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

What Are the MSTS Scores and Complications Associated With the Use of Three-dimensional Printed, Custom-made Prostheses in Patients Who Had Resection of Tumors of the Hand and Foot?

BACKGROUND

There are a few good options for restoring bone defects in the hand and foot. 3D-printed implants have been used in the pelvis and elsewhere, but to our knowledge, they have not been evaluated in the hand and foot. The functional outcome, complications, and longevity of 3D-printed prostheses in small bones are not well known.

QUESTIONS/PURPOSES

(1) What are the functional outcomes of patients with hand or foot tumors who were treated with tumor resection and reconstruction with a 3D-printed custom prosthesis? (2) What complications are associated with using these prostheses? (3) What is the 5-year Kaplan-Meier cumulative incidence of implant breakage and reoperation?

METHODS

Between January 2017 and October 2020, we treated 276 patients who had tumors of the hands or feet. Of those, we considered as potentially eligible patients who might have extensive loss in their joint that could not be fixed with a bone graft, cement, or any prostheses available on the market. Based on this, 93 patients were eligible; a further 77 were excluded because they received nonoperative treatment such as chemoradiation, resection without reconstruction, reconstruction using other materials, or ray amputation; another three were lost before the minimum study follow-up of 2 years and two had incomplete datasets, leaving 11 for analysis in this retrospective study. There were seven women and four men. The median age was 29 years (range 11 to 71 years). There were five hand tumors and six tumors of the feet. Tumor types were giant cell tumor of bone (five), chondroblastoma (two), osteosarcoma (two), neuroendocrine tumor (one), and squamous cell carcinoma (one). Margin status after resection was ≥ 1 mm. All patients were followed for a minimum of 24 months. The median follow-up time was 47 months (range 25 to 67 months). Clinical data; function according to the Musculoskeletal Tumor Society, DASH, and American Orthopedic Foot and Ankle Society scores; complications; and survivorship of implants were recorded during follow-up in the clinic, or patients with complete charts and recorded data were interviewed on the telephone by our research associates, orthopaedic oncology fellows, or the surgeons who performed the surgery. The cumulative incidence of implant breakage and reoperation was assessed using a Kaplan-Meier analysis.

RESULTS

The median Musculoskeletal Tumor Society score was 28 of 30 (range 21 to 30). Seven of 11 patients experienced postoperative complications, primarily including hyperextension deformity and joint stiffness (three patients), joint subluxation (two), aseptic loosening (one), broken stem (one), and broken plate (one), but no infection or local recurrence occurred. Subluxations of the metacarpophalangeal and proximal interphalangeal joints in two patients' hands were caused by the design of the prosthesis without a joint or stem. These prostheses were revised to a second-generation prosthesis with joint and stem, leading to improved dexterity. The cumulative incidence of implant breakage and reoperation in the Kaplan-Meier analysis was 35% (95% CI 6% to 69%) and 29% (95% CI 3% to 66%) at 5 years, respectively.

CONCLUSION

These preliminary findings suggest that 3D implants may be an option for reconstruction after resections that leave large bone and joint defects in the hand and foot. Although the functional results generally appeared to be good to excellent, complications and reoperations were frequent; thus, we believe this approach could be considered when patients have few or no alternatives other than amputation. Future studies will need to compare this approach to bone grafting or bone cementation.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Giant Cell Tumour of the Small Bones of Hand and Foot

Introduction Giant cell tumor (GCT) or bony tumor mainly involving long bones of arms and legs is very rarely associated with the small bones of hands and feet. Due to its nonspecific signs and symptoms, it is not easy to diagnose based on clinical findings; therefore, histopathological evidence is required to confirm it. Method A total of 16 patients with positive histopathological bone lesions enriched with giant cells were included in our study. After a complete evaluation of their case records, the required radiological assessment was carried out. Campanacci's method of staging was used to evaluate the advancement of lesions. The Musculoskeletal Tumour Society (MSTS) score was recorded postoperatively. All the patients were followed up for a mean duration of 2.8 years until they were lost to follow-up. Result The result of the current study shows that 62.5% of our patients presented in their twenties and 81.25% of patients came at a reasonably advanced stage. Hand and foot were involved in 1:1 cases. Patients were treated by one of the following options: extended curettage with bone graft or cement, wide excision, or en bloc resection. Phenol, a neoadjuvant, was used in all patients. Two of our patients (6.25%) who underwent curettage with bone graft showed up with recurrence during follow-up - one was then treated with wide excision and the other with amputation. Conclusion Giant cell tumors should undoubtedly be aggressively approached with the goal of preserving limb function while reducing recurrence risk to as minimal as possible. GCT of hand is more aggressive comparatively and should be treated accordingly.

Diagnostic value of H3F3A mutation and clinicopathological features of giant cell tumours in non-long bones

Aims

A histone H3F3A (H3.3) mutation involving a substitution in H3.3 G34 recently has been reported in GCTB within the frequency range (from 69 % to 96 %) and is a helpful diagnostic indicator of GCTB. However, the relationship between H3F3A mutations and the clinicopathological feature of GCTB involving non-long bones (irregular bones and small bones) is unclear.

Methods and results

H3F3A mutations were observed in a cohort of specimens (230 samples of GCTB) using immunohistochemistry and Sanger sequencing. The relationship between H3F3A mutations and the clinicopathological characteristics of patients with GCTB occurring in the non-long bones of the appendicular skeleton was investigated. No significant difference between H3F3A mutations in GCTB arising in non-long bones and the classic sites was found (P = 0.483). GCTB in non-long bones occurred more common in female (31/49, 63.3 %) than in male patients (P = 0.016). GCTB with H3.3 G34L/V/R mutation occurred more often in younger patients compared with those with H3.3 G34W mutation (P = 0.009). The majority of GCTB with soft tissue extension developed in irregular bones but not in small bones (P = 0.061). The H3.3 G34L/V/R mutations rate (7/45) in the non-long bones was significantly higher than that in long bones. The recurrence rate of the GCTB in long bones and non-long bones was 23.3 % (45/193) including 43 cases with local recurrene and 2 cases with lung metastasis. No recurrence occurred in cases with G34V/L/R mutations.

Conclusions

H3F3A was an effective diagnostic marker for GCTB of the non-long bones. The younger patients with GCTB of the non-long bones harboured H3.3 G34L/V/R mutations and may had a female preference and rarely recurrent.

Global Prevalence and Risk of Local Recurrence following Cryosurgery of Giant Cell Tumour of Bone: A Meta-Analysis

Simple Summary

Giant cell tumours are benign but locally aggressive and can potentially metastasise to the lungs. Reducing the risk of local recurrence while maintaining limb function and minimising adverse consequences is the best therapeutic strategy in treating giant cell tumours. Based on our observation through this meta-analysis, cryosurgery is one of the viable treatment options that can provide good oncologic and functional outcomes with minimal complication rates.

Abstract

The challenge in the surgical treatment of giant cell tumours of bone is the relatively high recurrence rate after curettage alone. The use of a local adjuvant following curettage, on the other hand, has lowered the rate of recurrence. This systematic review and meta-analysis aimed to investigate the prevalence and risk of local recurrence of giant cell tumours of the bone after cryosurgery and the subsequent complications. Web of Science, Scopus, ScienceDirect, PubMed, and Google Scholar were searched to identify articles published until 13 October 2021. A random-effects model was used to examine the pooled prevalence and risk ratio (RR) of local recurrence in patients with giant cell tumours after cryosurgery with 95% confidence intervals (CIs). This study was registered with PROSPERO (CRD42020211620). A total of 1376 articles were identified, of which 38 studies (n = 1373, 46.2% male) were included in the meta-analysis. Following cryosurgery, the pooled prevalence of local recurrence in giant cell tumours was estimated as 13.5% [95% CI: 9.3–17.8, I² = 63%], where European subjects exhibited the highest prevalence (24.2%). Compared to other local adjuvants. The RR of local recurrence following cryosurgery was 0.85 (95% CI: 0.63–1.17, I² = 15%), which was not statistically significant compared to other local adjuvants. We found 3.9% fracture, 4.0% infection, 2.1% nerve injury, and 1.5% skin necrosis as the common complications. Based on the sensitivity analyses, this study is robust and reliable. This meta-analysis estimated a low prevalence of local recurrence of giant cell tumours with low complications following cryosurgery. Thus, it can be one of the adjuvant options for treating giant cell tumours.

Benign Hand Tumors (Part I): Cartilaginous and Bone Tumors

Background: Benign tumors of the hand present in a wide array of histological subtypes and compose most of the bony tissue tumors in the hand. This study evaluates the characteristics and treatment of benign bone tumors in light of one institution's experience. Methods: Histologically confirmed benign tumors of the hand were retrospectively identified using International Classification of Diseases codes from 1992 to 2015. A medical chart review was conducted to collect patient characteristics and tumor epidemiology and treatment. Results: A total of 155 benign bone tumors were identified. The median age of patients at the time of surgery was 39.9 ± 12.8 years. All bone tumors were located in the digits, and most were treated by intralesional curettage (n = 118, 76%). Pathologic fractures occurred in 79 bone tumors (51%). Conclusion: Enchondromas (n = 118, 76%) were the most common bone tumor in this series, whereas giant cell tumors were the most destructive and also had the highest recurrence rate (40%). Awareness of tumor features may help physicians with diagnosis, and awareness of recurrence rates is important when counseling patients.

Outcome of Surgical Resection of Primary Malignant and Aggressive Benign Metacarpal Bone Tumors

Primary bone tumors of the hand are relatively rare. Different treatment options have been described in case reports. In this study, the authors present the diagnostic methods and treatment strategies that they used. The goal of this study is to present the oncologic and functional outcomes of surgical resection of primary malignant and aggressive benign metacarpal bone tumors. This retrospective study included 7 patients with primary malignant and aggressive benign bone tumors of the metacarpals who underwent surgical resection with or without metacarpal reconstruction between 2000 and 2017, with a minimum follow-up of 2 years. Clinical and radiologic evaluations were reviewed, and functional evaluation was performed with the Musculoskeletal Tumor Society scoring system. Seven patients (6 female; 1 male), with a mean age of 30.9±11.3 years, were included in the study. Six tumors were de novo, whereas 1 was recurrent. After resection, 5 patients had metacarpal reconstruction. Nonvascularized fibula was used for 3 patients, extracorporeal freezing of the metacarpal using liquid nitrogen was used for 1 patient, and metacarpal shift was used for 1 patient. Mean follow-up was 52.6±26.7 months. At the final follow-up, mean Musculoskeletal Tumor Society score was 27.4±1.6, and no local recurrence was documented. One patient had chest metastasis after 8 years of follow-up. The results show that surgical resection of primary malignant and aggressive benign tumors of the metacarpal bones can achieve satisfactory functional and oncologic outcomes. [Orthopedics. 2021;44(5):e633-e638.].

Giant cell tumour of hand bones: outcomes of treatment

The purpose of this study was to report the incidence of giant cell tumour of the hand bones in an Asian population, document treatment options and report outcomes of treatment. Of 698 giant cell tumours of bone that underwent surgery between January 2011 and December 2020 at our institute, only 22 (3%) were in the hand. Fourteen occurred in the metacarpals, eight in the phalanges. Fifteen were primary tumours and seven had recurrent disease. Twenty lesions had an associated soft tissue component. Two patients treated for primary disease and one who had been treated for recurrence had local recurrence. Recurrence occurred in two of nine patients treated with curettage, one of three with resection and none of five with ray or digit amputation. Both curettage and resection/amputation are acceptable treatment options for the rare condition of giant cell tumour of bone in the hand, with a need to individualize treatment decisions based on the site and extent of disease to minimize treatment morbidity while maximizing disease control.Level of evidence: IV.

Fibular Strut Arthrodesis for Salvage of Campanacci Grade III Giant Cell Tumor of the Hallucal Proximal Phalanx: A Case Report

Involvement of toe phalanges by giant cell tumor (GCT) is extremely rare; tumors in these locations tend to be aggressive. Whereas aggressive GCTs of the distal phalanx may be managed successfully by en-bloc resection without reconstruction or amputation, management of these lesions, when they involve the proximal phalanx, can be challenging. We present a Campannaci grade III GCT of the hallucal proximal phalanx in a 14-year old girl that had breached into the dorsal soft tissues and the metatarso-phalangeal joint. Wide local resection of the proximal phalanx along with reconstruction arthrodesis with an autologous, non-vascularized fibular strut graft was performed. There was no recurrence at 3 years of follow-up. The patient had an excellent functional outcome. To the best of our knowledge, this is the first case reporting the outcomes of fibular strut arthrodesis for salvage of GCT of the hallucal proximal phalanx.

Clinical outcome of a conservative approach to giant cell tumor of ankle and foot bones

Giant cell tumor of the bone (GCTB) affecting foot and ankle is rare, and the literature available on their clinical behavior and reconstructive options is scarce. Many authors consider these sites a special subset with high rates of local recurrence. Eighteen patients with GCTB of foot and ankle were treated from (March 2014 to February 2020). Extended curettage was offered wherever feasible. Twelve patients underwent extended curettage, three underwent resection and reconstruction, one patient had ray amputation, one had below knee amputation. One patient with multifocal disease was treated conservatively with denosumab. There were 11 females and the mean age was 31.7 years. Distal tibia (11 patients) was the commonest location, followed by the first metatarsal (four patients). At a median follow up of 46 months, two patients out of the 17 operated had a local recurrence. GCTB affecting the foot and ankle have a clinical course comparable to those at other locations. They should be treated with a conservative approach, where radical resection and amputation are reserved for only the non-curettable tumors.

Bilateral Lung Metastases From a Phalangeal Giant Cell Tumor of Bone

We describe a rare pediatric case of a phalangeal giant cell tumor of bone with extensive bilateral lung metastases following curettage, wide resection, and amputation. Concurrent peripheral blood eosinophilia and pleural effusion with marked eosinophilia (47%) were present. To discover genetic changes driving tumor metastasis, genomic and transcriptome profiling of the metastatic lung mass as well as germline analysis were performed. Whole exome sequencing detected a histone H3F3A p.G35V missense mutation in tumor cells. RNA sequencing revealed overexpression of receptor activator of nuclear factor kappa-B ligand (RANKL). The patient is alive with no residual disease and uncompromised respiratory function 29 months after amputation of primary tumor and 19 months after surgical resection of his metastatic lung disease.

Rare Coexistence of Giant Cell Tumor and Tuberculosis of the Metatarsal

The coexistence of giant cell tumor (GCT) and metatarsal bone tuberculosis (TB) of the foot has not been reported in the literature so far. We report a case of a 25-year-old male who presented with severe pain and swelling of his left foot for two months, which was aggravated on walking. A plain radiograph of the left foot showed an expansile eccentric lytic lesion of the base of the second metatarsal. He underwent extended curettage and antibiotic cement spacer insertion. Biopsy of the lesion revealed the presence of GCT, while tissue cultures were positive for Mycobacterium tuberculosis. He was treated with standard anti-tubercular treatment (ATT), four drug regimens for twelve months. He then underwent reconstruction of the second metatarsal with cement spacer exit and iliac crest bone grafting, following which the cultures were negative for TB. The diagnosis of this unexpected and unique combination of pathologies (GCT and TB) depends on a high index of clinical suspicion, relevant investigations, and accurate histological diagnosis.

Three-dimensional printed, proximal phalangeal prosthesis with metatarsophalangeal joint arthroplasty for the treatment of a giant cell tumor of the fifth toe: The first case report

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Customized, single-piece, 3D-printed, titanium phalangeal prosthesis of the 5th toe.

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Replacement of whole proximal phalanx with a mobile joint distally and proximally.

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Patient walks with full weight-bearing, no pain, and no recurrence or metastasis.

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Overriding toe occurred after two years due to scar contracture.

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Prosthesis design development, including size reduction, may improve outcomes.

Introduction

The majority of patients with bone sarcoma or an aggressive benign tumor of the toe can be successfully treated by amputation. However, limb-salvage surgery for toe tumors remains challenging.

Presentation of case

A 26-year-old female presented with an enlarging mass on her right 5th toe. Imaging studies revealed an expansile osteolytic, destructive lesion of the proximal phalanx of the 5th toe with metatarsophalangeal (MTP) joint invasion. A biopsy specimen confirmed a grade 1, giant cell tumor of the bone. An en bloc resection of the proximal phalanx was performed, and the defect was reconstructed with a patient-matched, three-dimensional, printed titanium proximal phalanx endoprosthesis with an MTP joint extension. The postoperative course was uneventful. The patient has walked with full weight-bearing since early postoperatively. No local recurrence or metastases were evident. However, scar formation occurred after two years, causing an overriding toe deformity.

Discussion

This case represents the first use of a toe prosthesis with MTP joint reconstruction. The complex MTP structure with a preserved metatarsal head facilitates the effort to mimic normal weight-bearing.

Conclusion

A three-dimensional printed prosthesis of the 5th toe is a viable alternative to a bone graft or amputation. However, to avoid stiffness and complications, further study is needed to improve the prosthesis design.

Giant cell tumor of the small bones of the foot

AIMS

This study aims to determine whether giant cell tumor of bone of the foot (GCTB-F) is more aggressive than GCTB at other sites using data from a single institution.

PATIENTS AND METHODS

We reviewed all patients with GCTB seen by our Unit from 1993 to 2012. Patients with GCTB-F were compared with all other patients with GCTB in terms of demographics and presentation. This group of GCTB-F was then compared with patients with GCTB of the appendicular skeleton (GCTB-AS) in terms of treatment and oncologic outcome at follow-up of at least 2 years.

RESULTS AND CONCLUSION

There were seven patients with GCTB-F (2.6%), most consulted over 12 months after symptoms. Compared to other GCTB ( n = 262), a bigger proportion of patients (28.5%) presented as recurrent lesions. All seven patients were classified as Campanacci III but none had lung metastasis at presentation or on follow-up. Compared to the group of 124 GCTB-AS, no GCTB-F patient received intralesional surgery. The 14% recurrence rate can be explained by contaminated non-intralesional surgery due to the advanced presentation and the technically challenging architecture of the foot. It would seem the aggressive tag of GCTB-F is not due to aggressive biologic behavior but to a combination of delayed presentation, delayed diagnosis, and difficult surgery.

Wide Resection and Iliac Crest Arthrodesis for Multiply Recurrent Giant Cell Tumor of First Metatarsal

Case

Giant cell tumor of bone is a benign, aggressive neoplasm commonly arising in the femur, tibia, and distal radius and less commonly in the hands and feet. We describe a 22-year-old woman who underwent wide resection of multiply recurrent first metatarsal giant cell tumor and reconstruction with iliac crest arthrodesis.

Conclusion

To our knowledge, there have been no previous reports of managing multiply recurrent giant cell tumor of the first metatarsal. The patient was without pain and exercising without difficulty 18 months following surgery. This method appears useful for reconstructing the foot following multiply recurrent giant cell tumor of the metatarsal.

Saving the ankle in distal fibular giant cell tumour - A case report

Distal Fibula Giant cell tumour (GCT) is a rare condition. The described methods of treatment for distal fibula GCT include excision of tumour and ankle arthrodesis, replacement of distal fibula with ipsilateral proximal fibula and autograft or allograft reconstruction. This case report describes treatment of distal fibula grade 3 GCT with involvement of syndesmosis with tumour excision, proximal fibular slide and reconstruction of ankle joint. With this technique the ankle joint movements are preserved and stability is maintained.

Giant Cell Tumor of the Metacarpal: Case Report

BACKGROUND

Giant cell tumor (GCT) of bone is a benign, though locally aggressive tumor, classically described as an eccentric lytic lesion, often with cortical expansion and destruction. It typically involves the metaphysis or epiphysis of long bones in skeletally mature patients, with a slight female predominance. The incidence in the small bones of the hand has been reported to be 2% to 5%.

METHODS

Treatment options have evolved in recent years, and currently include intralesional curettage with or without adjuvant therapy, wide resection, and occasionally amputation.

RESULTS

In this report, we present a long-term follow-up (10 years) of a patient with GCT involving a metacarpal, who was initially reconstructed with a metacarpal head allograft, which was eventually revised to a metacarpophalangeal (MCP) total joint arthroplasty.

CONCLUSIONS

To our knowledge, this is the only report of pyrocarbon being used for tumor reconstruction and the only report of late MCP allograft salvage.

Distal radius reconstruction with vascularized proximal fibular autograft after en-bloc resection of recurrent giant cell tumor

Background

Giant cell tumors (GCTs) located in the distal radius are likely to recur, and the treatment of such recurrent tumors is very difficult. Here, we report our clinical experience in distal radius reconstruction with vascularized proximal fibular autografts after en-bloc excision of the entire distal radius in 17 patients with recurrent GCT (RGCT) of the distal radius.

Methods

All 17 patients with RGCT in distal radius underwent plain radiography and/or magnetic resonance imaging (MRI) of the distal radius as the initial evaluation after hospitalization. Then the distal radius were replaced by vascularized proximal fibular autografts after en-bloc RGCT resection. We assessed all patients by using clinical examinations, plain radiography of the wrist and chest, and Mayo wrist scores in the follow-ups.

Results

After an average follow-up of 4.3 years (range: 1.5–10.0 years), no lung metastasis or local recurrence was detected in any of the 17 patients. In total, 14 patients had excellent or good functional wrist scores, 16 were pain free or had occasional pain, and 15 patients returned to work. The mean range of motion of the wrist was 101° (flexion-extension), and the mean grip strength was 77.2 % of the contralateral normal hand.

Conclusion

En-bloc excision of the entire distal radius and distal radius reconstruction with a vascularized proximal fibular autograft can effectively achieve local tumor control and preserve wrist function in patients with RGCT of the distal radius.

Reconstruction of an Entire Thumb Metacarpal: A Case Report

This case report discusses the reconstruction of an entire thumb metacarpal after a diagnosis of giant cell tumor of bone. The patient underwent excision of the entire thumb metacarpal, followed by interposition of a tricortical iliac crest bone graft and metacarpophalangeal and carpometacarpal joint arthrodeses. This option allowed salvage of the patient's native thumb with functional use as a stable post to which she can pinch and grasp objects. At 9 months postoperatively, there was no evidence of recurrence.

Primary osseous tumours of the elbow: 60 years of registry experience

BACKGROUND

We present the largest series of surgically treated primary bone tumours of the elbow in the English literature (75 cases). We sought to identify characteristics specific to these lesions and recommend an investigatory protocol.

METHODS

The national registry and case notes were reviewed between 1954-2014. Tumours were classified according to Enneking's spectrum.

RESULTS

There were no benign latent cases in this series as these were managed locally. All patients presented with persistent rest pain, with or without swelling. The distal humerus, in contrast to the proximal radius and ulna, was responsible for the majority and the more aggressive cases. Misdiagnosis was evident in 13% of cases; most of which were attributed to simple bone cysts. All patients that were referred required surgical intervention to either establish the diagnosis or for treatment. Benign tumours had a 19% recurrence rate, with giant cell tumour the most aggressive. Malignant tumours carried 39% local recurrence rate and a 5-year mortality of 61%.

CONCLUSIONS

The suspicion of a tumour should be raised in the patient with unremitting, unexplained, non-mechanical bony elbow pain. These echo the NICE recommendations and we recommend prompt specialist referral. With high rates of local recurrence, we recommend close postoperative monitoring.

Giant Cell Tumor of the Distal Phalanx of the Fourth Toe: A Case Report

Giant cell tumor of the bone is a benign, but locally aggressive, primary bone tumor of unknown origin. It most commonly occurs in the long bones and is only rarely found in the phalangeal bones, such as the distal phalanx of the foot. In our review of English-language published studies, only 4 other cases of giant cell tumor involving the distal phalangeal bone of the foot had been reported to date. We report a case of giant cell tumor arising in the distal phalanx of the fourth toe in a 28-year-old female. Although bisphosphonate therapy was administered, the tumor showed highly aggressive behavior with ulceration of the overlying skin, and the patient underwent phalangeal amputation 1.5 months after diagnosis.