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Gritsiuta AI, Bracken A, Downs P, Lara-Gutierrez J, Beebe K, Pechetov AA, Petrov RV. Surgical management of rare benign tumors of the sternum. ACTA ACUST UNITED AC 2021; 11:88-94. [PMID: 34395895 PMCID: PMC8360399 DOI: 10.15406/mojcr.2021.11.00389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Primary benign tumors of the sternum are an exceedingly rare entity. Surgical techniques regarding intervention for these lesions are not clearly defined in the literature given their scarcity. Operative techniques include en-bloc resection of the tumor, and this has proven to be successful in preventing local recurrence despite benign nature of the lesion. Given the often extensive defect created by the excision, reconstruction is frequently necessary; depending on the size of the defect, either autologous bone grafting or the use of synthetic materials may be indicated. This study serves to present two cases of rare primary benign tumors of the sternum, giant cell tumors and osteoma spongiosum and to summarize the available literature. We present a review of the literature of 17sternal giant cell tumor cases reported so far including our patient and unique case of osteoma spongiosum of the sternum, that discusses their surgical management, as well as reconstructive techniques that provided an excellent clinical result and a lack of recurrence on long term follow-up.
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Affiliation(s)
- Andrei I Gritsiuta
- Department of Surgical Services, University of Pittsburgh Medical Center, USA.,Department of Thoracic Surgery, Vishnevsky National Medical Research Center of Surgery, Russia
| | - Alexander Bracken
- Department of Surgical Services, University of Pittsburgh Medical Center, USA
| | - Patrick Downs
- Department of Surgical Services, University of Pittsburgh Medical Center, USA
| | | | - Karisa Beebe
- Department of Surgical Services, University of Pittsburgh Medical Center, USA
| | - Alexei A Pechetov
- Department of Thoracic Surgery, Vishnevsky National Medical Research Center of Surgery, Russia
| | - Roman V Petrov
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, USA
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Lipplaa A, Kroep JR, van der Heijden L, Jutte PC, Hogendoorn PCW, Dijkstra S, Gelderblom H. Adjuvant Zoledronic Acid in High-Risk Giant Cell Tumor of Bone: A Multicenter Randomized Phase II Trial. Oncologist 2019; 24:889-e421. [PMID: 31040253 PMCID: PMC6656477 DOI: 10.1634/theoncologist.2019-0280] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 04/06/2019] [Indexed: 11/17/2022] Open
Abstract
Lessons Learned. Adjuvant treatment with zoledronic acid did not decrease the recurrence rate of giant cell tumor of bone (GCTB) in this study. The efficacy could not be determined because of the small sample size. GCTB recurrences, even in the denosumab era, are still an issue; therefore, a randomized study exploring the efficacy of zoledronic acid in the adjuvant setting in GCTB is still valid.
Background. Bisphosphonates are assumed to inhibit giant cell tumor of bone (GCTB)‐associated osteoclast activity and have an apoptotic effect on the neoplastic mononuclear cell population. The primary objective of this study was to determine the 2‐year recurrence rate of high‐risk GCTB after adjuvant zoledronic acid versus standard care. Methods. In this multicenter randomized open‐label phase II trial, patients with high‐risk GCTB were included (December 2008 to October 2013). Recruitment was stopped because of low accrual after the introduction of denosumab. In the intervention group, patients received adjuvant zoledronic acid (4 mg) intravenously at 1, 2, 3, 6, 9, and 12 months after surgery. Results. Fourteen patients were included (intervention n = 8, controls n = 6). Median follow‐up was long: 93.5 months (range, 48–111). Overall 2‐year recurrence rate was 38% (3/8) in the intervention versus 17% (1/6) in the control group (p = .58). All recurrences were seen within the first 15 months after surgery. Conclusion. Adjuvant treatment with zoledronic acid did not decrease the recurrence rate of GCTB in this study. The efficacy could not be determined because of the small sample size. Because recurrences, even in the denosumab era, are still an issue, a randomized study exploring the efficacy of zoledronic acid in the adjuvant setting in GCTB is still valid.
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Affiliation(s)
- Astrid Lipplaa
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Judith R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lizz van der Heijden
- Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Paul C Jutte
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Sander Dijkstra
- Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
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Dubey S, Rastogi S, Sampath V, Khan SA, Kumar A. Role of intravenous zoledronic acid in management of giant cell tumor of bone- A prospective, randomized, clinical, radiological and electron microscopic analysis. J Clin Orthop Trauma 2019; 10:1021-1026. [PMID: 31736608 PMCID: PMC6844206 DOI: 10.1016/j.jcot.2019.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND The primary treatment of Giant cell tumor of bone is surgical management. Bisphosphonates are antiresorptive drugs which inhibit osteoclast mediated bone resorption and shown to have inhibitory effect on various tumors. The present study aims to establish clinical, ultrastructural and radiological response of intravenous zoledronic acid on giant cell tumor of bone. METHODOLOGY Design - Prospective randomized controlled study. A group of 30 patients of GCT bone were randomized into two equal groups. Patients in control group did not receive any adjuvant therapy before surgery. Patients in bisphosphonate group received three doses of intravenous zoledronic acid at four weeks interval prior to definitive surgery. The evaluation was done based on size of swelling, VAS score, plain radiograph, MRI and histopathological and Transmission electron microscopic examination findings. RESULTS Significant reduction in VAS score (from mean 5.33 to 1.8), increased mineralization particularly at periphery of lesion in plain radiograph, statistically significant increase in mean apoptotic index, P value < 0.0001 (mean 41.46 in bisphosphonate group and 6.06 in control group) was noted in bisphosphonate group. No significant change in tumor volume is noted in MRI. No significant side effects were noted. DISCUSSION One distinctive feature of pathogenesis of GCT bone is osteoclastogenesis which causes extensive bone destruction. Use of intravenous Zoledronic acid counteracts this bone destruction. Further, possible antiangiogenic effect of intravenous bisphosphonates inhibits tumor growth and provides symptomatic improvement. CONCLUSION IV Zoledronic acid alleviates pain, produce sclerosis and induce apoptosis hence decrease the rate of tumor progression and decrease the rate of local bone destruction, hence they are useful adjuvant to surgery in GCT.
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Affiliation(s)
- Siddharth Dubey
- Department of Orthopaedics, AIIMS, New Delhi, India,Corresponding author.
| | - Shishir Rastogi
- Department of Orthopaedics, Hamdard Institute of Medical Sciences and Research, India
| | | | | | - Arvind Kumar
- Department of Orthopaedics, Hamdard Institute of Medical Sciences and Research, India
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Kundu ZS, Sen R, Dhiman A, Sharma P, Siwach R, Rana P. Effect of Intravenous Zoledronic Acid on Histopathology and Recurrence after Extended Curettage in Giant Cell Tumors of Bone: A Comparative Prospective Study. Indian J Orthop 2018; 52:45-50. [PMID: 29416169 PMCID: PMC5791231 DOI: 10.4103/ortho.ijortho_216_17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Giant cell tumor (GCT) of the bone is known for its locally aggressive behavior and tendency to recur. It is an admixture of rounded or spindle-shaped mononuclear neoplastic stromal cells and multinucleated osteoclast-like giant cells with their proportionate dispersion among the former. Zoledronic acid (a bisphosphonate) is being used in various cancers such as myelomas and metastasis, for osteoporosis with an aim to reduce the resorption of bone, and as an adjuvant treatment for the management of GCT of bone for reduction of local recurrence. We have carried out a prospective comparative study to assess the effect of intravenous infusion of zoledronic acid on histopathology and recurrence of GCT of bone. MATERIALS AND METHODS The study was carried out in the biopsy proven GCTs in 37 patients; 15 males and 22 females, in the age range from 17 to 55 years. They were treated with extended curettage. Of these 37 patients, 18 were given three doses of 4 mg zoledronic acid infusion at 3-week intervals and extended curettage was performed 2 weeks after the last infusion whereas the other 19 were treated with extended curettage without zoledronic infusion. The post infusion histopathology of the curetted material was compared with the histopathology of initial biopsy. All the patients were evaluated at 3-month intervals for the first 2 years and then six monthly thereafter, for local recurrence and functional outcome of limb using the Musculoskeletal Tumor Society (MSTS) score. RESULTS In postzoledronic infusion cases, the histopathology of samples showed abnormal stromal cells secreting matrix leading to fibrosis and calcification. The type of fibrosis and calcification was different from pathological calcification and fibrosis what is usually observed. There was a good marginalization and solidification of tumors which made surgical curettage easier in six cases in the study group. There was noticeable reduction in the number of giant cells and alteration in morphology of stromal cells to the fibroblastic-fibrocytic series type in comparison to preinfusion histopathology. Recurrence occurred in one case out of 18 patients in infusion group whereas in four cases among 19 patients in control group. The functional results were assessed, and the overall average MSTS score was 27.50 (range 24-30) and 27.00 (range 23.50-30) in the study and control groups, respectively. CONCLUSIONS We observed that bisphosphonates reduce osteoclast activity and affects stromal cells in GCT, resulting in the reduction of their numbers and noticeable apoptosis. This results in better marginalization of the lesions and reduced recurrence. Extended curettage of friable GCT became easier and adequate which otherwise might not have been possible.
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Affiliation(s)
- Zile Singh Kundu
- Department of Orthopaedics, Pt B D Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India,Address for correspondence: Prof. Zile Singh Kundu, Department of Orthopaedics, Pt B D Sharma Postgraduate Institute of Medical Sciences, Rohtak - 124 001, Haryana, India. E-mail:
| | - Rajeev Sen
- Department of Pathology, Pt B D Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Ankur Dhiman
- Department of Orthopaedics, Pt B D Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Pankaj Sharma
- Department of Orthopaedics, Pt B D Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Ramchander Siwach
- Department of Orthopaedics, Pt B D Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Parveen Rana
- Department of Pathology, BPS-GMC, Sonepat, Haryana, India
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He Y, Zhang J, Ding X. Prognosis of local recurrence in giant cell tumour of bone: what can we do? Radiol Med 2017; 122:505-519. [PMID: 28271361 DOI: 10.1007/s11547-017-0746-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 02/22/2017] [Indexed: 12/16/2022]
Abstract
Giant cell tumour of bone (GCTB) is classified as an intermediate tumour with rare metastasis, but is challenged by local recurrence. This review focuses on the role of radiological evaluation in terms of prognosis of local recurrence in GCTB. We hope to highlight the value of radiological evaluation by integrating studies on the impact of surgical treatments and non-surgical factors on local recurrence of GCTB and the current statuses of genetic and molecular prognostic factors of GCTB. Radiological evaluation can provide diverse information on tumours. As a non-invasive method, magnetic resonance imaging (MRI) is especially valuable for the diagnosis and evaluation of bone tumours due to its heightened sensitivity to soft tissue disease and multiplanar image acquisition. Imaging findings should be integrated with clinical characteristics, pathology and genetic and molecular prognostic factors to direct clinical approach and reduce the local recurrence of GCTB. Therefore, it is necessary to establish a multi-perspective evaluation system by which prognostic factors can be reliably determined. We further advocate more large-scale prospective studies. With the help of radiological evaluation, the clinic treatment of GCTB can be guided and local recurrence might be reduced; additionally, MR imaging can identify local recurrence of GCTB after surgical treatment in the early stage.
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Affiliation(s)
- Yifeng He
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ji Zhang
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoyi Ding
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Ma Y, Xu W, Yin H, Huang Q, Liu T, Yang X, Wei H, Xiao J. Therapeutic radiotherapy for giant cell tumor of the spine: a systemic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24:1754-60. [PMID: 25943724 DOI: 10.1007/s00586-015-3834-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 02/07/2015] [Accepted: 02/22/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Giant cell tumor of the bone (GCTB) is a benign but locally aggressive tumor. Giant cell tumor of the spine (GCTS) accounts for 3-6 % of GCTB. Surgery remains the treatment of choice. For those not suitable for surgery, therapeutic radiotherapy (RT) is one classic modality. Although there are several articles on therapeutic RT for GCTS therapy, few systemic reviews have been performed on effects of therapeutic RT on GCTS. METHODS AND MATERIALS We searched EMBASE and Medline databases for papers reporting therapeutic radiotherapy for GCTS patients not suitable for surgical resection. The inclusion criteria and prognosis indicators have been defined prior to data extraction. Information of the included patients has been discreetly recorded. We analyzed the prognosis of therapeutic RT and multiple data concerning the GCTS patients. The indicators for prognosis were computed by SPSS software. The local control (LC) and overall survival (OS) rate was estimated by the Kaplan-Meier method. p values ≤0.5 were considered statistically significant. RESULT We included 13 studies comprising 42 patients who received therapeutic radiotherapy with doses ranging from 21 to 80 Gy. The results suggested a response rate of 100 %, OS of 97.6 %, 1-year local control rate (LC) of 85.4 %, 2-year LC rate of 80.2 %, and overall LC of 79 %. No patient reported malignant transformation albeit four had post-RT neurological complications. Four had distant metastasis of the tumor. Patients with previously repeated recurrence had worse prognosis after RT (p = 0.028). No association between dosage and prognosis was found. CONCLUSION Therapeutic RT could provide a satisfactory prognosis for GCTS patients according to this study, and can be an alternative treatment modality for GCTS patients not suitable for surgery.
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Affiliation(s)
- Yifei Ma
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
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Park YS, Lee JK, Baek SW, Park CK. The rare case of giant cell tumor occuring in the axial skeleton after 15 years of follow-up: Case report. Oncol Lett 2012; 2:1323-1326. [PMID: 22848310 DOI: 10.3892/ol.2011.402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Accepted: 08/24/2011] [Indexed: 11/06/2022] Open
Abstract
The majority of giant cell tumors (GCTs) occur in the ends of the long bones. The presence of more than one GCT in the axial skeleton is rare. A GCT is capable of remaining clinically latent following treatment and becoming active a number of years later. We report an extremely rare case of GCT occurring in the axial skeleton, involving the sacrum, thoracic spine and parieto-occipital skull in more than 15 years of follow-up.
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Affiliation(s)
- Ye-Soo Park
- Department of Orthopaedic Surgery, Guri Hospital, 249-1
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Giant cell tumor of bone: risk factors for recurrence. Clin Orthop Relat Res 2011; 469:591-9. [PMID: 20706812 PMCID: PMC3018195 DOI: 10.1007/s11999-010-1501-7] [Citation(s) in RCA: 251] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Accepted: 07/21/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Many surgeons treat giant cell tumor of bone (GCT) with intralesional curettage. Wide resection is reserved for extensive bone destruction where joint preservation is impossible or when expendable sites (eg, fibular head) are affected. Adjuvants such as polymethylmethacrylate and phenol have been recommended to reduce the risk of local recurrence after intralesional surgery. However, the best treatment of these tumors and risk factors for recurrence remain controversial. QUESTIONS/PURPOSES We evaluated the recurrence-free survival after surgical treatment of GCT to determine the influence of the surgical approach, adjuvant treatment, local tumor presentation, and demographic factors on the risk of recurrence. METHODS We retrospectively reviewed 118 patients treated for benign GCT of bone between 1985 and 2005. Recurrence rates, risk factors for recurrence and the development of pulmonary metastases were determined. The minimum followup was 36 months (mean, 108.4 ± 43.7; range, 36-233 months). RESULTS Wide resection had a lower recurrence rate than intralesional surgery (5% versus 25%). Application of polymethylmethacrylate decreased the risk of local recurrence after intralesional surgery compared with bone grafting; phenol application alone had no effect on the risk of recurrence. Pulmonary metastases occurred in 4%; multidisciplinary treatment including wedge resection, chemotherapy, and radiotherapy achieved disease-free survival or stable disease in all of these patients. CONCLUSION We recommend intralesional surgery with polymethylmethacrylate for the majority of primary GCTs. Because pulmonary metastases are rare and aggressive treatment of pulmonary metastases is usually successful, we believe the potential for metastases should not by itself create an indication for wide resection of primary tumors. LEVEL OF EVIDENCE Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Aghaloo TL, Felsenfeld AL, Tetradis S. Osteonecrosis of the jaw in a patient on Denosumab. J Oral Maxillofac Surg 2010; 68:959-63. [PMID: 20149510 DOI: 10.1016/j.joms.2009.10.010] [Citation(s) in RCA: 189] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Accepted: 10/03/2009] [Indexed: 01/15/2023]
Affiliation(s)
- Tara L Aghaloo
- Section of Oral and Maxillofacial Surgery, School of Dentistry, University of California, Los Angeles, Los Angeles, CA 90095, USA.
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Balke M, Schremper L, Gebert C, Ahrens H, Streitbuerger A, Koehler G, Hardes J, Gosheger G. Giant cell tumor of bone: treatment and outcome of 214 cases. J Cancer Res Clin Oncol 2008; 134:969-78. [PMID: 18322700 DOI: 10.1007/s00432-008-0370-x] [Citation(s) in RCA: 274] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2007] [Accepted: 02/15/2008] [Indexed: 11/24/2022]
Abstract
BACKGROUND Two hundred and fourteen patients with benign giant cell tumor of bone (GCTB), treated from 1980 to 2007 at the Department of Orthopedics of the University of Muenster (Germany), were analyzed in a retrospective study. PATIENTS AND METHODS The mean age was 33.3 years with a female-to-male ratio of 1.2 : 1. The mean follow up was 59.8 months. The recurrence rate of patients who received first treatment at our institution was 16.6%. The most common primary treatment was curettage (188 patients) usually followed by adjuvant local therapy. The effects of bone cement (PMMA), burring and hydrogen peroxide (H(2)O(2)) were statistically analyzed and the influence of a subchondral bone graft on the recurrence rate was evaluated. RESULTS PMMA alone (n = 52) reduces the likelihood of recurrence by the factor 8.2, additional high-speed burring (n = 39) by the factor 3.9 (compared to PMMA only). H(2)O(2) (n = 42) seems to have an additional effect comparable to that of phenol although it did not reach statistical significance. CONCLUSION The combination of all adjuncts (PMMA, burring, H(2)O(2) - n = 42) reduces the likelihood of recurrence by the factor 28.2 compared to curettage only and therefore should be recommended as a standard treatment. If the tumor reaches close to the articulating surface a subchondral bone graft (n = 42) can be performed without risking a higher recurrence rate. We add seven cases of pulmonary metastases and two cases of multicentricity to the literature. Bisphosphonates and interferon alpha may have a beneficial effect.
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Affiliation(s)
- Maurice Balke
- Department of Orthopedic Surgery, University of Muenster, Muenster, Germany.
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Abstract
Giant cell tumor (GCT) of bone though one of the commonest bone tumors encountered by an orthopedic surgeon continues to intrigue treating surgeons. Usually benign, they are locally aggressive and may occasionally undergo malignant transformation. The surgeon needs to strike a balance during treatment between reducing the incidence of local recurrence while preserving maximal function.Differing opinions pertaining to the use of adjuvants for extension of curettage, the relative role of bone graft or cement to pack the defect and the management of recurrent lesions are some of the issues that offer topics for eternal debate.Current literature suggests that intralesional curettage strikes the best balance between controlling disease and preserving optimum function in the majority of the cases though there may be occasions where the extent of the disease mandates resection to ensure adequate disease clearance.An accompanying treatment algorithm helps outline the management strategy in GCT.
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Affiliation(s)
- Ajay Puri
- Dept. of Orthopedic Oncology, Tata Memorial Hospital, Mumbai, India,Correspondence: Dr. Ajay Puri, Dept. of Orthopedic Oncology, Room No: 26, Tata Memorial Hospital, E. Borges Road, Parel, Mumbai - 400 012, India. E-mail:
| | - Manish Agarwal
- Dept. of Orthopedic Oncology, Tata Memorial Hospital, Mumbai, India
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