Giant cell tumors of the axial skeleton

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Investigation of Giant Cell Tumor of Bone and Tissue Engineering Approaches for the Treatment of Giant Cell Tumor of Bone

Primary bone tumors such as Ewing sarcoma, osteosarcoma, and chondrosarcoma, secondary bone tumors developed from progressive malignancies, and metastasized bone tumors are more prevalent and studied descriptively through biology and medical research. Less than 0.2% of cancer diagnoses are caused by rare bone-originating tumors, which despite being rare are particularly difficult due to their high death rates and substantial disease burden. A giant cell tumor of bone (GCTB) is an intramurally invasive but rare and benign type of bone tumor, which seldom metastasizes. The most often prescribed medication for GCTB is Denosumab, a RANKL (receptor activator of nuclear factor κB ligand) inhibitor. Because pharmaceutical drug companies rely on two-dimensional and animal models, current approaches for investigating the diverse nature of tumors are insufficient. Cell line based medication effectiveness and toxicity studies cannot predict tumor response to antitumor medicines. It has already been investigated in detail why molecular pathways do not reproduce in vitro, a phenomenon known as flat biology. Due to physiological differences between human beings and animals, animal models do not succeed in identifying side effects of the treatment, emulating metastatic growth, and establishing the link between cancer and the immune system. This review summarizes and discusses GCTB, the disease, its cellular composition, various bone tumor models, and their properties and utilization in research. As a result, this study delves deep into in vitro testing, which is vital for scientists and physicians in various fields, including pharmacology, preclinical investigations, tissue engineering, and regenerative medicine.

Giant cell tumor of sacral vertebra in an adolescent without neurodeficit: A case report and review of the literature

Background:

Giant cell tumors (GCTs) are locally aggressive benign primary bone tumors that rarely occur in the spine. Their treatment methods include denosumab, bisphosphonates, and/or different surgical techniques. Here, we present the successful treatment of a sacral GCT in a 13 years old.

Case Description:

A 13-year-old male presented with back pain and paraparesis of 3-week duration. Radiological studies demonstrated an S1 lytic lesion. He underwent an excisional biopsy and anterior and posterior resection combined with a lumbopelvic fusion. One year later, there has been no tumor recurrence.

Conclusion:

We successfully treated an S1 sacral GCT in a 13-year-old male utilizing a wide anteriorand posterior excision combined with a lumbopelvic fusion.

A rare case of sphenoid giant cell tumor: Case report & review of imaging features post short-term denosumab treatment

Background: Giant cell tumors (GCTs) are locally aggressive but rarely malignant bone neoplasms that uncommonly involve the skull. In this report, we describe a tumor of the sphenoid sinus. Case presentation: A 51-year-old female was presented with headache, and bilateral decreased visual acuity, CT scan, and brain MRI revealed an infra-sellar enhancing tumor expanding to the sellar and supra-sellar region which proved to be a GCT. the patient had received 03 months of preoperative denosumab-based treatment and imaging follow-up showed regression in size and morphology modifications of tumor tissue. Conclusion: This is one of few reports to describe the appearance of sphenoid bone GCT, and the first report to highlight the effects of short-term denosumab treatment in GCTb in such a location.

Denosumab in Giant Cell Tumor of Bone: Multidisciplinary Medical Management Based on Pathophysiological Mechanisms and Real-World Evidence

Simple Summary

The widely accepted local therapy in extremity giant cell tumor of bone (GCTB) is surgery, in the form of extended intralesional curettage with adequate disease clearance and retention of the limb, wherever possible. Denosumab is a relevant therapy option for advanced GCTB, to benefit tumor response and surgical down-staging. Most GCTB patients with localized disease can be successfully treated with surgical curettage; patients with primary unresectable lesions or metastases may experience long-term clinical and radiological remission and pain control with denosumab treatment, and in this clinical situation, denosumab is currently the treatment of choice.

Abstract

(1) Despite the benign nature of the giant cell tumor of bone (GCTB), it shows a local recurrence rate of up to 50% and a chance of malignant transformation. The widely accepted local therapy in extremity GCTB is surgery, in the form of extended intralesional curettage with adequate disease clearance and retention of the limb, wherever possible. Denosumab, a human monoclonal antibody directed against the RANKL and associated inhibition of the RANKL pathway, is a relevant therapy option for advanced GCTB, to benefit tumor response and surgical down-staging. (2) The literature review of patients with GCTB treated with denosumab is performed via PubMed, using suitable keywords from January 2009 to January 2021. (3) Current indications for denosumab use are not definitively clear and unambiguous. Most GCTB patients with localized disease can be successfully treated with surgical curettage, and the role of denosumab in preoperative therapy in this patient population remains unclear. (4) However, patients with primary unresectable lesions or metastases may experience long-term clinical and radiological remission and pain control with denosumab treatment, and in this clinical situation, denosumab is currently the treatment of choice.

Diagnostic Utility of Genetic and Immunohistochemical H3-3A Mutation Analysis in Giant Cell Tumour of Bone

To validate the reliability and implementation of an objective diagnostic method for giant cell tumour of bone (GCTB). H3-3A gene mutation testing was performed using two different methods, Sanger sequencing and immunohistochemical (IHC) assays. A total of 214 patients, including 120 with GCTB and 94 with other giant cell-rich bone lesions, participated in the study. Sanger sequencing and IHC with anti-histone H3.3 G34W and G34V antibodies were performed on formalin-fixed, paraffin-embedded tissues, which were previously decalcified in EDTA if needed. The sensitivity and specificity of the molecular method was 100% (95% CI: 96.97–100%) and 100% (95% CI: 96.15–100%), respectively. The sensitivity and specificity of IHC was 94.32% (95% CI: 87.24–98.13%) and 100% (95% CI: 93.94–100.0%), respectively. P.G35 mutations were discovered in 2/9 (22.2%) secondary malignant GCTBs and 9/13 (69.2%) GCTB after denosumab treatment. We confirmed in a large series of patients that evaluation of H3-3A mutational status using direct sequencing is a reliable tool for diagnosing GCTB, and it should be incorporated into the diagnostic algorithm. Additionally, we discovered IHC can be used as a screening tool. Proper tissue processing and decalcification are necessary. The presence of the H3-3A mutation did not exclude malignant GCTB. Denosumab did not eradicate the neoplastic cell population of GCTB.

Intralesional nerve-sparing surgery versus non-surgical treatment for giant cell tumor of the sacrum

Background

There is no standard treatment for giant cell tumors of the sacrum. We compared the outcomes and complications in patients with sacral giant cell tumors who underwent intralesional nerve-sparing surgery with or without (neo-) adjuvant therapies versus those who underwent non-surgical treatment (denosumab therapy and/or embolization).

Methods

We retrospectively investigated 15 cases of sacral giant cell tumors treated at two institutions between 2005 and 2020. Nine patients underwent intralesional nerve-sparing surgery with or without (neo-) adjuvant therapies, and six patients received non-surgical treatment. The mean follow-up period was 85 months for the surgical group (range, 25–154 months) and 59 months (range, 17–94 months) for the non-surgical group.

Results

The local recurrence rate was 44% in the surgical group, and the tumor progression rate was 0% in the non-surgical group. There were two surgery-related complications (infection and bladder laceration) and three denosumab-related complications (apical granuloma of the tooth, stress fracture of the sacroiliac joint, and osteonecrosis of the jaw). In the surgical group, the mean modified Biagini score (bowel, bladder, and motor function) was 0.9; in the non-surgical group, it was 0.5. None of the 11 female patients became pregnant or delivered a baby after developing a sacral giant cell tumor.

Conclusions

The cure rate of intralesional nerve-sparing surgery is over 50%. Non-surgical treatment has a similar risk of complications to intralesional nerve-sparing surgery and has better functional outcomes than intralesional nerve-sparing surgery, but patients must remain on therapy over time. Based on our results, the decision on the choice of treatment for sacral giant cell tumors could be discussed between the surgeon and the patient based on the tumor size and location.

Foot and Ankle Giant Cell Tumors Are Not so Aggressive After All: A Retrospective Study

Giant cell tumors are most commonly seen around the knee and rarely around the foot and ankle. Therefore there is a paucity of data regarding the options of surgery, outcomes and recurrence of Giant cell tumors involving the foot and ankle. We retrospectively studied patients with Giant cell tumors of the foot and ankle from January 2009 to December 2017. We identified 19 (N = 19) patients with a minimum of 1-year follow-up. Their data was retrieved from the electronic database and analyzed. The mean follow-up period was 36.2 (range 12-96) months. On an average, the patients underwent 1.6 surgeries. The surgeries performed were extended curettage and bone graft/cement in 8 (42.1%) patients, excision and bone graft in 8 (42.1%) patients and excision and mega prosthesis in 3 (15.79%) patients. The most common complication was wound infection seen in 3 (15.79%) patients. None of the patients who underwent index procedure in our center (biopsy and surgery) had local recurrence. There were 9 (47.36%) patients with primary procedure elsewhere - 7 of them had no recurrence after surgery in our center. One (5.26%) amputation was eventually performed due to complications and not as a primary surgery. At the final review, all 19 (100%) patients with >1 year follow up were in remission. Local recurrence and wound infection were exclusively found in patients who presented to us after invasive procedures done elsewhere. With good surgical clearance, the uncommon presentations of foot and ankle Giant cell tumors can be treated to attain complete remission.

The current standing on the use of denosumab in giant cell tumour of the bone

Giant cell tumour of the bone (GCTB) has been classically treated surgically. With the advent of denosumab, there is potential to use it as a targeted therapy to downstage the tumour and control its progression. Like all new therapies, the dosage, duration, and long-term effects of treatment can only be determined over the time through numerous trials and errors. The current recommendation of use of the monoclonal antibody is 3-4 months of neoadjuvant denosumab in patients with advanced GCTB for cases who were not candidates for primary curettage initially, and prolonged use for surgically unsalvageable GCTB. The use of Denosumab in the adjuvant setting to prevent recurrence is not established.

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.

Giant cell tumor of the thoracic spine causing acute paraplegia-a case report

Giant cell tumors (GCT) are rare and account for approximately 5% of all primary bone tumors. GCTs in the spine make up less than 10% of all GCTs, and less than 5% of all primary spinal tumors. Less than 10% of spinal GCTs occur above the sacrum and cases involving the thoracic spine are seldom reported in the literature. In our case the patient presented with acute paraplegia of bilateral lower extremities after being seen in the emergency department a day earlier. An MRI and CT scan demonstrated near complete destruction of T8 vertebral body with a possible pathologic lesion and fracture associated with dorsal and ventral spinal cord compression and significant signal change within the spinal cord. She underwent T7-T9 laminectomy with excisional biopsy and was subsequently diagnosed with a primary GCT of the thoracic spine. She was definitively treated with resection and T4-12 fusion and 120 mg of denosumab. At four years post follow-up there has been no recurrence of the tumor to date. This is a more acute presentation than has previously been reported. Patients with GCT of the spine typically present with pain and may have further progression to neurologic deficit. This patient's rapid onset of paraplegia is more acute than has been previously reported in the literature. The authors believe that prompt surgical excision and treatment with denosumab can completely resolve GCT of the thoracic spine.

Comprehensive treatment for multicentric giant cell tumors of the pelvis and spine using apatinib: A case report and literature review

Background

There are no standardized treatments for giant cell tumors of the bone (GCTB) in rare locations such as the spine and pelvis or for those that are inoperable and recurrent, let alone for multicentric GCTB. This study reports a novel case of multicentric GCTB treated with a promising antiangiogenic drug, apatinib, a small-molecule tyrosine kinase inhibitor. The efficacy of apatinib in the treatment of GCTB has not been reported previously.

Patients and Methods

A 27-year-old female presented with two giant cell tumors of the spine and sacrum-ilium diagnosed on December 15, 2016. Surgery and selective arterial embolization (SAE) were not reasonable options for this patient, and denosumab was unavailable; therefore, the antiangiogenic drug apatinib and the osteoclast inhibitor zoledronic acid were administered. Apatinib was initially administered at a dose of 850 mg daily, which was decreased to 425 mg daily after 7 months, and then increased again to 635 mg after 11 months. The patient was prescribed a maintenance dose of 500 mg daily after 16 months. The patient reported side effects of Grades I-III nausea, vomiting, and Grades II-III hand-foot syndrome. The patient underwent SAE at 26 months, and at that time, she was switched to denosumab instead of zoledronic acid.

Results

The patient showed noticeable symptomatic improvement and visibly reduced tumor size after the first month of treatment. Computed tomography in the 4^th month identified a partial response based on the RECIST criteria. The patient has achieved an objective reduction in tumor size at 32 months.

Conclusions

Comprehensive treatment including apatinib represents a potential new treatment strategy for inoperable GCTB, with tolerable side effects. However, further clinical trials are now necessary to confirm an effective dose and determine the efficacy and safety of apatinib in the treatment of GCTB.

Sacral Giant Cell Tumor-Induced Cauda Equina Syndrome: Case Report with Successful Management

Sacral giant cell tumor (GCT) is a rare entity. It often presents late after massive enlargement of tumor. Here we are reporting a case of sacral GCT treated successfully at our institute. A 30-year-old male patient presented with paraplegia, significant sensory disturbance below L2 level, along with severe vesicorectal dysfunction. On imaging, giant mass was seen filling the sacrum with homogenous enhancement and flow voids from L5 level to S4 level. The patient underwent surgical exploration with L4–5 decompressive laminectomy, near-total resection of tumor, and lumboiliac fixation. The patient recovered symptomatically in postoperative period. Sacral GCT is a rare but treatable lesion. Its presentation as sudden cauda equina syndrome is rare, but final management should be aggressive with en bloc resection and fixation.

The two faces of giant cell tumor of bone

Giant cell tumor (GCT) is a bone-destructive benign neoplasm characterized by distinctive multinucleated osteoclast-like giant cells with osteolytic properties distributed among neoplastic stromal cells. GCT is locally aggressive with progressive invasion of adjacent tissues and occasionally displays malignant characteristics including lung metastasis. GCT is characterized genetically by highly recurrent somatic mutations at the G34 position of the H3F3A gene, encoding the histone variant H3.3, in stromal cells. This leads to deregulated gene expression and increased proliferation of mutation-bearing cells. However, when GCT complicates Paget disease of bone (GCT/PDB) it behaves differently, showing a more malignant phenotype with 5-year survival less than 50%. GCT/PDB is caused by a germline mutation in the ZNF687 gene, which encodes a transcription factor involved in the repression of genes surrounding DNA double-strand breaks to promote repair by homologous recombination. Identification of these driver mutations led to novel diagnostic tools for distinguishing between these two tumors and other osteoclast-rich neoplasms. Herein, we review the clinical, histological, and molecular features of GCT in different contexts focusing also on pharmacological treatments.

The role of interventional radiology in elective orthopaedic practice

Interventional radiology is a subspecialty of radiology that provides a range of minimally invasive diagnostic and therapeutic procedures. It continues to expand and evolve, and has had a marked impact on clinical care in many settings, in some cases averting the need for major surgery and hospital admission. While its role in the setting of trauma is relatively well established, with arterial embolisation a valuable option in the management of haemodynamically unstable patients, it is less prominent in the elective setting. This article provides an overview of emerging applications of interventional radiology in the elective treatment of orthopaedic conditions.

Sphenoid Sinus Giant Cell Tumor: A Case Report and Literature Review

We describe a 27-year-old female with a giant cell tumor of her sphenoid sinus, presenting with nasal obstruction and cranial neuropathies. Both the surgical and subsequent medical management are reviewed. Additionally, we review the overall presentation, pathophysiology, and management of giant cell tumors of the skull base. Current treatment recommendations are presented.

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.

Increased Risk of Lung Metastases in Patients with Giant Cell Bone Tumors: A Systematic Review

Giant cell tumors of the bone are rare, usually benign, tumors consisting of large, multinucleated bone cells. Remarkably, these tumors are characterized by aggressive growth. They tend to recur frequently and, in rare cases, metastasize to the lungs. Previous studies tried to identify risk factors for lung metastasis by giant cell bone tumors. Those studies reported different results due to a small number of patients. Therefore, a particularly high risk associated with this type of bone tumor prompted this systematic review and meta-analysis to identify risk factors for the development of lung metastases. The risk factors for lung metastasis by giant cell bone tumors searched for in this study were gender, age, lung metastasis and recurrence period, follow-up time, primary or recurrent tumor, Campanacci grading, tumor localization, disease course, treatment of primary and recurrent tumors, and pulmonary metastases treated by surgery, radiation, and chemotherapy. This meta-analysis identified the features outlined above by comparing the groups of patients with giant cell bone tumors and lung metastases with the control group consisting of patients without lung metastases. The search for suitable studies revealed 63 publications with a total of 4,295 patients with giant cell bone tumors. Of these, 247 (5.8%; 95% confidence interval (95%CI) 5.1-6.5%) patients had lung metastases. Further, the risk factors for lung metastases were the following: recurrence (p < 0.0001), lung metastasis time (p < 0.0001), Campanacci grade II (p = 0.028) and grade III (p = 0.006), localization in the lower limbs (p = 0.0007), curettage (p = 0.0005), and local irradiation of the primary tumor (p = 0.008). All studies showed a high-risk bias due to the absence of blinding of the participants, personnel, and outcome assessment. Special attention should be paid to tumor recurrence in the long follow-up time, since more advanced giant cell bone tumors, particularly in lower extremities, tend to reoccur and metastasize to the lung. Surgical treatment and local irradiation should be performed thoughtfully, with extended follow-up periods.

Axial giant cell tumor - current standard of practice

Giant cell tumors of bone are relatively rare in the axial skeleton, accounting for approximately 6.7% of all cases. Due to their anatomical complexity, difficult access and proximity to vital neurovascular structures, management of these tumors poses a huge challenge on the treating surgeon. Several data series reported on axial GCTB involve short series of limited cases with varied methods used in their local control due to which, proper guidelines are unavailable for the management of such difficult cases. Though the present data support the use of denosumab for effective management of these lesions but there is varied consensus on dosage and duration of treatment. This review article summarizes the basic features and treatment modalities related to axial GCTB stressing on multidisciplinary approach to achieve optimum outcomes.

Role of Bisphosphonates as Adjuvants of Surgery in Giant Cell Tumor of Spine

Background

The role of bisphosphonates is well established in giant cell tumor of bone (GCTB) of extremities, but its role in spine GCTB is still not established. Our main purpose was to evaluate the role of bisphosphonates in spinal GCTB with the help of radiologic assessment.

Methods

A retrospective analysis of all spine GCTB patients who underwent an operation from July 2005 to January 2014 was done. Patients of spine GCTB in whom bisphosphonates were given constituted the study group. This group was compared to patients in whom bisphosphonates were not given. Preoperative and postoperative radiographs and CT scans were studied. A thorough evaluation of the presence of sclerosis was done on them. Bisphosphonates were considered to be effective if either sclerosis or new bone formation was present.

Results

A total of 13 cases of spine GCT underwent operation from July 2005 to January 2014. All patients of GCTB spine who underwent an operation after 2008 at our institute were given bisphosphonates postoperatively. Of 13 cases, bisphosphonates were given postoperatively in 6 patients: 5 patients were female and 1 patient was male. Of these 6 patients, 3 patients had sacrum GCTB and 1 patient each had T9, T11, and L5 vertebrae GCTB. Average follow-up period was 39.33 months (minimum follow-up was 18 months and maximum follow-up was 72 months). Postoperative sclerosis was present in all 6 patients. No recurrence of the tumor was present in the bisphosphonate group, but 2 patients had a recurrence in the group that did not receive bisphosphonates.

Conclusions

Bisphosphonates are effective and safe adjuvant therapy along with appropriate surgical intervention in spinal GCTBs and may have a role in decreasing the recurrence of this tumor.

Giant-cell tumor of the rib cage extending to the spine : Case report

PURPOSE

We present the case of a patient with a giant cell tumor of the thoracic wall that invaded the thoracic spine.

MATERIAL AND METHODS

A giant cell tumor that affects the spine and the thoracic wall is very rare but can grow to a large size. We report a case of giant cell tumor of the left chest wall extending to the thoracic spine in a 28-year-old man. Positron emission tomography (PET) showed a tumor of 11 × 4 × 13 cm in size and the histopathology specimen of the first surgical procedure diagnosed a giant cell tumor. The tumor was treated by oblique osteotomy guided with pedicle wires.

RESULTS

A giant cell tumor was histologically confirmed following radical surgery. After 1 year of follow-up the patient was asymptomatic. There has been no recurrence of the tumor.

CONCLUSION

The use of transpedicular Kirschner wires could be a good technical support for transpedicular oblique sagittal osteotomy.

Giant Cell Tumor of the Sacrum: Series of 19 Patients and Review of the Literature

There are still some debates regarding the best treatment of Giant Cell Tumor (GCT) of the sacrum. Since GCT of this location is rare, therapeutic strategies are mainly based on the treatment of GCT in other anatomic locations. The objective of this study was to evaluate the oncologic and clinical results of surgical management of sacral GCT with and without local adjuvant therapy. Medical records of 19 patients diagnosed with GCT of the sacrum, were retrospectively reviewed. Sixteen patients were treated by intralesional curettage and three patients with marginal resection. Musculoskeletal tumor society (MSTS) score was used for the evaluation of functional outcome. Prolonged pain was the most common complication after treatment. Mean Pre and post-operative pain based on visual analogue scale (VAS) was 6.1 ± 1.99 and 3.05 ± 1.64, respectively. Postoperative neurologic deficit appeared in six patients. In addition, infection occurred in five patients. One case of spinopelvic instability was also observed after surgery. At average follow up of 158.5 ± 95.9 months (25 to 316 months), recurrence was seen in eight (42.7%) out of seventeen patients treated by intralesional curettage. The size of the tumor significantly correlated with the tumor recurrence (r=0.654, P=0.001). Mean MSTS score was 74.7 ± 16.78. Those patients, in whom sacral nerve roots remained intact before and after surgery, had better functional outcome. Preservation of sacral nerve roots is associated with better functional outcome and less pain. Although an acceptable surgical outcome was observed in our cohort, the problem of local recurrence still warrants further investigations for better local control of the tumor.

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

STUDY DESIGN

Multicenter, ambispective observational study.

OBJECTIVE

The aim of this study was to quantify local recurrence (LR) and mortality rates after surgical treatment of spinal giant cell tumor and to determine whether en bloc resection with wide/marginal margins is associated with improved prognosis compared to an intralesional procedure.

SUMMARY OF BACKGROUND DATA

Giant cell tumor (GCT) of the spine is a rare primary bone tumor known for its local aggressiveness. Optimal surgical treatment remains to be determined.

METHODS

The AOSpine Knowledge Forum Tumor developed a comprehensive multicenter database including demographics, presentation, diagnosis, treatment, mortality, and recurrence rate data for GCT of the spine. Patients were analyzed based on surgical margins, including Enneking appropriateness.

RESULTS

Between 1991 and 2011, 82 patients underwent surgery for spinal GCT. According to the Enneking classification, 59 (74%) tumors were classified as S3-aggressive and 21 (26%) as S2-active. The surgical margins were wide/marginal in 27 (36%) patients and intralesional in 48 (64%) patients. Thirty-nine of 77 (51%) underwent Enneking appropriate (EA) treatment and 38 (49%) underwent Enneking inappropriate (EI) treatment. Eighteen (22%) patients experienced LR. LR occurred in 11 (29%) EI-treated patients and six (15%) EA-treated patients (P = 0.151). There was a significant difference between wide/marginal margins and intralesional margins for LR (P = 0.029). Seven (9%) patients died. LR is strongly associated with death (Relative Risk 8.9, P < 0.001). Six (16%) EI-treated patients and one (3%) EA-treated patients died (P = 0.056). With regards to surgical margins, all patients who died underwent intralesional resection (P = 0.096).

CONCLUSION

En bloc resection with wide/marginal margins should be performed when technically feasible because it is associated with decreased LR. Intralesional resection is associated with increased LR, and mortality correlates with LR.

LEVEL OF EVIDENCE

3.

Giant cell tumor of the thoracic spine completely removed by total spondylectomy after neoadjuvant denosumab therapy

PURPOSE

Denosumab, a novel monoclonal antibody that targets the receptor activator of nuclear factor-κB (RANK) ligand (RANKL), has recently been used to treat patients with giant cell tumor of bone (GCTB). However, few reports have described the clinical results of denosumab therapy for spinal GCTB and evaluated treatment efficacy with respect to the entirety of the resected vertebra after denosumab therapy.

METHODS

We present the case of a 51-year-old man with T12 GCTB that was completely removed by a total spondylectomy following 10 courses of neoadjuvant denosumab therapy. Post-therapy radiological findings indicated epidural tumor reduction in the spinal canal and sclerotic rim formation. However, the affected vertebra collapsed despite denosumab therapy and a massive bridging callus formation was present between the spinal GCTB and adjacent vertebra.

RESULTS

These morphological changes made the tumor margins unclear and increased the difficulty of dissection of the segmental arteries from the vertebral body and en bloc corpectomy by a posterior-approach. Pathological findings indicated increased woven bone at the peripheral lesion of the resected vertebra and RANKL-positive stromal cells remained around the woven bone.

CONCLUSIONS

These findings support that GCTB stromal cells survived around the newly formed woven bone after long-term denosumab treatment and total surgical resection of such primary spinal lesions as the gold-standard treatment, even following administration of denosumab. Surgeons should note that prolonged adjuvant denosumab therapy may increase the difficulty of performing a posterior-approach total en bloc spondylectomy.

Denosumab treatment for progressive skull base giant cell tumor of bone in a 14 year old female - a case report and literature review

Background

Giant cell tumor of bone (GCT) is a rare primary bone tumor, which can metastasize and undergo malignant transformation. The standard treatment of GCT is surgery. In patients with unresectable or metastatic disease, additional therapeutic options are available. These include blocking of the receptor activator of NF-kappa B ligand (RANKL) signaling pathway, which plays a role in the pathogenesis of GCT of bone, via the anti-RANKL monoclonal antibody denosumab.

Case Presentation

Herein we report on a female teenager who presented in a very poor clinical condition (cachexia, diplopia, strabismus, dysphonia with palsy of cranial nerves V, VI, VIII, IX, X, XI and XII) due to progressive disease, after incomplete resection and adjuvant radiotherapy, of a GCT which affected the cervical spine (C1 and C2) as well as the skull base; and who had an impressive clinical response to denosumab therapy. To the best of our knowledge, this is the youngest patient ever reported with a skull base tumor treated with denosumab.

Conclusion

In situations when surgery can be postponed and local aggressiveness of the tumor does not urge for acute surgical intervention, upfront use of denosumab in order to reduce the tumor size might be considered. Principally, the goal of denosumab therapy is to reduce tumor size as much as possible, with the ultimate goal to make local surgery (or as in our case re-surgery) amenable. However, improvement in quality of life, as demonstrated in our patient, is also an important aspect of such targeted therapies.

Electronic supplementary material

The online version of this article (doi:10.1186/s13052-017-0353-0) contains supplementary material, which is available to authorized users.

Current status and unanswered questions on the use of Denosumab in giant cell tumor of bone

Denosumab is a monoclonal antibody to RANK ligand approved for use in giant cell tumour (GCT) of bone. Due to its efficacy, Denosumab is recommended as the first option in inoperable or metastatic GCT. Denosumab has also been used pre-operatively to downstage tumours with large soft tissue extension to allow for less morbid surgery. The role of Denosumab for conventional limb GCT of bone is yet to be defined. Further studies are required to determine whether local recurrence rates will be decreased with the adjuvant use of Denosumab along with surgery. The long term use and toxicity of this agent is unknown as is the proportion of patients with primary or secondary resistance. It is advised that complicated cases of GCT requiring Denosumab treatment should be referred and followed up at expert centres. Collaborative studies involving further clinical trials and rigorous data collection are strongly recommended to identify the optimum use of this drug.

Denosumab for Treatment of a Recurrent Cervical Giant-Cell Tumor

A 43-year-old male patient with C5 giant cell tumor (GCT) underwent tumor resection and anterior bone fusion of C4–C6. The tumor recurred locally 9 months after surgery with the patient complaining of neck and shoulder pain similar to his preoperative symptoms. Denosumab was administered and his pain disappeared after a two-month administration, with a sclerotic rim formation seen at the tumor site on computed tomography. He has been followed for 18 months with no evidence of tumor recurrence. Complete resection is generally recommended, but is not easy for many patients with cervical GCT because of the existence of neurovascular structures. Some patients suffer from recurrence and treatment becomes more difficult. As such, denosumab may be an efficacious option for treatment of recurrent GCT of the cervical spine, although long-term follow-up is required to monitor for presence or absence of recurrence.

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

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

Incidence Trends in the Diagnosis of Giant Cell Tumor of Bone in Sweden Since 1958

BACKGROUND

The Swedish Cancer Registry (founded in 1958) constitutes a unique resource for epidemiological studies of giant cell tumor of bone with potential for use for population-based studies of incidence over time. The aim of this study was to provide what we believe is the first modern population-based assessment of the incidence trends of giant cell tumor, a unique osteoclastogenic lytic stromal tumor with both benign and malignant histological forms, and to compare the findings with data from the same registry on osteosarcoma, a tumor that may display similar histological characteristics.

METHODS

Cases were identified with use of codes for pathological bone tumor (International Classification of Diseases [ICD]-7 196). Specific morphological coding distinguishes benign (PAD 741) from malignant giant cell tumor (PAD 746) and osteosarcoma (PAD 766).

RESULTS

During the period of 1958 to 2011, 4625 bone tumors were reported, including 505 giant cell tumors (383 benign and 122 malignant) and 1152 osteosarcomas. From 1958 to 1982 the ratio of malignant to benign giant cell tumors was 1.3, whereas from 1983 to 2011 the ratio inverted to 0.09, suggesting a change in the reporting or diagnosis of malignant or benign cases. Cases of giant cell tumor diagnosed from 1983 to 2011 displayed an age and sex distribution (median age at diagnosis, 34.0 years; 54% female) that were consistent with those in large published case series but differed from those in 1958 to 1982 (median age at diagnosis, 31.5 years; 48% female). The most current data (1983 to 2011) showed the giant cell tumor incidence in Sweden to be 1.3 per million per year, while the osteosarcoma incidence was 2.3 per million per year.

CONCLUSIONS

Early Swedish Cancer Registry data (1958 to 1982) revealed a higher proportion of malignant giant cell tumors than seen in large sequential case series and a distinct age and sex profile compared with more recent data (1983 to 2011). This likely represents changes in the diagnostic workup and introduction of multidisciplinary review of giant-cell-containing tumors around 1982. Recent data may reflect the impact of expert centralized biopsy and multidisciplinary case review and more comprehensive reporting of benign giant cell tumors.

Therapeutic radiotherapy for giant cell tumor of the spine: a systemic review

BACKGROUND

Giant cell tumor of the bone (GCTB) is a benign but locally aggressive tumor. Giant cell tumor of the spine (GCTS) accounts for 3-6 % of GCTB. Surgery remains the treatment of choice. For those not suitable for surgery, therapeutic radiotherapy (RT) is one classic modality. Although there are several articles on therapeutic RT for GCTS therapy, few systemic reviews have been performed on effects of therapeutic RT on GCTS.

METHODS AND MATERIALS

We searched EMBASE and Medline databases for papers reporting therapeutic radiotherapy for GCTS patients not suitable for surgical resection. The inclusion criteria and prognosis indicators have been defined prior to data extraction. Information of the included patients has been discreetly recorded. We analyzed the prognosis of therapeutic RT and multiple data concerning the GCTS patients. The indicators for prognosis were computed by SPSS software. The local control (LC) and overall survival (OS) rate was estimated by the Kaplan-Meier method. p values ≤0.5 were considered statistically significant.

RESULT

We included 13 studies comprising 42 patients who received therapeutic radiotherapy with doses ranging from 21 to 80 Gy. The results suggested a response rate of 100 %, OS of 97.6 %, 1-year local control rate (LC) of 85.4 %, 2-year LC rate of 80.2 %, and overall LC of 79 %. No patient reported malignant transformation albeit four had post-RT neurological complications. Four had distant metastasis of the tumor. Patients with previously repeated recurrence had worse prognosis after RT (p = 0.028). No association between dosage and prognosis was found.

CONCLUSION

Therapeutic RT could provide a satisfactory prognosis for GCTS patients according to this study, and can be an alternative treatment modality for GCTS patients not suitable for surgery.

Synchronous Multicentric Giant Cell Tumour of Distal Radius and Sacrum with Pulmonary Metastases

Giant cell tumour (GCT) is an uncommon primary bone tumour, and its multicentric presentation is exceedingly rare. We report a case of a 45-year-old female who presented to us with GCT of left distal radius. On the skeletal survey, osteolytic lesion was noted in her right sacral ala. Biopsy confirmed both lesions as GCT. Pulmonary metastasis was also present. Resection-reconstruction arthroplasty for distal radius and thorough curettage and bone grafting of the sacral lesion were done. Multicentric GCT involving distal radius and sacrum with primary sacral involvement is not reported so far to our knowledge.

The clinical approach toward giant cell tumor of bone

We provide an overview of imaging, histopathology, genetics, and multidisciplinary treatment of giant cell tumor of bone (GCTB), an intermediate, locally aggressive but rarely metastasizing tumor. Overexpression of receptor activator of nuclear factor κB ligand (RANKL) by mononuclear neoplastic stromal cells promotes recruitment of numerous reactive multinucleated giant cells. Conventional radiographs show a typical eccentric lytic lesion, mostly located in the meta-epiphyseal area of long bones. GCTB may also arise in the axial skeleton and very occasionally in the small bones of hands and feet. Magnetic resonance imaging is necessary to evaluate the extent of GCTB within bone and surrounding soft tissues to plan a surgical approach. Curettage with local adjuvants is the preferred treatment. Recurrence rates after curettage with phenol and polymethylmethacrylate (PMMA; 8%-27%) or cryosurgery and PMMA (0%-20%) are comparable. Resection is indicated when joint salvage is not feasible (e.g., intra-articular fracture with soft tissue component). Denosumab (RANKL inhibitor) blocks and bisphosphonates inhibit GCTB-derived osteoclast resorption. With bisphosphonates, stabilization of local and metastatic disease has been reported, although level of evidence was low. Denosumab has been studied to a larger extent and seems to be effective in facilitating intralesional surgery after therapy. Denosumab was recently registered for unresectable disease. Moderate-dose radiotherapy (40-55 Gy) is restricted to rare cases in which surgery would lead to unacceptable morbidity and RANKL inhibitors are contraindicated or unavailable.

[Benign and semimalignant spinal tumors. Characteristics in children and adults]

Diagnostic radiology and magnetic resonance imaging (MRI) are the most important imaging tools in the evaluation of benign bone tumors. Computed tomography (CT) is an additional tool for bony lesions, such as in cases of confirmation of the diagnosis of osteoid osteomas. For benign bony lesions three-stage skeletal scintigraphy is an optional additional diagnostic tool. The identification of benign or semimalignant bone tumors is not always clear; therefore percutaneous biopsy is necessary in most cases. In benign spinal tumors an intralesional curettage with reconstruction and stabilization is sufficient. In cases of semimalignant tumors, e.g. giant cell tumors localized in the spine, an en bloc resection is necessary because of the high recurrence rate.

The multidisciplinary management of giant cell tumor of bone

Giant cell tumor of bone is a locally aggressive lesion with a predilection for local recurrence, and in a small proportion of patients, metastatic disease can develop. Surgery is the mainstay of management for extremity-based lesions. For tumors located in challenging anatomical locations such as the sacrum and spine however, surgery may be associated with unacceptable functional morbidity. There are limited data regarding other treatment modalities such as radiation therapy, cytotoxic chemotherapy, interferon and bisphosphonates. Serial arterial embolization can be effective in some cases. Recent evidence has demonstrated denosumab to be a promising agent in the treatment of unresectable or metastatic disease.

Giant cell tumors of the sacrum--a nationwide study on midterm results in 26 patients after intralesional excision

PURPOSE

Evaluation of recurrences, complications and function at mid-term follow-up after curettage for sacral giant cell tumor (GCT).

METHODS

We retrospectively studied all 26 patients treated for sacral GCT in the Netherlands (from 1990 to 2010). Median follow-up was 98 (6-229) months. All patients underwent intralesional excision, 21 with local adjuvants, 5 radiotherapy, 3 IFN-α, 1 bisphosphonates. Functional outcome was assessed using Musculoskeletal Tumor Society (MSTS) score. Statistics were performed with Kaplan-Meier, Cox regression, log rank and Mann-Whitney U.

RESULTS

Recurrence rate was 14/26 after median 13 (3-139) months and was highest after isolated curettage (4/5). Soft tissue masses >10 cm increased recurrence risk (HR = 3.3, 95 % CI = 0.81-13, p = 0.09). Complications were reported in 12/26 patients. MSTS was superior in patients without complications (27 vs. 21; p = 0.024).

CONCLUSION

Recurrence rate for sacral GCT was highest after isolated curettage, indicating that (local) adjuvant treatment is desired to obtain immediate local control. Complications were common and impaired function.

Giant cell tumours of the mobile spine: characteristic imaging features and differential diagnosis

PURPOSE

The aim of this study was to investigate the characteristic imaging features of giant cell tumours (GCTs) of the mobile spine.

MATERIALS AND METHODS

Thirty pathologically proven GCTs of the mobile spine were reviewed. X-ray (n = 18), computed tomography (CT) (n = 24) and magnetic resonance (MR) (n = 21) images were retrospectively evaluated.

RESULTS

Five tumours were located in the cervical spine, 15 tumours were located in the thoracic spine and 10 tumours in the lumbar spine. The characteristic X-ray findings included an osteolytic and expansile lesion with a "soap bubble" or purely lytic appearance. Cortical destruction was commonly seen. Margin sclerosis was seen in two lesions. No mineralised tumour matrix or periosteal reaction appeared. The CT findings were similar but outlined the cortical alterations in a more accurate way. The characteristic MR findings included a well-defined and expansile mass with heterogeneous low-to-iso signal intensity on T2-weighted images. Cystic areas were commonly seen in 17 cases. Five cases presented fluid-fluid levels, suggesting the development of aneurysmal bone cyst. The solid portions of the tumours were enhanced with a very heterogeneous signal pattern reflecting high blood supply after contrast-enhanced scan. Tumour involvement in the epidural space occurred in 12 cases, causing spinal cord and/or nerve root compression. Involvement of intervertebral discs and/or adjacent vertebrae appeared in two cases.

CONCLUSIONS

Although rare, GCT can occur in the mobile spine as a kind of benign but locally aggressive tumour. Radiologists should be familiar with its characteristic imaging features in order to make a correct diagnosis and to help preoperative evaluations.

Major complications following total en bloc spondylectomy for giant-cell tumor

The authors present the case of a 32-year-old Caucasian female with a giant-cell tumor of the eighth thoracic vertebra, causing unremitting pain, segmental kyphosis and imminent local instability. A total en bloc spondylectomy by a posterior-only approach was performed, complemented with anterior-column reconstruction with a titanium mesh and structural allograft, as well as pedicle screw fixation. Despite the surgery being uneventful, several complications developed over the ensuing weeks: bilateral hemothorax, empyema and sepsis, requiring numerous revision surgeries for postoperative infection. The same pathogen was identified in different samples collected, including a sample from the allograft used. Only the aggressive therapeutic measures adopted allowed improvement in clinical and analytic parameters. The present report alerts to the possible complications following major spine surgery, and raises concerns on the safety of the bone allografts provided, renewing the interest in the development of alternative bone substitutes.

Denosumab: a potential new and innovative treatment option for aneurysmal bone cysts

INTRODUCTION

Aneurysmal bone cysts (ABCs) are expansive and destructive lesions positive for osteoclast markers, resembling benign giant cell tumors (GCTs). Treatment options include surgical resection, curettage and cavity filling, embolization, injection of fibrosing agents, or radiotherapy. Particularly in children and adolescents with spinal ABCs, these options may be unsatisfactory, and innovative forms of treatment are needed. Denosumab is a human monoclonal antibody that inhibits osteoclast function by blocking the cytokine receptor activator of the nuclear factor-kappa B ligand. Satisfactory results with denosumab in treating GCTs and immunohistochemical similarities suggest that it may also have positive effects on ABCs.

METHODS AND RESULTS

This report is the first description of the therapeutic use of denosumab in two patients with spinal ABCs. Two boys (aged 8 and 11) had recurrent ABCs at C5 after surgery with intralesional tumor resection. Treatment options were discussed by the interdisciplinary tumor board. Arterial embolization was attempted, but failed due to an absence of appropriate afferent arteries. After the families had received extensive information and provided written consent, denosumab therapy was initiated as an individualized treatment, despite the absence as yet of scientific evidence. After the start of denosumab therapy, both patients recovered from pain and neurologic symptoms significantly and are now in a healthy condition with no severe side effects. Magnetic resonance imaging check-ups after 2 or 4 months of denosumab treatment, respectively, showed tumor regression in both patients.

DISCUSSION

Longer follow-up and clinical studies are warranted to establish the value of denosumab in the treatment of ABCs.

Giant cell tumours of the small bones of the hands and feet

Giant cell tumours (GCTs) of the small bones of the hands and feet are rare. Small case series have been published but there is no consensus about ideal treatment. We performed a systematic review, initially screening 775 titles, and included 12 papers comprising 91 patients with GCT of the small bones of the hands and feet. The rate of recurrence across these publications was found to be 72% (18 of 25) in those treated with isolated curettage, 13% (2 of 15) in those treated with curettage plus adjuvants, 15% (6 of 41) in those treated by resection and 10% (1 of 10) in those treated by amputation.

We then retrospectively analysed 30 patients treated for GCT of the small bones of the hands and feet between 1987 and 2010 in five specialised centres. The primary treatment was curettage in six, curettage with adjuvants (phenol or liquid nitrogen with or without polymethylmethacrylate (PMMA)) in 18 and resection in six. We evaluated the rate of complications and recurrence as well as the factors that influenced their functional outcome.

At a mean follow-up of 7.9 years (2 to 26) the rate of recurrence was 50% (n = 3) in those patients treated with isolated curettage, 22% (n = 4) in those treated with curettage plus adjuvants and 17% (n = 1) in those treated with resection (p = 0.404). The only complication was pain in one patient, which resolved after surgical removal of remnants of PMMA. We could not identify any individual factors associated with a higher rate of complications or recurrence. The mean post-operative Musculoskeletal Tumor Society scores were slightly higher after intra-lesional treatment including isolated curettage and curettage plus adjuvants (29 (20 to 30)) compared with resection (25 (15 to 30)) (p = 0.091). Repeated curettage with adjuvants eventually resulted in the cure for all patients and is therefore a reasonable treatment for both primary and recurrent GCT of the small bones of the hands and feet.

Cite this article: Bone Joint J 2013;95-B:838–45.

Use of gluteus maximus adipomuscular sliding flaps in the reconstruction of sacral defects after tumor resection

Background

While performing sacrectomy from a posterior approach enables the en bloc resection of sacral tumors, it can result in deep posterior peritoneal defects and postoperative complications. We investigated whether defect reconstruction with gluteus maximus (GLM) adipomuscular sliding flaps would improve patient outcomes.

Methods

Between February 2007 and February 2012, 48 sacrectomies were performed at He Nan Cancer Hospital, Zhengzhou City, China. We retrospectively examined the medical records of each patient to obtain the following information: demographic characteristics, tumor location and pathology, oncological resection, postoperative drainage and complications. Based on the date of the operation, patients were assigned to two groups on the basis of closure type: simple midline closure (group 1) or GLM adipomuscular sliding reconstruction (group 2).

Results

We assessed 21 patients in group 1 and 27 in group 2. They did not differ with regards to gender, age, tumor location, pathology or size, or fixation methods. The mean time to last drainage was significantly longer in group 1 compared to group 2 (28.41 days (range 17–43 days) vs. 16.82 days (range 13–21 days, P < 0.05)) and the mean amount of fluid drained was higher (2,370 mL (range 2,000–4,000 mL) vs. 1,733 mL (range 1,500–2,800 mL)). The overall wound infection rate (eight (38.10%) vs. four (14.81%), P < 0.05) and dehiscence rate (four (19.05%)] vs. three (11.11%), P < 0.05) were significantly higher in group 1 than in group 2. The rate of wound margin necrosis was lower in group 1 than in group 2 (two (9.82%) vs. three (11.11%), P < 0.05).

Conclusions

The use of GLM adipomuscular sliding flaps for reconstruction after posterior sacrectomy can significantly reduce the risk of infection and improve outcomes.

Spinal Cord Injury due to the Giant Cell Tumor of the Second Thoracic Vertebra: A Case Report

Giant cell tumor (GCT) is a relatively rare neoplasm. In GCT, the bone affection of the axial skeleton is extremely rare. Most GCT arises in the meta-epiphyseal ends of the long bones. Its peak incidence is between 30 to 40 years of age. GCT is usually classified as benign, but shows locally aggressive behavior and may occasionally undergo a malignant transformation. The patients with GCT in the spine often complain of the lower back pains, as the tumors primarily involve the sacrum. We report a case of an adolescent female complaining of the upper back pain with a sudden weakness of the lower extremities, later diagnosed with the GCT of the T2 vertebra. The present patient showed American Spinal Injury Association Impairment Scale (AIS) D before the surgery, which changed to AIS E after the treatments including the surgery, radiation therapy and rehabilitation.

Solid variant of aneurysmal bone cyst on the cervical spine of a child: case report, differential diagnosis and treatment rationale

INTRODUCTION

Despite numerous descriptive publications, the nature, character, differential diagnosis and optimal treatment of aneurysmal bone cysts (ABCs), remain obscure. The authors report a case of the solid variant of aneurysmal bone cyst (S-ABC) occurring in the posterior components and body of C7 vertebra focusing on the differential diagnosis and surgical treatment rationale.

CASE REPORT

Right shoulder and neck pain were the presenting symptoms of 9-year-old boy. Torticollis developed later on but no neurological deficit was found. Imaging revealed an osteolytic lesion with significant extraosseous extension. Although diagnosis favoured an ABC, imaging studies did not provide clear diagnostic criteria. CT guided biopsy performed preoperatively was also not directly diagnostic. Given that differential diagnoses included S-ABC but also giant cell tumor (GCT) of bone, decision was made to proceed with a staged, back and front, complete resection of the affected bony elements of C7. Preoperative spinal angiography showed supply to the tumor from the right ascending and deep cervical artery territories. Particle embolization was not performed due to the presence of ipsilateral supply to the anterior spinal artery at the C6 level and contralateral supply at the C7 level. Intraoperatively, histology taken from posterior elements, although again not clearly diagnostic, favoured S-ABC variant rather than GCT. Thus, initial plan was revised and anterior surgery was postponed as the extent of the dissection would have been dependent on the presumed diagnosis. The final histological report confirmed the diagnosis of an S-ABC. In view of this, it was decided to embolize the lesion to avoid a second stage anterior surgery. At embolization, repeat spinal angiography showed reduced tumor blush following the surgery. Distal branches of the deep cervical artery were occluded with platinum coils (avoiding the risks associated with the use of particles or liquid embolic agents). No further procedure was planned.

CONCLUSION

Imaging and histological pattern of this specific type of ABC, differential diagnosis from GCT and the surgical protocol followed with the patient consist of an interesting case of revising the initial plan, according to the upcoming histological reports.