Curettage and reconstruction by the sandwich technique for giant cell tumours around the knee

Resultados da curetagem estendida com e sem aloenxerto ósseo para tumores de células gigantes de grau II no joelho. Um estudo comparativo retrospectivo

Objetivo Este é o primeiro estudo a estabelecer a utilidade da curetagem estendida com ou sem enxerto ósseo em tumores de células gigantes (TCGs) de grau II na articulação do joelho com o objetivo de explorar os resultados funcionais pós-operatórios.

Métodos Revisamos retrospectivamente 25 casos de TCGs de grau II de Campanacci submetidos a curetagem estendida entre janeiro de 2014 e dezembro de 2019. Os participantes foram divididos em 2 grupos: um grupo de 12 pacientes foi submetido a curetagem estendida com aloenxerto ósseo e cimento ósseo, enquanto o outro grupo, com 13 pacientes, foi submetido a curetagem estendida apenas com cimento ósseo. A qualidade de vida foi avaliada pela Pontuação Revista da Musculoskeletal Tumor Society (MTS, na sigla em inglês) e pela Pontuação da Knee Society (KS, na sigla em inglês), enquanto as taxas de recidiva e complicações foram avaliadas em cada coorte na última consulta de acompanhamento. O teste de Fisher e os testes t de duas amostras foram usados para comparação de resultados categóricos e contínuos, respectivamente

Resultados A média de idade dos pacientes foi de 28,09 (7,44) anos; 10 (40%) pacientes eram do sexo masculino e 15 (60%) pacientes eram do sexo feminino. O fêmur distal e a tíbia proximal foram acometidos em 13 (52%) e 12 (48%) dos pacientes, respectivamente. Não houve diferença significativa na pontuação revista da MTS (25,75 versus 27,41; p = 0,178), na pontuação da KS (78,67 versus 81,46; p = 0,33) e nas taxas de recidiva (0 versus 0%; p = 1) e complicações (25 versus 7,69%; p = 0,21).

Conclusões A curetagem estendida com ou sem aloenxerto ósseo tem resultados funcionais semelhantes em pacientes com TCGs de grau II no joelho, sem qualquer diferença importante na incidência de recidivas e complicações. No entanto, a conveniência cirúrgica e o custo-benefício podem favorecer a utilização apenas de cimento ósseo, enquanto a prevenção da osteoartrite em longo prazo precisa ser investigada para favorecer o enxerto ósseo.

Joint Salvage and Biological Repair of Massive-Cavity Bone Defects After Extensive Curettage of Campanacci Grade II or III Giant Cell Tumor Around the Knee With Vascularized Fibular Autograft and Cancellous Allograft

OBJECTIVE

The aim of the study was to report the clinical outcomes of repair of massive-cavity bone defects after extensive curettage of Campanacci grade II or III giant cell tumor (GCT) around knee with vascularized fibular autograft and cancellous allograft.

METHODS

There were 12 consecutive patients with Campanacci grade II or III GCT around knee treated in our department between 2004 and 2016. All the patients underwent clinical evaluation, plain radiography, and/or magnetic resonance imaging of the knee right after admission. To preserve their knee function, we repaired the massive-cavity bone defects after extensive curettage of GCT by vascularized fibular autografts and cancellous allograft. All the patients were evaluated through clinical examinations, plain radiography of the knee and chest, and Musculoskeletal Tumor Society (MSTS) scores of the lower extremity in the follow-ups.

RESULTS

The follow-up ranged from 1.5 to 12.0 years (mean, 4.2 years). There were no local recurrences or lung metastasis in any of the 12 patients at the last follow-up. Ten patients had no pain or experienced occasional pain, and 9 were able to resume their previous work. The mean range of motion of knee flexion was 117 degrees, and the extension was -6 degrees. The mean MSTS score was 24.7, and a total of 10 patients had excellent or good MSTS scores.

CONCLUSIONS

It is reliable to achieve knee joint salvage and repair massive-cavity bone defects after extensive curettage with vascularized fibular autograft and cancellous allograft in patients with Campanacci grade II or III GCT around the knee.

Giant cell tumour of bone around the knee: a systematic review of the functional and oncological outcomes

Giant cell tumour of bone (GCT) is a relatively rare, locally aggressive benign neoplasm observed in the long bone epiphyseal-metaphyseal regions of young adults.

The optimal treatment strategy for these tumours remains controversial, and a huge amount of contradictory data regarding the functional and oncological outcomes can be found. Therefore, we performed a systematic review intended to investigate the functional and oncological outcomes after surgical treatment of GCTs arising around the knee, namely in the distal femur and proximal tibia.

A trend towards better oncological control was found using wide resections, nonetheless, curettage-based techniques achieve a highly acceptable recurrence rate with overall better knee function. A slight advantage favouring proximal tibia GCTs regarding the Musculoskeletal Tumor Society (MSTS) score was also observed.

Prospective studies comparing groups of more homogeneous patients, tumours, and treatment options should be developed to obtain more conclusive and definitive results regarding the optimal strategy for treating GCTs.

Cite this article: EFORT Open Rev 2021;6:641-650. DOI: 10.1302/2058-5241.6.200154

Joint preservation surgery in grade 2 and 3 giant cell tumors of bone around the knee

Objective: To evaluate the clinical and functional outcomes of joint preservation surgery in high-grade giant cell tumors (GCT) around the knee joint. Methods: A retrospective review of 25 patients of high-grade GCT (Campanacci grade 2 and 3) involving proximal tibia or distal femur managed by extended curettage, bone grafting, and stabilization with knee spanning external fixator between 2016 and 2018 was done. The radiographic outcomes, functional outcomes (Musculoskeletal Tumor Society [MSTS] score for lower limb), and complications including donor site morbidity were evaluated. Results: The mean age of the patient population was 24.04 years with an average follow-up period of 30.24 months. Fourteen patients had involvement of distal femur, and 11 involved proximal tibia. There were 16 cases of grade 2 lesions and 9 cases of grade 3 lesions. Twenty-four out of the 25 patients had radiological consolidation of graft, while one patient had graft subsidence. Twenty-two out of 25 patients had full extension and knee flexion more than 100 degrees. The mean MSTS score was 25.2. Three patients had an MSTS score under 20. All three patients had an extension lag with a restricted range of motion. Conclusion: Joint preservation surgery, when done in line with the basic principles of tumor surgery, gives good radiographic and functional outcomes even in grade 2 and 3 giant cell tumors of bone around the knee and should be attempted before replacement surgeries.

Two rare cases of Giant cell tumor of Distal Ulna

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Giant cell tumours are locally aggressive with a relatively high recurrence rate.

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Common sites are distal femur, proximal tibia and distal radius.

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Contained lesions at these sites managed by joint preservation procedures such as extended curettage with cementing or bone graft.

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GCT in spine, calcaneum and distal ulna are rare, with no uniform consensus regarding the ideal treatment.

Giant cell tumours, though benign, are locally aggressive bone tumours with a relatively high recurrence rate. These usually occur in distal radius, distal femur, proximal tibia and humerus. Treatment options for contained lesions at these sites include joint preservation procedures such as extended curettage with cementing or bone graft. GCT in spine, calcaneum and distal ulna are rare, with no uniform consensus regarding the ideal treatment.

Here we report two cases of GCT distal ulna managed with extended curettage and polymethylmethacrylate cementing showing good functional and radiological outcomes without signs of recurrence during 2 years follow up.

Giant Cell Tumour Around Knee Managed by Curettage and Zoledronic Acid with Structural Support by Fibula Cortical Struts

Introduction:

Giant cell tumour (GCT) of the bone is a benign tumour with a high tendency to recur after surgery. This study aimed to analyse prospectively the rate of local recurrence following management of giant cell tumours by curettage, using intravenous zoledronic acid as an adjuvant, and fibular struts to support the empty cavity after curettage.

Materials and Methods:

This study was carried out in ten cases of biopsy-proven GCTs: five males and five females, in the age group between 18 and 39 years. All patients were given three doses of zoledronic acid, one pre-operative and two post-operative. Extended curettage was done three weeks after the pre-operative dose of zoledronate. The cavity was left empty in all the cases. Fibular struts were used to support the cavity from collapse. Patients were followed-up for post-operative local recurrence. The functional status of the patients was assessed during each visit using the Musculoskeletal Tumour Society (MSTS) score.

Results:

There were no recurrences at a follow-up of two years. All patients had a stable knee and were able to bear weight fully. The average knee flexion was 75º. The average MSTS score of the study was 92%.

Conclusion:

Extended curettage using hydrogen peroxide, systemic zoledronic acid adjuvant and leaving the cavity empty without using cancellous bone graft did not lead to a recurrence of GCT. Non-vascularised fibular strut provided adequate support while the cavity left empty after curettage did not collapse and there was good knee function.

The impact of curettage technique on local control in giant cell tumour of bone

INTRODUCTION

Although consensus has been reached regarding the main aspects of intralesional surgery for giant cell tumour of the bone (GCTB), debates continue about the most effective combination of local adjuvants. The purpose of study was to analyze the previous experience and determine the most effective curettage approach for GCTB.

METHODS

We summarized the findings from 89 papers published from 1962 to 2020 related to this subject. Database consisted of 137 treated groups that included 6441 patients who underwent different curettage techniques without pre-operative administration of bisphosphonates or RANKL inhibitors.

RESULTS

Recurrence rates after simple curettage ranged between 27 and 82% with a median value at 47%. The use of one or two local adjuvants reduced the incidence of recurrences approximately by 50% when compared with simple curettage. High-speed burring combined with chemical adjuvants or followed by poly(methyl methacrylate) cementation with or without bone grafting further improved the local control leading to good and excellent results; however, these were not documented in all studies. Simultaneous use of burring, chemical adjuvants, and cementation, which we named here as combined curettage, allowed to down local relapses to the range of 0-26%, with a median at 11%. Oncologic outcomes after combined curettage are significantly better when compared with simple curettage (p < 0.0001) and other variants of enhancement (p = 0.001).

CONCLUSIONS

Combined curettage appears to provide the most potent and comprehensive impact on residual tumour cells located in risk zones. This approach should be considered for locally advanced tumours when function-preserving surgery is planned. Additional comparative studies are required to define the optimal curettage enhancement for each individual patient.

Outcomes of En bloc resection followed by reconstruction of giant cell tumor around knee and distal radius. A case series

INTRODUCTION

This study is to evaluate the outcomes of En bloc resection and reconstruction in patients with GCT of the bone around the knee and in the distal radius.

MATERIALS AND METHODS

We reviewed 41 cases of GCT of the bone that was treated by En bloc resection around the knee joint and in the distal radius from 2011 to 2018. The local recurrence, metastases, complications and functional score were evaluated for each operation technique.

RESULTS

The average of MSTS score for all group was 78% (excellent). In the knee joint, the megaprostheses group had an excellent MSTS score of78.9% and good 21.1%. The MAMC group had an excellent MSTS score of40.0%, good 50.0% and fair 10.0%. One patient in the megaprostheses group had metastasis to the lung and 1 patient in the knee arthrodesis group has a recurrence. Infection occurred in 2 cases of megaprostheses while only 1 case in MAMC. Both of the groups in knee joint GCT had 1 patient with implant loosening. In the distal radius, FVFG group had an excellent MSTS score 100% and NVFG group had an excellent score 77.7%, good 11.1% and fair 11.1%. One patient in the NVFG group had an infection, 1 patient has implant loosening and another one patient had graft failure. Two patients in the NVFG group had a recurrence. No metastasis was found in both of the group types of surgery in distal radius GCT.

CONCLUSION

Functional outcome of a patient with GCT of the bone after En bloc resection and reconstruction with the above techniques had comparable results with previous studies.

Wide resection versus curettage with adjuvant therapy for giant cell tumour of bone

PURPOSE

To determine the association between type of surgery (wide resection versus curettage with adjuvant therapy) and outcome in patients with giant cell tumour (GCT) of bone.

METHODS

Records of 30 male and 52 female consecutive patients aged 10 to 62 years who underwent wide resection (n=57) or curettage with adjuvant therapy (n=25) for primary GCT of bone were reviewed. The surgical decision was based on patient age, tumour location, functional demand, and patient preference. The median tumour size was 8.5 cm. Tumours were classified as stage 1 (n=4), stage 2 (n=60), and stage 3 (n=18), and 25%, 68.3%, and 83.3% of them were treated with wide resection, respectively. Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) score; the maximum score was 30.

RESULTS

The wide resection and curettage with adjuvant therapy groups were comparable in terms of patient age, gender, tumour size, location, symptoms, tumour stage, type of biopsy, and MSTS score. The MSTS score was excellent in 50.2% of patients, good in 38.7% of patients, and fair and poor in the remaining patients. The MSTS score was not associated with tumour stage or type of surgery. Four patients in the wide resection group had metastasis to the lung. They also had lower haemoglobin level (10.6 vs. 12.7 g/dl, p=0.020) and higher percentage of stage-3 tumour (100% vs. 17.9%, p=0.001) but had no recurrence (0% vs. 6.4%, p=0.774), compared with those without metastatsis. All died from massive haemoptysis and respiratory failure. Eight patients died; their haemoglobin level was lower than that of patients who were still living (11.2 vs. 12.7 g/dl, p=0.032). Mortality was associated with metastasis (100% vs 5.2%, p<0.001) but not recurrence or complication. Two patients in each group had recurrence; recurrence was not associated with type of surgery.

CONCLUSION

There was no association between type of surgery and tumour recurrence, metastasis, or outcome. Curettage with adjuvant therapy was more commonly performed for stage 1 and 2 tumours, whereas wide resection was more for stage 3 tumours. Metastasis was associated with stage 3 tumour and mortality but not recurrence.