analyzed from a prospective database of 1495 cases. All subjects with benign primary tumors under the age of 25 years, who were enrolled between 1990 and 2012 (Median FU was 2.4 years), were identified. Patient- and case-related characteristics were collected and statistically analyzed. Results: 161 patients (66f;95m; age 17.0 ± 4.7 years at time of diagnosis) were identified. The most common tumors were osteoblastomas n = 53 (32.9%), osteoid osteomas n = 45 (28.0%), and aneurysmal bone cysts n = 32 (19.9%). The tumor grade, according to the Enneking Classification S1/S2/S3, was 14/73/74 (8.7/45.3/46.0%), respectively. Tumor-related pain was present in 156 (96.9%) patients. Diagnosis was achieved by biopsies in 2/3 of the cases. Spinal fixation was used in >50% of the cases. Resection was Enneking appropriate in n = 100 (62.1%) of cases. Local recurrence occurred in 21 (13.1%) patients. Two patients died within a 10-year follow-up period. Conclusion: This is one of the largest international multicenter cohorts of young patients surgically treated for benign spinal tumors. The heterogenic young patient cohort presented at a mid-term follow-up without a correlation between the grade of aggressiveness in resection and local recurrence rates. Further prospective data are required to identify prognostic factors that determine oncological and functional outcomes for young patients suffering from these rare tumors.

Comparison of the prognostic factors of total en bloc spondylectomy and total piecemeal spondylectomy in patients with Enneking stage III giant cell tumor in the thoracic and lumbar spine

PURPOSE

To compare total en bloc spondylectomy with marginal margins against piecemeal spondylectomy with intralesional margins in the surgical treatment of Enneking stage III spinal giant cell tumor (GCT) in terms of local recurrence.

METHODS

A retrospective survival analysis of patients with Enneking stage III GCT who underwent TES with marginal margins or total piecemeal spondylectomy with intralesional margins was performed between January 2006 and April 2020. Local recurrence-free survival (LRFS) was the time between the date of surgery and recurrence. Factors with p-values < 0.05 in the univariate analysis were included in the multivariate analysis using proportional hazard analysis.

RESULTS

Sixty patients (25 men and 35 women) with a mean age of 35.6 (range 11-71) years were included. The mean follow-up duration was 93 (range 24-198) months. Two patients were lost to follow-up 6 and 14 years after the procedure. Over a 10-year period, the recurrence rate was 13.3%. The 2-, 5-, and 10-year LRFS rates were 95%, 88%, and 78%, respectively. Univariate analysis identified total piecemeal spondylectomy and no adjuvant radiotherapy as prognostic factors for LRFS. Multivariate Cox-regression models showed a significant association between local recurrence and total piecemeal spondylectomy and no adjuvant radiotherapy.

CONCLUSION

TES with marginal margins is better than total piecemeal spondylectomy with intralesional margins owing to its lower postoperative recurrence rate. Adjuvant radiotherapy should be administered to reduce postoperative recurrence rates.

The Effect of Denosumab and Risk Factors for Recurrence in Spinal Giant Cell Tumors: A Systematic Review and Meta-Analysis

PURPOSE

Giant cell tumors (GCTs) are common benign primary bone tumors and are well known for their locally aggressive performance and tendency to recur. The purpose of this study was to analyze the effects of denosumab and risk factors for recurrent spinal GCTs.

MATERIALS AND METHODS

We searched PubMed, EMBASE, Web of Science, and Cochrane Library databases to identify differences between individuals treated with and without denosumab and risk factors for spinal GCT recurrence. Patient data, including age, sex, tumor resection range, location, denosumab use, Campanacci grade, and radiotherapy, were documented. Comparable factors were evaluated using odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence intervals (CIs).

RESULTS

Sixteen studies were included. The overall incidence of spinal GCT recurrence was 29%. Campanacci grade III tumors showed better recurrence outcomes than grades I and II (OR, 16.36; 95% CI, 4.19-63.93; p<0.001). Gross total resection (OR, 0.09; 95% CI, 0.04-0.19; p<0.001), radiotherapy (OR, 0.27; 95% CI, 0.11-0.65; p=0.004), and the use of denosumab during subtotal resection (OR, 2.95; 95% CI, 1.07-8.17; p=0.04) were important factors for reducing recurrence.

CONCLUSION

Clinicians must consider the effects of gross total resection, radiotherapy use, and denosumab use in cases of subtotal resection during spinal GCT treatment. So far, many researchers have used denosumab in spinal GCT, but none have clearly suggested an endpoint. Most studies, however, recommend using it for more than 6 months.

A Multiparametric Method Based on Clinical and CT-Based Radiomics to Predict the Expression of p53 and VEGF in Patients With Spinal Giant Cell Tumor of Bone

Purpose

This project aimed to assess the significance of vascular endothelial growth factor (VEGF) and p53 for predicting progression-free survival (PFS) in patients with spinal giant cell tumor of bone (GCTB) and to construct models for predicting these two biomarkers based on clinical and computer tomography (CT) radiomics to identify high-risk patients for improving treatment.

Material and Methods

A retrospective study was performed from April 2009 to January 2019. A total of 80 patients with spinal GCTB who underwent surgery in our institution were identified. VEGF and p53 expression and clinical and general imaging information were collected. Multivariate Cox regression models were used to verify the prognostic factors. The radiomics features were extracted from the regions of interest (ROIs) in preoperative CT, and then important features were selected by the SVM to build classification models, evaluated by 10-fold crossvalidation. The clinical variables were processed using the same method to build a conventional model for comparison.

Results

The immunohistochemistry of 80 patients was obtained: 49 with high-VEGF and 31 with low-VEGF, 68 with wild-type p53, and 12 with mutant p53. p53 and VEGF were independent prognostic factors affecting PFS found in multivariate Cox regression analysis. For VEGF, the Spinal Instability Neoplastic Score (SINS) was greater in the high than low groups, p &lt; 0.001. For p53, SINS (p = 0.030) and Enneking stage (p = 0.017) were higher in mutant than wild-type groups. The VEGF radiomics model built using 3 features achieved an area under the curve (AUC) of 0.88, and the p53 radiomics model built using 4 features had an AUC of 0.79. The conventional model built using SINS, and the Enneking stage had a slightly lower AUC of 0.81 for VEGF and 0.72 for p53.

Conclusion

p53 and VEGF are associated with prognosis in patients with spinal GCTB, and the radiomics analysis based on preoperative CT provides a feasible method for the evaluation of these two biomarkers, which may aid in choosing better management strategies.

Radiologic and clinical changes after denosumab treatment for giant cell tumors of the mobile spine: a quantitative study

Objectives

To analyze the radiologic and clinical changes after denosumab treatment in patients with giant cell tumors (GCTs) in the mobile spine.

Methods

Clinical data and images by computed tomography and magnetic resonance imaging at a single center were retrospectively reviewed before and after denosumab treatment.

Results

Pre- and post-treatment data from 24 patients were evaluated. On imaging, marginal ossification and/or bone formation was observed in 22 patients (91.7%). The median maximum diameter of the GCT reduced from 52.5 to 48.2 mm (p < 0.001), and the mean proportion of tumor to spinal canal area decreased from 36.8 to 18.5% (p < 0.001). Out of six patients with compression, three patients (50%) showed no compression after treatment. The signal intensity (SI) ratio between the solid part of the tumor and the normal spinal cord on T2-weighted MR images was 0.77 ± 0.22 and decreased to 0.58 ± 0.22 (p = 0.001). On clinical symptoms, the mean visual analog scale scores were reduced from 5.3 to 2.0 (p < 0.001) and the Karnofsky Performance Scale scores increased from a median of 65 to 80 (p < 0.001). Post-treatment, performance scores improved in eight patients (33.3%) (p = 0.003), and the neurological function of four patients improved according to Frankel grade (p = 0.046).

Conclusions

Bone formation, tumor reduction, regression of epidural lesion and the decrease in SI ratio on T2-weighted image should be considered as the effectiveness of denosumab in the treatment of spinal GCT. In clinical application, denosumab can relieve pain, improve neurological function, and improve the quality of life of spinal GCT patients.

Pathological Clinical Analysis and Imaging Manifestations for Spinal Bone Tumors Based on Cement Injection

In order to explore the imaging manifestations and pathological characteristics of spine tumors, this article explores the clinical diagnosis and treatment methods through multi-sample case analysis with the support of imaging, and proposes a targeted treatment method that uses a special PVP needle with a beveled puncture surface for puncture. Moreover, this article uses the supporting PVP syringe for bone cement injection, develops a health status questionnaire, and adopts a scoring method for comprehensive assessment. The purpose of this article is to show that through the combination of preoperative radiotherapy and postoperative bracing, bone cement injection to treat vertebral tumors can immediately obtain satisfactory pain relief. Finally, through case analysis and image performance, we can see that the method proposed in this article has a certain effect.

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.

Complication Avoidance in Surgical Management of Vertebral Column Tumors

The surgical management of spinal tumors has grown increasingly complex as treatment algorithms for both primary bone tumors of the spine and metastatic spinal disease have evolved in response to novel surgical techniques, rising complication rates, and additional data concerning adjunct therapies. In this review, we discuss actionable interventions for improved patient safety in the operative care for spinal tumors. Strategies for complication avoidance in the preoperative, intraoperative, and postoperative settings are discussed for approach-related morbidities, intraoperative hemorrhage, wound healing complications, cerebrospinal fluid (CSF) leak, thromboembolism, and failure of instrumentation and fusion. These strategies center on themes such as pre-operative imaging review and medical optimization, surgical dissection informed by meticulous attention to anatomic boundaries, and fastidious wound closure followed by thorough post-operative care.

Clinical Significance of Preoperative CT and MR Imaging Findings in the Prediction of Postoperative Recurrence of Spinal Giant Cell Tumor of Bone

Objectives

To explore the predictive value of preoperative imaging in patients with spinal giant cell tumor of bone (GCTB) for postoperative recurrence and risk stratification.

Methods

Clinical data for 62 cases of spinal GCTB diagnosed and treated at our hospital from 2008 to 2018 were identified. All patients were followed up for more than 2 years according to the clinical guidelines after surgery. Medical history data including baseline demographic and clinical characteristics, computed tomography (CT) and magnetic resonance imaging (MRI) findings of recurrent and non‐recurrent patients were compared. Two musculoskeletal radiologists read the images and were blinded to the clinical data. The imaging features associated with postoperative recurrence were analyzed by multivariate logistic regression, and receiver operating characteristic (ROC) curve analysis was performed to determine the optimal cutoff value of the largest lesion diameter predicting recurrence after surgery.

Results

According to whether the disease recurred within the follow‐up period, patients were divided into the recurrence group and the non‐recurrence group. Of 62 patients (29 males and 33 females), 17 had recurrence and 45 did not. The recurrence rate was 27.4%. The mean follow‐up time was 73.66 (± 32.92) months. The three major treatments were total en bloc spondylectomy (n = 26), intralesional spondylectomy (n = 20), and curettage(n = 16). A total of 16 CT and MRI features were analyzed. A univariate analysis showed no significant difference in age, sex, treatment, multi‐vertebral body involvement, location, boundary, expansile mass, residual bone crest, paravertebral soft tissue mass, CT value, and MRI signal on T1‐weighted imaging (WI), T2‐WI, and T2‐WI fat suppression (FS) sequences (P > 0.05). The largest lesion diameter [(4.68 ± 1.79) vs (5.92 ± 2.17) cm, t = 2.287, P = 0.026] and the vertebral compression fracture (51% vs 82%, χ² = 5.005, P = 0.025) were significantly different between the non‐recurrence and recurrence groups. Logistic regression analysis showed that both largest lesion diameter (odds ratio [OR], 1.584; 95% confidence interval [CI], 1.108–2.264; P = 0.012) and compression fracture (OR, 8.073; 95%CI, 1.481–11.003; P = 0.016) were independent predictors of postoperative recurrence. When we set the cutoff value for the largest lesion diameter at 4.2 cm, the sensitivity and specificity for distinguishing the recurrence and non‐recurrence of GCTB were 94.1% and 42.2%, respectively, and the area under the curve (AUC) was 0.671. The combined model achieved a sensitivity, specificity and accuracy of 47.1%, 97.8% and 83.9%, respectively.

Conclusions

In spinal GCTB, maximum lesion diameter and the vertebral compression fracture are associated with tumor recurrence after surgery, which may provide helpful information for planning personalized treatment.

Clinical Trials in Spinal Tumors: A Two-Decade Review

OBJECTIVE

Clinical trials are essential for assessing advancements in spine tumor therapeutics. The purpose of this study is to characterize trends in clinical trials for primary and metastatic tumor treatments over the past two decades.

METHODS

ClinicalTrials.gov was queried using the search term "spine" for all interventional studies spanning 1999 to 2020 with categories of "Cancer", "Neoplasm", "Tumor", or "Metastasis". Tumor type, phase data, enrollment numbers and home institution country were recorded. The sponsor was categorized as academic institution, industry, government or other and intervention type as procedure, drug, device, radiation or other. Frequency of each category and cumulative frequency over twenty years were calculated.

RESULTS

106 registered trials for spine tumors were listed. All except two that began before 2008 have been completed, enrollment of 51-100 subjects (29.8%) was the most common, and the majority were phase II (54.4%). Most examined metastatic tumors (58.5%) and new trials per year increased 3.4-fold between 2009 and 2020. The majority were conducted in the United States (56.4%). The most common intervention strategy was radiation (32.1%), although between 2010-2020 procedural studies became the most frequent (2.4 per year). The majority were sponsored by academic institutions (63.2%), and over twenty years have sponsored 3.2-fold more studies than industry partners.

CONCLUSIONS

The number of clinical trials for spine tumor therapies has rapidly increased over the past 15 years, driven by studies at United States academic medical institutions investigating radiosurgery for treatment of metastases. Targeted therapies for tumor subtypes and sequelae have updated international best practices.

Wide Surgery in the Cervical Spine: Indications, Results, and Complications in a Series of 30 Patients Affected by Primary Bone Tumors

BACKGROUND

En bloc surgery is the mainstay treatment for primary malignant bone tumors, as well as in the cervical spine. Unfortunately, literature on the topic is limited to case reports and small series.

METHODS

We reviewed all patients affected by primary cervical spine bone tumors treated with en bloc surgeries from 1996 to 2016 and identified 30 eligible cases. We evaluated the clinical presentation and tumor characteristics and reported surgical results, complications, recurrence, and survival rates.

RESULTS

Only 17 of 30 patients had not been previously treated at presentation. Osteosarcoma and chordoma were the most frequent tumors, and pain was reported in all cases. En bloc spondylectomy, hemispondylectomy, and posterior arch en bloc resection were performed in 16, 12, and 2 patients, respectively. The obtained margin was adequate (wide and marginal) in 60% of cases and intralesional in the remaining cases. Two deaths occurred in the immediate postoperative period. Neurological deterioration, dural tear, and dysphagia were the most frequent complications. The 5-year local recurrence-free survival was 70.4%. The recurrence rate was 38.5% and 11.7% in previously and non-previously treated patients, respectively (χ²: 2.94; P = 0.086). Overall survival at 5 years was 58% and 47% for all series and malignant tumors, respectively.

CONCLUSION

Primary cervical spine bone tumors present a difficult approach. Findings suggest that patients treated with en bloc surgery show recurrence and survival rates comparable to the same tumors located in the thoracolumbar spine.

Spondylectomy in the treatment of neoplastic spinal lesions - A retrospective outcome analysis of 582 patients using a patient-level meta-analysis

This study aims at identifying predictors of postoperative complications, lesion recurrence, and overall survival in patients undergoing en bloc spondylectomy (EBS) for spinal tumors. For this purpose a systematic review of the literature was conducted and patient-level data extracted. Linear-regression models were calculated to predict postoperative complications, lesion recurrence and overall survival based on age, tumor etiology, surgical approach, mode of resection (extra- vs. intralesional), tumor extension, and number of levels treated. A total of 582 patients were identified from the literature: 45% of females, median age 46 years (5-78); most common etiologies were: sarcoma (46%), metastases (31%), chordoma (11%); surgical approach was anterior (2.5%), combined (45%), and posterior (52.4%); 68.5% underwent EBS; average levels resected were 1.6 (1-6); average survival was 2.6 years; Complication rate was 17.7%. The following significant correlations were found: postoperative complications and resection mode (Odds ratio [OR] 1.35) as well as number of levels treated (OR 1.35); tumor recurrence and resection mode (OR 0.78); 5-year survival and age (OR 0.79), tumor grade (OR 0.65), tumor stage at diagnosis (OR 0.79), and resection mode (OR 1.68). EBS was shown to improve survival, decreases recurrence rates but also has a higher complication rate. Interestingly, the complication rate was not influenced by tumor extension or tumor etiology.

Metachronous multicentric giant cell tumour of bone in a 12-year-old girl: A case report and review of literature

While giant cell tumour of bone is a relatively common tumour in adults, it is exceedingly rare in children. Multicentric metachronous giant cell tumour is an even rarer presentation of this tumour in skeletally immature patients. We present here the challenges in management of this rare tumour.

A 12-year-old girl presented with a giant cell tumour affecting four different bones sequentially, three times within a 3-year period. The disease first appeared in the right distal fibula, then a year later in ipsilateral talus and calcaneus and finally a year later, in the T5 vertebral body, all requiring surgical treatment. Our strategy was to manage this lesion aggressively based on the limited literature available and present our own long-term surveillance strategy. Our patient responded well to treatment each time and has remained disease-free for 24 months from her last surgery.

This is a rare case of metachronous multicentric giant cell tumour of bone in a skeletally immature patient requiring aggressive treatment and surveillance.

Total en bloc spondylectomy combined with the satellite rod technique for spinal tumors

Background

Instrumentation failure (IF) is a common complication after total en bloc spondylectomy (TES) in spinal tumors. This study aims to evaluate the clinical outcomes of TES combined with the satellite rod technique for the treatment of primary and metastatic spinal tumors.

Methods

The clinical data of 15 consecutively treated patients with spinal tumors who underwent TES combined with the satellite rod technique by a single posterior approach from June 2015 to September 2018 were analyzed retrospectively. Radiographic parameters including the local kyphotic angle (LKA), anterior vertebral height (AVH), posterior vertebral height (PVH), and intervertebral titanium mesh cage height (ITMCH) were assessed preoperatively, postoperatively, and at the final follow-up. The visual analog scale (VAS), Oswestry Disability Index (ODI), and American Spinal Injury Association (ASIA) scale were used to assess quality of life and neurological function. The operative duration, volume of blood loss, and complications were also recorded.

Results

The mean operation time and volume of blood loss were 361.7 min and 2816.7 mL, respectively. During an average follow-up of 31.1 months, 2 patients died of tumor recurrence and multiple organ metastases, while recurrence was not found in any other patients. Solid fusion was achieved in all but one patient, and no implant-related complications occurred during the follow-up. The VAS, ODI, and ASIA scores significantly improved from before to after surgery (P < 0.05). The LKA, AVH, and PVH significantly improved from before to immediately after surgery and to the final follow-up (P < 0.05), and the postoperative and final follow-up values did not significantly differ (P > 0.05).

Conclusions

TES combined with the satellite rod technique can yield strong three-dimensional fixation and reduce the occurrence of rod breakage, thereby improving the long-term quality of life of patients with spinal tumors.

Incidence, Management, and Outcomes of Spinal Giant Cell Tumor of Bone in Adult Patients: A National Cancer Database Analysis

OBJECTIVE

Giant cell tumors (GCTs) constitute 5% of all primary bone tumors with spinal GCTs (SGCTs) accounting for 2%-15% of all GCTs. The standard of care for SGCT has been maximal surgical resection. However, many adjuvant therapies have been used owing to the difficulty in achieving gross total resection combined with the high local recurrence rate. The purpose of the present study was to analyze the incidence, management, and outcomes of SGCT.

METHODS

Patients with diagnosis codes specific for SGCT were queried from the National Cancer Database from 2004 to 2016. The outcomes were investigated using Cox univariate and multivariate regression analyses, and survival curves were generated for comparative visualization.

RESULTS

The search criteria identified 92 patients in the NCDB dataset from 2004 to 2016 with a diagnosis of SGCT. Of the 92 patients, 64.1% had undergone surgical intervention, 24.8% had received radiotherapy, and 15.2% had received immunotherapy. Univariate analysis revealed that age ≥55 years and tumor location in the sacrum/coccyx were associated with worsened overall survival (OS) and that surgical resection was associated with improved OS. On multivariate analysis, age 55-64 years was associated with worsened OS, and radical surgical resection was associated with improved OS. The survival analysis revealed improved OS with surgery but not with radiotherapy, chemotherapy, or immunotherapy.

CONCLUSION

SGCT is a rare primary bone tumor of the vertebral column. The standard of care has been surgical resection with the goal of gross total resection; however, adjuvant therapies have often been used. Our study found that surgical resection significantly improved OS and that immunotherapy neared significance in improving OS.

Recurrent giant cell tumour of the thoracic spine managed by total en bloc spondylectomy and denosumab therapy: a case report

Background

Giant cell tumour (GCT) of the bone is a rare, invasive benign bone tumour, which typically originates in the metaphyseal ends of long bones and rarely in the spine. Here, we report a rare case of recurrent GCT of the thoracic vertebra, which was managed by three-level total en bloc spondylectomy (TES) after denosumab therapy.

Case presentation

A 50-year-old woman presented with a 2-month history of progressive lower back pain. Magnetic resonance imaging revealed destruction of the T11 vertebra and a soft tissue mass. The patient underwent tumour resection. Computed tomography at the 2-year follow-up revealed relapse of the resected tumour, which had spread to the T12 vertebral body. Subsequently, denosumab therapy was administered to the patient for 1 year. The growth of the tumour was controlled, and its boundary line was clear. Thereafter, TES for the T10-T12 vertebrae was performed, and spinal reconstruction was completed through a one-stage single posterior approach. The patient’s condition improved postoperatively, and no evidence of recurrence of GCT of the bone or spinal deformity was observed at the 32-month follow-up.

Conclusions

Denosumab therapy contributed to tumour regression. Three-level TES may be an effective and feasible strategy for managing large recurrent GCTs of the spine after denosumab therapy.

Denosumab in the treatment of giant cell tumor of the spine. Preliminary report, review of the literature and protocol proposal

BACKGROUND

The interest on the role of Denosumab in the treatment strategy of giant cell tumor of the spine is growing. En bloc resection is considered the Enneking appropriate treatment, but morbidity and functional loss are sometimes unacceptable. Denosumab could play a role as a stand-alone treatment, but also as preoperative treatment or as postoperative after intralesional surgery.

MATERIALS AND METHODS

A cohort of 10 out of 12 cases of spinal GCT consecutively treated with Denosumab are analyzed and discussed compared to the cases reported in the literature. A staging of the radiological effect of the treatment is proposed.

RESULTS

The stand-alone and postoperative treatments are still running (12 to 88 months). One therapy was stopped after 15 months, once a satisfactory local effect was achieved, but the treatment had to be restarted 2 months later due to the recurrence of the erosive images. The new treatment was successful. At 1-year follow-up after the gross total excision followed by postoperative Denosumab treatment, no evidence of local recurrence was found. The preoperative treatment duration ranged from 3 to 24 months. No local recurrence followed the en bloc resections.

CONCLUSIONS

Denosumab alone is effective in relieving pain, increasing the ossification and sometimes reducing the tumor volume. It can be considered an excellent solution in spine GCTs whose surgical treatment cannot be Enneking appropriate or is associated with unacceptable morbidity or loss of functions. It is still impossible to state when to safely stop the treatment. Denosumab also plays a role as preoperative protocol. These slides can be retrieved under Electronic Supplementary Material.

Endothelin-1 Activates the Notch Signaling Pathway and Promotes Tumorigenesis in Giant Cell Tumor of the Spine

STUDY DESIGN

Experimental study.

OBJECTIVE

To examine the role of endothelin-1 (ET-1) and the Notch signaling pathway in giant cell tumor (GCT) of the spine.

SUMMARY OF BACKGROUND DATA

Previously published studies have shown that the Notch signaling pathway has a role in tumor invasion and that ET-1 is involved in tumor invasion and angiogenesis. However, the roles of both Notch signaling and ET-1 in GCT of the spine remain unknown.

METHODS

Expression of ET-1 in tissue samples from patients with spinal GCT, and adjacent normal tissue, were analyzed by immunohistochemistry and western blot. GCT stromal cells (GCTSCs) were isolated and ET-1 expression was demonstrated by immunofluorescence. Cell viability and cell migration of GCTSCs and human vascular endothelial cells following ET-1 treatment were assessed using the cell counting kit-8 assay and a transwell assay. Receptor activator of nuclear factor kappa-B ligand (RANKL) and osteoprotegerin (OPG) mRNA expression was determined following ET-1 treatment of GCTSCs using quantitative real-time polymerase chain reaction. In GCTSCs treated with ET-1 and the ET-1 signaling antagonist, BQ-123, levels of cyclin D1, vascular endothelial growth factor, matrix metalloproteinase-2 and -9 (MMP-2 and MMP-9), Jagged1, Hes1, Hey2, and Notch intracellular domain were examined by western blot.

RESULTS

Compared with normal adjacent tissue, ET-1 was highly expressed in GCT tissue. In GCTSCs studied in vitro, treatment with ET-1 significantly increased GCTSC and human vascular endothelial cells growth and migration and increased the expression of RANKL and OPG, meanwhile the ratio of RANKL/OPG was increased, in GCTSCs, it upregulated the production of cyclin D1, vascular endothelial growth factor, MMP-2, MMP-9, Jagged1, Hes1, Hey2, and Notch intracellular domain expression in a dose-dependent manner. Treatment with BQ-123 reversed these effects.

CONCLUSION

In GCT of the spine, ET-1 showed increased expression. In cultured GCTSCs, ET-1 treatment activated the Notch signaling pathway.

LEVEL OF EVIDENCE

2.

Current surgical strategies for treating spinal tumors: Results of a questionnaire survey among members of the German Spine Society (DWG)

PURPOSE

Questionnaire survey among the members of the German Spine Society (Deutsche Wirbelsäulen-Gesellschaft, DWG) to objectify oncological infrastructure and current standard of care in spinal tumor treatment in Germany.

METHODS

All DWG-members were contacted via the society's e-mail and asked to respond in anonymized form to a related questionnaire. Questions were asked regarding surgical specialty, type of institution involved, numbers of spinal procedures, as well as questions on treatment for primary tumors, whether the respondent belonged to a tumor center, decision-making procedures for surgery, and the type of procedure.

RESULTS

84 centers providing surgical treatment for spinal tumors in their departments were identified. 52.6% were carrying out more than 500 spinal procedures per year. There was a significant association (P ≤ 0.05) between the numbers of spinal surgeries, the number of treated tumor patients per year, the organisation in a tumor center and the treatment of primary tumors. 76% are part of a local tumor center for interdisciplinary decision making (i.e.surgical treatment and adjuvant therapy). 74% of the institutions stated that conventional postoperative radiotherapy is standardly administered in the case of secondary lesions, with 24% of them referring patients to external services for radiotherapy.

CONCLUSION

In spite of often large numbers of spinal operations, the centers perform relatively small numbers of tumor operations, particularly for primary tumors. A nearly three-quarter majority of the departments are integrated into interdisciplinary tumor care. However, there is a marked number that do not belong to an interdisciplinary organisation. Further advances in multidisciplinarity and oncology training are a continuous issue to increase treatment quality in spinal tumor patients.

All-posterior total en bloc spondylectomy for thoracic spinal tumors

Total en bloc spondylectomy (TES) involves disruption of the bony neural ring via bilateral pediculotomy and posterior en bloc laminectomy followed by the en bloc vertebrectomy. All-posterior TES allows for resection of malignant and benign aggressive spine tumors with minimal morbidity. The purpose of this report is to describe two cases of all-posterior spondylectomy using the recently developed Resegone retractor (K2M, Leesburg, VA, USA) which facilitates an all-posterior resection. The technique is well described and generally includes 3 major portions: a resection of the posterior elements with bilateral costotransversectomy, passage of threadwire saws anterior to the vertebral bodies, and en bloc resection of the anterior column. With the device in place, the sawing of the bone can be performed without risking pull-through into the cord, while cutting through the desired path in a smooth and parallel fashion.

Total en bloc resection of primary and metastatic spine tumors

Primary and metastatic tumors of the spine represent a significant cause of patient morbidity, and present a management challenge to treating providers. From a neurosurgical standpoint, resection surgery may be warranted in cases of spinal instability, progressive disease, neurological compromise, or intractable symptoms. Removal of a tumor "en bloc" offers a more aggressive modality over more conservative resection techniques. En bloc resection entails the removal of the entirety of a tumor without violation of its capsule, and may offer improved rates of local control and overall survival in appropriately selected patients. Conversely, this technique carries a higher complication rate, and requires a unique set of technical skills as compared to more traditional resection. Here, we describe the technical aspects of en bloc resection, as well as specific indications and considerations when employing this operative technique.

Primary Bone Tumor of the Spine-An Evolving Field: What a General Spine Surgeon Should Know

STUDY DESIGN

A narrative review of the literature.

OBJECTIVE

This article reviews the general principles of treatment and investigation for primary bone tumors of the spine. Furthermore, it explores the emerging alternatives.

METHODS

A review was performed using Medline, Embase, and Cochrane databases.

RESULTS

Primary bone tumors of the spine are rare entities that general spine surgeons may encounter only a few times in their career. The treatment algorithm of these complex tumors is filled with nuances and is evolving constantly. For these reasons, patients should be referred to experienced tertiary or quaternary centers who can offer a comprehensive multidisciplinary approach. For most malignant spinal bone tumors, surgery remains the cornerstone of treatment. Respecting oncologic principles has been associated with improved survival and decreased local recurrence in multiple settings. However, even in experienced centers, these surgeries carry a significant risk of adverse events and possible long-term neurologic impairment. The associated morbidity of these procedures and the challenges of local recurrence have encouraged professionals caring for these patients to explore alternatives or adjuncts to surgical treatment.

CONCLUSIONS

Over the past few years, several advances have occurred in medical oncology, radiation oncology and interventional radiology, changing the treatment paradigm for some tumors. Other advances still need to be refined before being applied in a clinical setting.

Mini-open Lateral En Bloc Corpectomy: Cadaveric Feasibility and Early Clinical Experience

BACKGROUND

Open approaches to the thoracolumbar spine for en bloc vertebral body tumor resection are associated with significant surgical morbidity. Less invasive surgical techniques may reduce complications.

OBJECTIVE

To present our experience with a staged posterior midline and mini-open anterolateral extracoelomic approach to en bloc corpectomy for vertebral body tumor resection in cadaver specimens and patients.

MATERIALS AND METHODS

The feasibility and safety of the staged posterior midline and mini-open anterolateral extracoelomic approach were evaluated in 3 cadaveric specimens. The procedure was performed at 3 levels (L1-L3) in each cadaver specimen (9 levels) and then in 1 clinical case. The cadaveric neurovascular structures were evaluated for tissue injury, whereas the operative experience, patient complications, and early surgical and clinical outcomes were reviewed.

RESULTS

The approach allowed for en bloc corpectomy without any injury to the cadaveric neurovascular structures. The procedure was reproducible in the clinical setting, which showed favorable clinical and radiographic patient outcomes.

CONCLUSIONS

Early clinical experience suggests the staged posterior midline and mini-open anterolateral extracoelomic approach is feasible and safe for en bloc tumor resection compared with open techniques with related morbidity. Long-term studies are needed to understand the strengths and limitations of this technique.

Giant cell tumor of the eleventh thoracic vertebra in a pediatric patient: an interesting case report and comprehensive literature review

INTRODUCTION

Giant cell tumors of the mobile spinal column are very rare tumors, especially in the pediatric age group. Although they are benign tumors, they have locally aggressive growth pattern and high risk of recurrence.

CASE PRESENTATION

We report a 15-year-old female patient with thoracic giant cell tumor who underwent percutaneous vertebroplasty and had cement extravasation into the spinal canal. Because of the deterioration of the patient's neurological condition, total enbloc spondylectomy and cement excision were performed. She underwent instrumentation and fusion procedures in order to prevent spinal instability.

CONCLUSION

The main purpose of the treatment is gross total resection of the giant cell tumor. However, adjuvant methods such as denosumab should be added to the treatment protocol in patients who are older than 2 years old and can not undergo gross total resection due to tumor size and anatomic localization.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Biomimetic 3D-printed custom-made prosthesis for anterior column reconstruction in the thoracolumbar spine: a tailored option following en bloc resection for spinal tumors : Preliminary results on a case-series of 13 patients

PURPOSE

Various techniques for anterior column reconstruction have been described after en bloc resection of spinal tumors. Limited evidence exists regarding one being superior to another. The purpose of this study is to evaluate 3D-printed vertebral bodies for spinal reconstruction after en bloc resection in the thoracolumbar spine.

METHODS

Prospective observational study on custom-made 3D-printed titanium reconstruction of vertebral bodies after en bloc resection for spinal tumor was conducted between November 2015 and June 2017. 3D-printed vertebral bodies were monitored for mechanical complications such as (1) migration, (2) subsidence into the adjacent vertebral bodies, and/or (3) breakage. Complications and related details were recorded.

RESULTS

Thirteen patients (7 females and 6 males) were enrolled, and reconstruction of the anterior column was performed using custom-made 3D-printed titanium prosthesis after en bloc resection for spinal tumor (8 primary bone tumors and 5 solitary metastases). Subsidence into the adjacent vertebral bodies occurred in all patients at both proximal and distal bone-implant interfaces; however, it was clinically irrelevant (asymptomatic, and no consequences on posterior instrumentation), in 11 out of 12 patients (92%). In 1 patient (#4), severity of the subsidence led to revision of the construct. At an average 10-month follow-up (range 2-16), 1 implant was removed due to local recurrence of the disease and 1 was revisioned due to progressive distal junctional kyphosis.

CONCLUSION

Preliminary results from this series suggest that 3D printing can be effectively used to produce custom-made prosthesis for anterior column reconstruction. These slides can be retrieved under Electronic Supplementary Material.

Nomograms for prognostic factors of spinal giant cell tumor combining traditional clinical characteristics with inflammatory biomarkers after gross total resection

Giant cell tumor (GCT) of bone is a common primary bone tumor, which exhibits local aggressiveness and recurrent potential, especially for the spinal lesion. Increasing evidence indicates that inflammation plays a vital role in tumorigenesis and progression. The prognostic value of inflammatory biomarkers in GCT has not been established. A retrospective analysis was conducted in patients with spinal GCT in Changzheng Hospital Orthopedic Oncological Center (CHOOC) between January 2005 and October 2015 and 129 patients were identified eligible. Traditional clinical parameters and inflammatory indexes such as Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and albumin/globulin ratio (AGR) were concluded and analyzed. Kaplan-Meier analysis was used to calculate the disease-free survival (DFS). Cox regression analysis was performed to assess the prognostic factors. Nomograms were established to predict DFS quantitatively for the first time, and Harrell’s concordance index (c-index) was adopted to evaluate prediction accuracy. As results, the DFS was 78.3% in the cohort. Patients were stratified into 2 groups by NLR (≤ 2.70 and > 2.70), PLR (≤ 215.80 and > 215.80), LMR (≤ 2.80 and >2.80) and AGR (< 1.50 and ≥ 1.50). Patients with NLR > 2.70, PLR > 215.80, LMR ≤ 2.80 and AGR < 1.50 were significantly associated with decreased DFS (p < 0.05). Multivariate analysis indicated that treatment history, tumor length, bisphosphonate treatment, NLR and PLR were independent factors of DFS (p < 0.05, respectively). In addition, nomogram on DFS was established according to all significant factors, and c-index was 0.728 (95% CI: 0.710-0.743). Nomograms based on DFS can be recommended as practical models to evaluate prognosis for spinal GCT patients.