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

The Effectiveness of Denosumab in Middle Eastern Patients With Giant Cell Tumor of the Bone: A Single-Center, Retrospective Study

BACKGROUND

Giant cell tumor of the bone (GCTB) is an aggressive benign tumor, which constitutes 5% of all primary bone tumors. Denosumab, a receptor activator of nuclear factor κB ligand monoclonal antibody, inhibits osteoclast-induced bone destruction and has demonstrated promising results in patients with GCTB. However, the long-term efficacy of the drug has not been extensively studied, especially in the Middle East.

METHODOLOGY

In this study, we retrospectively analyzed the five-year progression-free survival (PFS) in patients with GCTB at a single Saudi center. PFS was defined as the time from diagnosis until disease progression, relapse, or death. Events were censored after five years from diagnosis.

RESULTS

Sixty-two patients with GCTB were included in the study. The median age at diagnosis was 31.16 years, and 38 (61.3%) patients were female. Twenty-nine patients (46.8%) received denosumab during the study period. The median duration of denosumab treatment was 5.06 months, and the median number of cycles was 6. The median PFS was not reached, and the five-year PFS rate was 60.3%. Age, gender, body mass index, performance status at presentation, and tumor location had no impact on five-year PFS. Denosumab treatment prolonged PFS; however, this was not statistically significant compared to non-denosumab patients (P = 0.603).

CONCLUSIONS

Denosumab does not seem to provide superior long-term outcomes compared to surgery alone. Although our findings are generally consistent with other studies in the literature, larger long-term studies are needed to confirm our findings.

Endoscopic Endonasal Surgery for Uncommon Pathologies of the Sellar and Parasellar Regions

Endoscopic skull base surgery has become an integral part of the present neurosurgical armamentarium. The pioneering efforts in which the purely endoscopic transsphenoidal approach was introduced have triggered a growing tide of using the endoscopic endonasal procedures for a large variety of skull base lesions. Because of their anatomical peculiarities, lesions of the sellar and parasellar regions lend themselves very well to the endoscopic endonasal approaches. Apart from the common pathological entities, many other less frequent pathologies are encountered in the sellar and parasellar area. In this chapter, we review the surgical technique of the endoscopic endonasal transsphenoidal approach and its extensions applied to a variety of rare and uncommon pathological entities involving the sella turcica and clivus. An overview of these pathological entities is also presented and exemplified.

Intrathoracic Extension of a Giant Cell Tumour of the Medial End of Clavicle: A Case Report with Review of Literature

Introduction

The clavicle is a very rare site for primary bone tumours, and Giant cell tumours of the clavicle are even rarer. Very few cases have been reported in the literature.

Method

The authors report a rare presentation of intrathoracic extension of a giant cell tumour of the medial end of the clavicle, in an 18-year-old female. The patient had painful swelling at the sternal end of the clavicle associated with a painful shoulder range of motion. Complete resection of the mass was done, preserving the lateral half of the clavicle.

Result and Discussion

At a 3-year follow-up, the patient has a good clinical outcome with no signs of recurrence. Being a very rare entity, no clear guidelines are available for the management of GCT of Clavicle. Adequate resection of the tumour mass remains the mainstay of treatment and has shown promising results. Denosumab has been proved to be effective in some studies, but the high cost of treatment is a major limitation in the Indian scenario.

Conclusion

Resection of the tumour mass with partial cleidectomy provided good results in this patient.

Total neurological recovery after surgical decompression and treatment with denosumab of large unresectable spinal giant cell tumour expanding to mediastinum

There is a controversy over the medical treatment of unresectable spinal giant cell tumour (GCT) regarding dosing and duration. We studied a spinal GCT case that had expanded to the thoracic spinal canal and mediastinum and was successfully treated by surgical decompression and denosumab. A woman in her 30s presented with weakness in both the lower extremities. MRI revealed a large tumour in the posterior mediastinum expanding from the thoracic vertebrae (T3–6), which compressed the spinal cord. The patient underwent urgent spinal decompression with instrumentation and her tissue was sent for a pathology study. Histologically and immunohistochemistry confirmed the diagnosis of GCT. Since it was an unresectable tumour, this patient was treated with denosumab. Her neurological problem resolved after 6 months of treatment. After 4 years of follow-up, the patient displayed no further progression and no side effects from long-term denosumab usage.

In situ cryoablation of sacral Giant Cell Tumor using three-dimensional (3D) model: A case report

Three-dimensional planning of in-situ (trans-sacral) image guided cryoablation provides a method to treat sacral GCTs that accommodates the intricacies of the pelvis offering a safer, more efficacious alternative. Here we report on IM a 23-year-old female with a sacral GCT. She presented to Tel Aviv Medical Center with ongoing pain as well as neurological symptoms. For six years, the patient was in-and-out of the hospital for Denosumab treatment and recurrent infections. Eventually, further treatment became necessary, and she was treated with image guided cryoablation. By six months follow-up, the patient was mobile and pain-free.

A Rationale for the Activity of Bone Target Therapy and Tyrosine Kinase Inhibitor Combination in Giant Cell Tumor of Bone and Desmoplastic Fibroma: Translational Evidences

Giant cell tumor of bone (GCTB) and desmoplastic fibroma (DF) are bone sarcomas with intermediate malignant behavior and unpredictable prognosis. These locally aggressive neoplasms exhibit a predilection for the long bone or mandible of young adults, causing a severe bone resorption. In particular, the tumor stromal cells of these lesions are responsible for the recruiting of multinucleated giant cells which ultimately lead to bone disruption. In this regard, the underlying pathological mechanism of osteoclastogenesis processes in GCTB and DF is still poorly understood. Although current therapeutic strategy involves surgery, radiotherapy and chemotherapy, the benefit of the latter is still debated. Thus, in order to shed light on these poorly investigated diseases, we focused on the molecular biology of GCTB and DF. The expression of bone-vicious-cycle- and neoangiogenesis-related genes was investigated. Moreover, combining patient-derived primary cultures with 2D and 3D culture platforms, we investigated the role of denosumab and levantinib in these diseases. The results showed the upregulation of RANK-L, RANK, OPN, CXCR4, RUNX2 and FLT1 and the downregulation of OPG and CXCL12 genes, underlining their involvement and promising role in these neoplasms. Furthermore, in vitro analyses provided evidence for suggesting the combination of denosumab and lenvatinib as a promising therapeutic strategy in GCTB and DF compared to monoregimen chemotherapy. Furthermore, in vivo zebrafish analyses corroborated the obtained data. Finally, the clinical observation of retrospectively enrolled patients confirmed the usefulness of the reported results. In conclusion, here we report for the first time a molecular and pharmacological investigation of GCTB and DF combining the use of translational and clinical data. Taken together, these results represent a starting point for further analyses aimed at improving GCTB and DF management.

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.