Treatment and outcome of giant cell tumors of the pelvis

Current Concepts in the Treatment of Giant Cell Tumor of Bone: An Update

Curettage is recommended for the treatment of Campanacci stages 1-2 giant cell tumor of bone (GCTB) in the extremities, pelvis, sacrum, and spine, without preoperative denosumab treatment. In the distal femur, bone chips and plate fixation are utilized to reduce damage to the subchondral bone and prevent pathological fracture, respectively. For local recurrence, re-curettage may be utilized when feasible. En bloc resection is an option for very aggressive Campanacci stage 3 GCTB in the extremities, pelvis, sacrum, and spine, combined with 1-3 doses of preoperative denosumab treatment. Denosumab monotherapy once every 3 months is currently the standard strategy for inoperable patients and those with metastatic GCTB. However, in case of tumor growth, a possible malignant transformation should be considered. Zoledronic acid appears to be as effective as denosumab; nevertheless, it is a more cost-effective option. Therefore, zoledronic acid may be an alternative treatment option, particularly in developing countries. Surgery is the mainstay treatment for malignant GCTB.

Ischiopubic Ramus Resection as Treatment for Giant Cell Tumor of the Bone: Surgical Techniques in Two Clinical Cases

Giant cell tumors (GCTs) of the ischium are rare and often diagnosed at an advanced stage. In fact, there is no defined treatment algorithm to treat this lesion. We present two case reports of Campanacci's stage three ischiopubic GCT confirmed with biopsy. They were effectively treated with excision of the ischiopubic ramus, aggressive curettage, drilling, and phenolization at the margins. The surgery was performed in a gynecological position with an approach over the ischiopubic ramus. Both cases present no recurrence (two and 10-year follow-up), and neither has a significant impact on the quality of life. A thorough plan and surgical technique were essential for the success of this intervention.

Treatment of pelvic giant cell tumor by wide resection with patient-specific bone-cutting guide and reconstruction with 3D-printed personalized implant

BACKGROUND

This study reports our experience in the treatment of aggressive pelvic GCT through wide resection assisted with patient-specific bone-cutting guides (PSBCGs) and subsequent reconstruction with 3D-printed personalized implants (3DPIs), aiming to present the operative technique of this method and evaluate its clinical efficacy.

METHODS

We retrospectively analyzed seven patients who underwent wide resection of pelvic GCT followed by reconstruction with 3DPIs from August 2019 to February 2021. There were two males and five females, with a mean age of 43 years. PSBCGs and 3DPIs were prepared using 3D-printing technology. The operational outcomes, local recurrence, radiological results, and any associated complications of this technique were assessed. And the functional outcomes were assessed according to the Musculoskeletal Tumor Society (MSTS) 93 functional score.

RESULTS

The mean follow-up time was 35.3 months (range 28-45 months). There was no intraoperative complication. Negative surgical margins were achieved in all patients. Postoperative pelvic radiographs showed that 3DPIs matched the shape and size of the bone defect. The anterior-posterior, inlet, and outlet pelvic radiograph demonstrated precise reconstruction consistent with the surgical planning. In addition, tomosynthesis-Shimadzu metal artifact reduction technology (T-SMART) showed good osseointegration at an average of three months after surgery (range 2-4 months). There was no local recurrence or tumor metastasis. The average MSTS score was 24.4 (range 23-27) at the last follow-up. Delayed wound healing was observed in one patient, and the wounds healed after debridement. Prosthesis-related complications were not detected during the follow-up, such as aseptic loosening or structure failure.

CONCLUSIONS

The treatment of aggressive pelvic GCTs through wide resection assisted with PSBCGs and subsequent reconstruction with 3DPIs is a feasible method, which provides good clinical results and reasonable functional outcomes.

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.

Treatment alternatives and clinical outcomes of bone filling after benign tumour curettage. A systematic review

BACKGROUND

Benign and pseudo-neoplastic bone lesions are usually treated by curettage and filling of the cavity. This filling is usually achieved with the use of autologous bone grafts, bone cement, allografts, xenografts, or synthetic bone substitutes. Recently, some authors have suggested that these defects do not require filling for consolidation but the respective rate of complications of each method is not well defined. Therefore, we did a systematic review aiming to answer: (1) Not filling bone cavities after benign bone tumour curettage may increase the rate of fractures? (2) Can the volume of the bone defect in itself be a specific or reliable predictor of fracture? (3) Does the mean functional outcome, recurrence, non-weight bearing time, other postoperative complications or bone consolidation time vary between the methods of filling?

PATIENTS AND METHODS

The PubMed (2407 articles) and Latin American and Caribbean Health Sciences Literature (LILACS) (50 articles) databases were reviewed, without restriction considering publication date. After exclusion criteria, 62 articles were selected for data collection. Filling or not filling (UN), methods of filling, fracture rate, bone defect size, mean functional outcome, recurrence, non-weight bearing time, other postoperative complications, consolidation time were the data of interest.

RESULTS

The number of patients was 2555 distributed among the different filling methods. Unfilled cavities were associated with higher fracture rate [20/302 (6.62%)] versus 4/189 (2.12%) for allografts, 14/343 (4.08%) for cement filling, 4/247 for autograft (1.62%), and 12/580 (2.07%) for bone substitute. The volume of the bone defect alone is not a specific or reliable predictor of fracture. All filling methods were similar regarding the mean functional outcome, recurrence rate and consolidation time. The bone cement allowed early weight bearing time (mean of weeks): UN: 9.67; autologous bone grafts: 9.8; bone cement: 0.5; allografts: 9.0; synthetic bone substitutes: 9.96.

CONCLUSION

Not filling the bone cavity after benign bone tumour curettage is an alternative, but can increase fracture rate, even in small volume bone defects. The use of prophylactic fixation drastically reduces the fracture rate. Filling with cement reduces weight bearing time. There are little differences between the methods used to fill, even compared to not filling the cavity.

LEVEL OF EVIDENCE

III; systematic review.

Current Concepts in the Treatment of Giant Cell Tumors of Bone

Simple Summary

According to the 2020 World Health Organization classification, a giant cell tumor of bone is an intermediate malignant bone tumor. Denosumab treatment before curettage should be avoided due to the increased risk of local recurrence. Administration of denosumab before en bloc resection of the giant cell tumors of the pelvis and spine facilitates en bloc resection. Nerve-sparing surgery after embolization is a possible treatment for giant cell tumors of the sacrum. Denosumab therapy with or without embolization is indicated for inoperable giant cell tumors of the pelvis, spine, and sacrum. A wait-and-see approach is recommended for lung metastases at first, then denosumab should be administered to the growing lesions. Radiotherapy is not recommended owing to the risk of malignant transformation. Local recurrence after 2 years or more should be indicative of malignant transformation. This review summarizes the treatment approaches for non-malignant and malignant giant cell tumors of bone.

Abstract

The 2020 World Health Organization classification defined giant cell tumors of bone (GCTBs) as intermediate malignant tumors. Since the mutated H3F3A was found to be a specific marker for GCTB, it has become very useful in diagnosing GCTB. Curettage is the most common treatment for GCTBs. Preoperative administration of denosumab makes curettage difficult and increases the risk of local recurrence. Curettage is recommended to achieve good functional outcomes, even for local recurrence. For pathological fractures, joints should be preserved as much as possible and curettage should be attempted. Preoperative administration of denosumab for pelvic and spinal GCTBs reduces extraosseous lesions, hardens the tumor, and facilitates en bloc resection. Nerve-sparing surgery after embolization is a possible treatment for sacral GCTBS. Denosumab therapy with or without embolization is indicated for inoperable pelvic, spinal, and sacral GCTBs. It is recommended to first observe lung metastases, then administer denosumab for growing lesions. Radiotherapy is associated with a risk of malignant transformation and should be limited to cases where surgery is impossible and denosumab, zoledronic acid, or embolization is not available. Local recurrence after 2 years or more should be indicative of malignant transformation. This review summarizes the treatment approaches for non-malignant and malignant GCTBs.

Large giant cell tumor of the posterior iliac bone - an atypical location. A case report and literature review

Giant cell tumor (GCT) is a locally aggressive tumor but with benignity features, representing approximately 18% of non-malignant bone tumors in European countries, with slight female predominance. Malignancy in GCT is rare, about <2% of cases and is more common at older ages. Is known that usually occurs at the epiphyses of long bones, but extremely rare may have another location, such as the pelvic bone. An atypical location – the posterior iliac bone, found at a 34-year-old male –, is the case report we studied and described. Starting from the patient’s complains, like a mass in the left buttock region described as “recently appeared”, firm, not-mobile, with no distinctive borders and no tenderness at palpation, and a recent history trauma, multiple investigations have been performed, which have highlighted an osteolytic lesion, close to the sacroiliac joint, only with infiltration of the gluteal, iliac and paravertebral muscles. The treatment of choice was hemi-pelvectomy, with wide tumoral resection, and selective embolization of the nutrient vessels 24 hours prior to the surgical procedure. At two years postoperative, we found a good functional result and the computed tomography (CT) scan revealed no signs of recurrence.

Prognostic Factors for Survival in Patients with Malignant Giant Cell Tumor of Bone: A Risk Nomogram Analysis Based on the Population

Background

Malignant giant cell tumor of bone (MGCTB) is a rare histological type of malignant tumor that has a high tendency for local relapse and distant metastasis and ultimately leads to a poor prognosis. The purpose of this study was to describe the epidemiological features, identify the prognostic factors, and construct nomograms for patients with MGCTB.

Material/Methods

Patients with MGCTB that was histologically diagnosed between 1973 and 2014 were selected from the Surveillance, Epidemiology, and End Results (SEER) database as a training set. Survival analysis, Lasso regression, and random forests were used to identify the prognostic variables and establish the nomograms for patients with MGCTB, while an external cohort of 37 patients from our own institution and an external cohort of 163 patients from the SEER database in 2016 were used to validate the generalization performance of the nomograms.

Results

In total, univariate and multivariable analysis indicated that age, International Classification of Diseases for Oncology, historical stage, primary site, surgery information, radiotherapy, and chemotherapy were independent prognostic variables for overall survival or cause-specific survival. Nomograms based on the multivariable models were built to predict survival, and we achieved a higher C-index in subsequent multidimensional validation.

Conclusions

Age, historical stage, and chemotherapy were independent prognostic variables for overall survival and cause-specific survival of MGCTB patients, and radiotherapy and primary site were independent prognostic variables for overall survival. Nomograms based on significant clinicopathological features and clinical experience can be effective in predicting the probability of survival for MGCTB patients.

Denosumab in giant cell tumour of bone in the pelvis and sacrum: Long-term therapy or bone resection?

INTRODUCTION

Surgery of GCTB in sacrum and pelvis is challenging, with high rates of complications and local recurrence. Denosumab can consolidate the peripheral rim of the tumour, thus reducing the rate of morbidities of surgery. The aim of this paper is to evaluate the use of denosumab in pelvic/sacrum giant cell tumours of bone (GCTB).

PATIENTS AND METHODS

We retrospectively reviewed a cohort of 26 patients with aggressive GCTB in sacrum or pelvis treated with denosumab at two referral centres. Clinical response and local recurrence were recorded and the radiologic responses were evaluated with the MDA criteria.

RESULTS

69% of the pelvic GCTB treated with denosumab presented partial or good radiologic responses (type 2A or 2B) after 49 weeks of treatment. Denosumab was administered as adjuvant therapy prior and after surgery in 11 patients (group A), and as the only treatment in 15 patients (group B). In group A, 62% of local recurrence was observed in patients treated with intralesional curettage. No recurrences were identified after en bloc resection. In group B, 9 patients were on continuous bimonthly long term denosumab administration with type 2A and 2B responses. Six patients stopped denosumab and 66% remained stable after 10 months of follow-up.

CONCLUSIONS

Long-term denosumab therapy can be considered with curative intent for pelvic and sacrum GCTB. If surgical intervention is required wide resection may be advisable to reduce the risk of recurrence.

Solitary fibrous tumor of the ilium: A case report

RATIONALE

Solitary fibrous tumors (SFTs) are rare spindle cell tumors that are most commonly found in the mediastinal pleura. Although there are increasingly more reports of extra-pleural SFTs, reports of SFTs in bone are very rare. To our knowledge, a SFT of the ilium has not yet been reported. With low specificity on computer tomograpy and magnetic resonance imaging, SFTs are easily misdiagnosed.

PATIENT CONCERNS

A 33-year-old man visited our hospital due to repeated right ilium pain for 3 months. The pain was dull and bearable, with no hip joint dyskinesia. The relevant physical examinations are negative. The patient was healthy before and had a negative family history. Radiologically, a large mass with inhomogeneous attenuation and intensity and obvious heterogeneous enhancement was misdiagnosed as a giant cell tumor of ilium.

DIAGNOSES

The man was diagnosed as the solitary fibrous tumor of right ilium.

INTERVENTIONS

The patient was performed an "incision biopsy of the right ilium" and "extended resection of tumor".

OUTCOMES

The pathology and immunohistochemistry was confirmed as the solitary fibrous tumors. The patient was followed-up by computed tomography of pelvis in local hospital every 6 mouths, and there is no recurrence and any symptoms.

LESSONS

We learned that the solitary fibrous tumor could locate in the ilium, and when we see imaging manifestations like this case, we should think it may be SFT.

An acetabular-preserving procedure for pelvic giant cell tumor involving partial acetabulum

Background

The management of pelvic giant cell tumors (GCTs) involving the acetabulum remains a challenge for surgeons on how to balance the relative benefits of minimizing recurrence and maintaining postoperative hip function. The present study was to present and evaluate the clinical indications, operative technique, and outcomes of pelvic GCTs involving partial acetabulum treated with multiplanar osteotomy and reconstruction of autogenous femoral head bone grafts combined with cementless total hip arthroplasty (THA).

Methods

We retrospectively reviewed seven patients with pelvic GCTs involving partial acetabulum who underwent multiplanar osteotomy and reconstruction of autogenous femoral head bone grafts combined with cementless THA from January 2010 to October 2014. We assess the outcome including the bone graft healing, nonunion, hardware failure, infection, tumor recurrence, and metastasis. And the functional outcome was evaluated by the Musculoskeletal Tumor Society (MSTS)93 score.

Results

All patients were followed up for a mean of 38.1 months (range 26–61 months). All bone grafts are union. No failure of acetabular components, wound healing problem, or deep infection was suspected. No patient experienced metastasis. Recurrence was observed in one out of seven patients, treated by extended resection and implanting iodine ions in the surgical area. The mean MSTS93 score was 29.4 (range 28–30). All patients were disease-free and resumed activities of daily living at the most recent follow-up.

Conclusions

As long as one of the two columns is retained and the resulting defect does not exceed the supra-acetabular line, multiplanar osteotomy and reconstruction of autogenous femoral head bone grafts combined with cementless THA is a viable strategy for the treatment of pelvic GCTs involving partial acetabulum. However, a large-scale prospective clinical study is still needed to verify these procedures.

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.

Advantages of Pressurized-Spray Cryosurgery in Giant Cell Tumors of the Bone

BACKGROUND

Giant Cell Tumor is considered a benign, local and aggressive tumor. Although considered a benign bone tumor, it is still the subject of discussion and research because of the associated local bone destruction, as well as high rates of recurrence and distant metastases. Options are being developed for both surgical techniques and adjuvant therapies.

AIMS

The present study evaluated the administration of cryotherapy via a pressurized-spray technique in giant cell tumors of the bone.

STUDY DESIGN

Cross-sectional study.

METHODS

The study included 40 patients who were treated with extensive curettage and cryotherapy at various locations during the period from February 2006 to December 2013. Informed consent forms were obtained from the participants and ethics committee approval was taken from the local ethics committee of Ondokuz Mayıs University. The pressurized-spray technique was performed using liquid nitrogen. The patients were evaluated with respect to age, gender, radiological appearance, treatment modality, duration of follow-up, skin problems and recurrence.

RESULTS

Twenty-one patients were female; 19 were male. The average age of the patients was 33 years (range: 16-72 years), and the average duration of follow-up was 43 months (range: 12-80 months). The average time from the onset of the complaints to the diagnosis was 6 months (range: 2-12 months). Based on the Campanacci classification: 9 patients were Grade I; 25 patients were Grade II; six patients were Grade III. The lesion was located in the femur in 14 patients, in the tibia in 11 patients, in the radius in 5 patients, in the pelvis in 4 patients, in the fibula in 3 patients, in the metatarsal in 2 patients and in the phalanges of the hand in one patient. One patient had postoperative early fracture. None of the patients had skin problems and infection. Three (7.5%) of the patients had recurrence.

CONCLUSION

It was found that cryotherapy was highly effective in the lesions, especially those located in the femur and tibia and remained insufficient in the lesions expanded outside the cortex. Wound healing problems, infection and fracture risk are lower with this technique.

What role for radiobiphosphonates bone scintigraphy in the monitoring of an unusual bone giant cell tumor: a case report and literature review

We report the case of 24 years old female patient, followed since ten years ago for bone giant cell tumor (GCT) of the right knee, which was complicated by pulmonary metastases. Surgical treatment and pulmonary metastasectomies have not allowed definitive cure of this disease with the appearance of metachronous bone lesions after eight years of evolution. The literature review confirms the originality of this observation: the age of the patient, the initial and metastasis locations and the occurrence of lung metastases with unfavorable prognosis. Through this clinical case, the authors highlight the role of radiobiphosphonates bone scintigraphy in detecting synchronous or metachronous bone lesions, and in monitoring of these locations under medical treatment.

Surgical treatment for pelvic giant cell tumor: a multi-center study

Background

The purpose of this study was to discuss the clinical results which related to the location of giant cell tumors (GCTs) in the pelvis so as to determine the ideal surgical treatment protocol.

Methods

We report 29 cases who accepted surgical treatment from five clinical centers during the last 12 years. All patients were divided into three groups according to tumor locations, and they were also classified into two groups in light of surgical treatments. The parameters for outcome evaluation consisting of general condition, surgical complications, local disease control, and Musculoskeletal Tumor Society (MSTS) 93 functional score had been analyzed, respectively.

Results

Surgical treatment in the acetabular area usually resulted in postoperative complications and poor function. One patient who accepted intralesional surgery and two who accepted wide resection had local recurrence. The mean functional score was 25.4 for the 8 patients who received intralesional surgery and 21.9 for the 21 patients who received wide resection. Surgical complications occurred in 1 patient who underwent intralesional surgery and the other 6 patients who underwent wide resection.

Conclusions

We conclude that surgical treatment of pelvic GCTs in the acetabular area is difficult to select as it is always accompanied by complications and poor function. Compared to wide resection, intralesional surgery combined with a meticulous preoperative planning may lower the recurrence rate and obtain favorable postoperative functional results.

Giant cell tumor of the pelvis: a systematic review

This is a systematic review of articles concerning the morbidity, recurrence rate, treatment and treatment complications of pelvic giant cell tumors (GCTs). The key words "giant cell tumor, pelvis" were used to identify articles which included data on patients with pelvic GCTs in English and Chinese databases of published reports from 1949-2012. The articles were filtered by title, abstract and full text. Thirty-eight articles and 165 patients were identified for this review. Data on all identified patients were studies; data in different articles on the same patients was not used repeatedly. The following patient data were collected where possible and subjected to systematic analysis; age, location of GCT, treatment, follow-up, complications, recurrence and whether alive or dead. The mean age of onset was 33.2 years (range, 14-73 years), the peak ages of onset being between 21 and 40 years. A pronounced sex difference was identified, the male : female ratio being 1:1.7. The acetabulum was the commonest area for pelvic GCTs. Forty-eight tumors were primarily located in the iliac, 60 in the acetabular and 31 in the ischiopubic area. Twenty-seven patients experienced complications of treatment. Patients who had been treated by wide resection had the most complications; these included incisional infection and delayed healing of incisions. Local recurrence was common, having occurred in 39/158 patients (24.6%), comprising 24/72 (33.3%) who had undergone intralesional surgery only; 9/20 (45.0%) who had undergone radiotherapy only; 1/51 (2.0%) who had undergone wide resection; and 5/14 patients (35.7%) who had undergone radiation therapy or cryotherapy plus intralesional surgery. Mortality was low (3.2%, 5/158). Pelvic GCT is not common, the acetabular area appears to the most frequent site and the peak age is the third and fourth decades. Although the recurrence rate is high for all pelvic GCTs, the mortality is low. Treatment has a critical influence on recurrence. In spite of the associated complications, the lower local recurrence rate makes wide resection a reasonable option for patients with extensive and/or aggressive GCTs.

Customized iliac prosthesis for reconstruction in giant cell tumour: A unique treatment approach

Giant cell tumour (GCT) of flat bones of pelvis is extremely rare. GCT of the ilium and ischium represent less than 0.05% of all GCT. Iliac bone GCT has been treated traditionally by intra-lesion curettage with bone grafting, wide resection with or without reconstruction and hemi-pelvectomy in very aggressive tumours. None of the above treatments were without morbidities. Reconstruction using bone grafts and bone cement has also been inadequate. In GCT, where life expectancy is not decreased significantly, surgical treatment should be aimed at giving optimum functional outcome. We are reporting here a rare case of giant cell tumour of ilium bone in a 25-year-old female and its unique treatment approach. We designed a computed tomography (CT) based customized iliac prosthesis using Materialise Mimics and 3-Matic software. 3D model of pelvis was generated from the CT. After deciding the extent of resection on affected side, we virtually mirrored an identical portion of opposite ilium to the affected side. Connecting plates were made over the mirrored part and merged with it. Multiple relevant holes were made to attach various muscles to the prosthesis. Prosthesis was made in medical grade titanium by using Computerized Numerical Control (CNC) machine. The method is called as computer based subtractive manufacturing. Wide resection was done and the prosthesis was placed using multiple 3.5 millimetres screws through the connecting plates. Muscles were stitched to relevant holes using ethibond suture. Post-operative course was unremarkable. Patient was made to walk with full weight bearing after 5 weeks. Powers of abductors at 6 months is 4/5 and patient walks normally without a limp.

Giant cell tumor of axial vertebra: surgical experience of five cases and a review of the literature

Background

Due to the complex anatomy of the upper cervical spinal column region and the variable aggressiveness of giant cell tumors (GCTs), there exists no standard treatment for GCTs of axial vertebra. To the best of our knowledge, there are only a few case reports in the literature and no large sum numbers of clinical trials about the treatment of, or research into, axial vertebra GCTs.

Methods

Between 2009 and 2013, five patients pathologically diagnosed with axial vertebra GCTs were treated at our hospital. We performed intralesional excision and odontoid process reconstructive surgery to preserve the odontoid process, followed with adjuvant radiation therapy after surgery.

Results

For those with an intact bone shell, part of the β-TCP (beta tricalcium phosphate) artificial bone could be seen clearly after surgery and became blurred three months after surgery, as seen on a radiograph. One year later, the part of β-TCP artificial bone was fused as a block. Subsequently, autogenous bone regenerated successfully and artificial bone degraded thoroughly. For those with a defective cortical bone, partial fusion of the odontoid process, autograft ilium and third vertebra body could be seen three months after surgery, and complete fusion was seen nine months later. The odontoid process was preserved successfully, and the upper cervical spine was reconstructed effectively, without implant failure or infection.

Conclusions

In this study, the odontoid process and function of upper cervical vertebra was preserved successfully through lesion curettage, combined with reconstruction with bone grafting, and adjuvant radiation therapy after surgery. During the follow-up periods, no recurrence or complications was observed.

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.

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 tumor of bone in childhood: clinical aspects and novel therapeutic targets

Giant cell tumor of bone (GCTB) is a rare primary bone tumor that primarily affects young adults, but can be seen in children. The primary modality of treatment is surgical resection; however, this is not always possible given the location and extent of the neoplasm. Recent developments in the understanding of the underlying molecular pathogenesis of disease have pointed to interactions between the stromal component producing receptor activator of nuclear factor-kappaB (RANK) and RANK-ligand (RANKL) causing the formation of osteoclast-like giant cells that drive bone destruction. The development of a monoclonal humanized antibody to RANKL, denosumab, has been shown to reduce skeletal-related events from osteoporosis and from bony metastases from solid tumors. Recent phase II clinical trials with denosumab in skeletally mature adolescents over age 12 years and adults with GCTB, have shown both safety and efficacy, leading to its accelerated US FDA approval on 13 June 2013. In children who are skeletally immature, safety and efficacy has not been established, and there has been only published anecdotal use.

Recurrent Giant cell tumour in distal Humerus: A Case report

Introduction:

Giant cell tumour of bone (GCT) is a common benign primary bone tumour, seen commonly in the distal Femur, proximal Tibia and distal Radius. Very few cases of GCT are reported in distal humerus. We report an unusual presentation of recurrent Giant cell tumour in a 25 year old male in the medial condyle and epicondyle of left Humerus.

Case Series:

Patient presented elsewhere with lytic lesion of left elbow three years ago. As it is an uncommon site for tumors, it was misdiagnosed as tuberculous osteomyelitis and was inadequately curetted. Patient presented to us with recurrence of tumor one year after the primary surgery. We did en-bloc resection of the tumour, with judicious removal of partial trochlea. Though reconstruction was planned, it was found to be not necessary as the elbow was stable per-operatively. Patient regained near normal movements of the elbow with no instability. His Mayo Elbow Performance score improved from 30 to 85. There is no recurrence or metastasis of the tumor in the two-year follow-up.

Conclusion:

Though bone tumors are rare in distal Humerus, biopsy is needed to confirm the diagnosis of any lytic lesion in this region for proper management.

Intralesional excision versus wide resection for giant cell tumor involving the acetabulum: which is better?

BACKGROUND

Because of the anatomic complexity of the pelvis, there is no standard surgical treatment for giant cell tumors (GCTs) of the pelvic bones, especially in the periacetabular region. Treatment options include intralesional curettage with or without adjunctive techniques and wide resection. The best surgical treatment of a pelvic GCT remains controversial.

QUESTIONS/PURPOSES

We compared wide resection and intralesional excision in terms of (1) local control, (2) function, and (3) complications.

METHODS

We retrospectively identified 27 patients with periacetabular benign GCTs who underwent surgery from July 1999 to July 2009. Intralesional surgery was performed in 13 patients and wide resection in 14 patients. We determined surgical complications, local disease control, and Musculoskeletal Tumor Society (MSTS) 93 functional score. The minimum followup was 18 months (mean, 50 months; range, 18-121 months).

RESULTS

Four of 13 patients who had intralesional surgery and none of 14 who had wide resection had local recurrence. The mean functional score was 24 for the 13 patients who underwent intralesional surgery and 22 for the 14 patients who had wide resection. One minor and one major complication occurred among patients who underwent intralesional surgery and one minor and six major complications occurred among patients who underwent wide resection.

CONCLUSIONS

Even with a higher complication rate with wide resection and prosthetic reconstruction, we believe the lower local recurrence rate makes wide resection a reasonable option for patients with extensive and/or aggressive GCTs involving the acetabulum.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Giant cell tumors of the axial skeleton

Background. We report on 19 cases of giant cell tumor of bone (GCT) affecting the spine or sacrum and evaluate the outcome of different treatment modalities. Methods. Nineteen patients with GCT of the spine (n = 6) or sacrum (n = 13) have been included in this study. The mean followup was 51.6 months. Ten sacral GCT were treated by intralesional procedures of which 4 also received embolization, and 3 with irradiation only. All spinal GCT were surgically treated. Results. Two (15.4%) patients with sacral and 4 (66.7%) with spinal tumors had a local recurrence, two of the letter developed pulmonary metastases. One local recurrence of the spine was successfully treated by serial arterial embolization, a procedure previously described only for sacral tumors. At last followup, 9 patients had no evidence of disease, 8 had stable disease, 1 had progressive disease, 1 died due to disease. Six patients had neurological deficits. Conclusions. GCT of the axial skeleton have a high local recurrence rate. Neurological deficits are common. En-bloc spondylectomy combined with embolization is the treatment of choice. In case of inoperability, serial arterial embolization seems to be an alternative not only for sacral but also for spinal tumors.

Bone and soft tissue tumors of hip and pelvis

Objective is to identify epidemiologic and radiologic criteria allowing specific diagnoses of tumors and tumor-like lesions in the hip region and pelvis, and to optimize pre-operative staging. Patients with pelvic tumors are usually older, and their tumors are larger relative to patients with tumors in extremities. The majority of tumors in the pelvis are malignant (metastases, myeloma, chondrosarcoma, Ewing-, osteo-, and MFH/fibrosarcoma), while those in the proximal femur are in majority benign (fibrous dysplasia, solitary bone cyst, and osteoid osteoma). Soft tissue masses in the thigh in the elderly are typically sarcomas without tumor specific signs. Common tumor-like lesions occurring in the hip and pelvis that can mimic neoplasm are: infections (including tuberculosis), insufficiency/avulsion fractures, cysts, fibrous dysplasia, aneurysmal bone cyst, Langerhans cell histiocytosis, and Paget's disease. Local MR staging is based on the compartmental anatomy. The psoas and gluteal muscles are easily invaded by sarcoma originating in the ileum. The pectineus muscle protects the neurovascular bundle at the level of the hip. The thigh is separated into three compartments, some structures (Sartorius muscle) cross borders between compartments. Immobile joints (SI-joints, osteoarthritic hip) are relatively easily crossed by sarcoma and giant cell tumor.