Surgical management and long-term outcomes of intracranial giant cell tumors: a single-institution experience with a systematic review

OBJECTIVE

Intracranial giant cell tumors (GCTs) are extremely rare neoplasms with dismal survival and recurrence rates. The authors aimed to confirm independent adverse factors for progression-free survival (PFS) and to propose an optimal treatment algorithm.

METHODS

The authors reviewed the clinical data of 43 cases of intracranial GCTs in their series. They also reviewed 90 cases of previously reported GCTs in the English language between 1982 and 2017 using Ovid MEDLINE, Embase, PubMed, and Cochrane databases with keywords of "giant cell tumor" or "osteoclastoma" and "skull," "skull base," "temporal," "frontal," "sphenoid," or "occipital." These prior publication data were processed and used according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Aforementioned risk factors for the authors' series and the pooled cases were evaluated in patients not lost to follow-up (m = 38 and n = 128, respectively).

RESULTS

The authors' cohort included 28 males and 15 females with a mean age of 30.5 years. Gross-total resection (GTR) was achieved in 15 (34.9%) patients. Fifteen patients (39.5%) who did not undergo GTR received postoperative radiotherapy with a mean total dose of 54.7 ± 4.1 Gy. After a mean follow-up of 71.3 months, 12 (31.6%) patients experienced recurrence, and 4 (10.5%) died of disease. The actuarial 5-year PFS and overall survival (OS) were 68.6% and 90.0% in the authors' cohort, respectively. A multivariate Cox regression analysis verified that partial resection (HR 7.909, 95% CI 2.296-27.247, p = 0.001), no radiotherapy (HR 0.114, 95% CI 0.023-0.568, p = 0.008), and Ki-67 ≥ 10% (HR 7.816, 95% CI 1.584-38.575, p = 0.012) were independent adverse factors for PFS. Among the 90 cases in the literature, GTR was achieved in 49 (54.4%) cases. Radiotherapy was administered to 33 (36.7%) patients with a mean total dose of 47.1 ± 5.6 Gy. After a mean follow-up of 31.5 months, recurrence and death occurred in 17 (18.9%) and 5 (5.6%) cases, respectively. Among the pooled cases, the 5-year PFS and OS were 69.6% and 89.2%, respectively. A multivariate model demonstrated that partial resection (HR 4.792, 95% CI 2.909-7.893, p < 0.001) and no radiotherapy (HR 0.165, 95% CI 0.065-0.423, p < 0.001) were independent adverse factors for poor PFS.

CONCLUSIONS

GTR and radiotherapy were independent favorable factors for PFS of intracranial GCTs. Based on these findings, GTR alone or GTR plus radiotherapy was advocated as an optimal treatment; otherwise, partial resection plus radiotherapy with a dose ≥ 45 Gy, if tolerable, was a secondary alternative. Lack of randomized data of the study was stressed, and future studies with larger cohorts are necessary to verify these findings.Systematic review no.: CRD42018090878 (crd.york.ac.uk/PROSPERO/).

Giant Cell Tumors of the Bone With Pulmonary Metastasis

Giant cell tumors of the bone are benign but locally aggressive, and they rarely metastasize to the lungs. The purpose of this study was to retrospectively review the clinical presentation, long-term outcomes, and treatment of pulmonary metastasis of these tumors. Between 1991 and 2004, a total of 168 patients with giant cell tumors of the bone were treated at the authors' institution, 7 of whom developed lung metastasis. Four of the 7 patients were men, and mean age of these patients at initial surgery was 40 years (range, 19-56 years). All patients underwent wide excision and reconstruction or curettage and bone grafting for the bony lesions. Lung metastases were detected at a mean of 44 months after the treatment of bone lesions. Five patients had multiple metastases, and 2 had solitary pulmonary metastases. Six of these patients underwent delayed treatment, locally aggressive, or multiple recurrent and surgical procedures. All of the aforementioned procedures had similar risk factors to those previously reported in the literature. One patient had multiple giant cell tumors of the bone. At last follow-up, 2 patients had died due to complications from the pulmonary metastases or chemotherapy. One patient underwent a metastasectomy 4 years after treatment due to the progression of pulmonary metastasis. The remaining 4 patients were alive and healthy after chemotherapy or conservative treatment. Therefore, early detection, adequate treatment of the primary bone lesion, conservative treatment of lung metastases, and regular long-term follow-up are recommended.

Efficacy of first-line chemotherapy in patients with advanced lung sarcomatoid carcinoma

BACKGROUND

Sarcomatoid carcinomas (SCs) are rare tumors that may arise in the lung, accounting for 0.4% of non-small-cell lung cancers; the prognosis is poor. Only few retrospective small-size series have studied the efficacy of chemotherapy (CT) for metastatic SC.

METHODS

Multicenter study of patients with advanced or metastatic SC who received first-line CT. Clinical characteristics at baseline, response to first-line CT (Response Evaluation Criteria in Solid Tumors version 1.1), progression-free survival (PFS), and overall survival (OS) were retrospectively collected.

RESULTS

Ninety-seven patients were included. Median age was 62 (54-72) years. The majority of patients were men (70%), white (84%), and smokers (84%). Overall, 73% of patients received first-line platinum-based CT. At first tumor evaluation, 69% of patients experienced progression, 31% had disease control, and 16.5% had partial response. Partial response was observed in 20% of patients receiving platinum-based CT, and in none of those receiving non-platinum-based CT (p = 0.018). Median PFS was 2.0 months (confidence interval [CI] 95%: 1.8-2.3). PFS was not statistically different between patients receiving or not receiving a platinum-based CT. Median OS was 6.3 months (CI 95%: 4.7-7.8). There was a trend toward better OS for patients treated with platinum-based CT (7.0 months [CI 95%: 4.9-9.0] versus 5.3 months [CI 95%: 2.8-7.6]; p = 0.096). In multivariate analysis, disease control at first evaluation (hazard ratio = 0.38 [CI 95%: 0.21-0.59]) and at platinum-based CT (hazard ratio = 0.92 [CI 95%: 0.85-0.99]) was associated with better OS.

CONCLUSION

SC is associated with poor prognosis and high rate of resistance to conventional first-line CT. New therapeutic strategies are needed, based on better knowledge of the carcinogenesis of SC.

Clinical and immunohistochemical characteristics of benign giant cell tumour of bone with pulmonary metastases: case series

PURPOSE

Giant cell tumour of bone with pulmonary metastases is rare. However, some patients die of pulmonary metastases, and histological examination cannot distinguish between benign tumour and malignant metastases. In this study, we present clinical and immunohistochemical findings associated with giant cell tumour of bone with pulmonary metastases.

METHODS

Five patients with benign giant cell tumour of bone with pulmonary metastases (one man and 4 women) were studied. Patients' ages ranged between 20 and 23 years (mean age, 21.8 years). Tumours were in the distal femur in 2 cases, and in the proximal tibia, distal tibia, and lumbar spine in one case each. The tissue specimens from primary tumours, recurrent tumours, and pulmonary metastases were studied using immunohistochemical techniques.

RESULTS

Three of the 5 primary tumours were of the spontaneous regression or growth cessation type, or the continuously slow-growing type, showing 4.2% to 6.2% of positive cells for Ki-67 after immunohistochemical staining. However, 2 patients with the rapid-growing type of disease died of pulmonary metastases; their primary, recurrent, and metastatic tumour specimens contained 9.0% to 11.5% of positive cells for Ki-67.

CONCLUSION

Three of the 5 primary tumours had a benign clinical pattern and immunohistochemistry. Two of the 5 patients died of pulmonary metastases, which had an aggressive clinical pattern and a high prevalence of positive cells in Ki-67. Examination of Ki-67 should be carried out for aggressive type of giant cell tumour.

Proximal femoral reconstruction with custom mega prosthesis

Seventy-seven patients with proximal femoral tumours underwent limb salvage surgery with custom mega prostheses between July 1989 and January 2002. We describe 44 cases with a mean follow-up of 57.8 months. Forty-one patients presented with malignant neoplasms of which 11 were malignant giant cell tumours, eight were chondrosarcoma and five were metastases. Wide margins were achieved for all malignant tumours, and marginal resection was done for all benign and metastatic lesions. Six patients died of disease and two were lost to follow-up. Mechanical complications were observed in six cases, fracture being the most common. Oncological complications occurred in five patients. Functional activity was satisfactory in 79% of patients.

Oncologic and functional results after treatment of giant cell tumors of bone

Surgical treatment of giant cell tumor of bone has always been a difficult problem because of its local aggressive behavior. Oncologic results and functional outcome are reported here in a retrospective study of 36 patients, treated by various surgical procedures. The average age at the time of diagnosis was 34 years, and the median follow-up period was 7 years. Twenty-three patients were treated by intralesional excision with local adjuvant therapy, and 11 patients by extralesional excision. Two patients received radiotherapy only. Seven local tumor recurrences (30%) were encountered after intralesional procedures, while local tumor control was the rule after extralesional excision. Intralesional excision with local adjuvant therapy resulted in significantly better functional results compared with extralesional excision. Wide excision was associated with a poor functional outcome and marginal excision with a good functional outcome. For the treatment of giant cell tumor of bone, intralesional excision with local adjuvant therapy is recommended because of a good functional outcome. When applying cryosurgery as the local adjuvant, more vigorous freezing may be necessary to improve local tumor control.

Limb salvage surgery for locally aggressive and malignant bone tumors

Since 1983, 77 patients have had limb salvage surgery for locally aggressive or malignant bone tumor of the limbs or pelvis. Twenty-nine patients had locally aggressive lesions with giant cell tumors the most prevalent, and 48 patients had malignant lesions, of which osteosarcomas predominated. Resection with a wide margin could be achieved in most of the patients. A mobile joint reconstruction was performed in 57 patients and an arthrodesis in 14 patients. At follow-up, 14 patients have died of disease, 7 patients have survived with disease, and 56 patients (73%) have survived without disease. Local recurrences were encountered in 4 patients (5%). The overall functional results were classified as excellent in 11 patients, good in 45 patients, and fair in 9 patients. Twelve patients had poor results because of failure of the reconstruction or amputation due to complications. Twenty-seven complications were encountered, among which infection was the most serious. Careful selection of patients and consideration of procedure chosen to reconstruct the defect are important for a successful outcome. This decision is based on a number of factors related to the tumor and the patient. Presently, major neurovascular involvement, displaced pathological fracture, inappropriate biopsy incision, extreme youth of the patient, and infection were considered to be contraindications to resection in our institution. Although various procedures promise functional restoration, the reconstructive procedure should be individualized and designed to meet the needs of the patient.

[Interscapular-thoracic resection in the treatment of patients with tumors of the musculoskeletal system]

Data of 13 patients with tumors of the locomotor system subjected to +interscapular-thoracic resection (ITR) are presented. Main technical aspects of ITR are described. Complications took place in 6 patients, including marginal necrosis of the skin in 4 patients. As a whole the 5-year survival made up 49.9% +/- 13.8%. Data are presented on rehabilitation measures which allow to widen the functional possibilities of the extremity.

Neoplasms arising in Paget's disease of bone: a study of 82 cases

Eighty-two cases of neoplasms arising in Paget's disease of bone from the Mid-America Bone Tumor Registry, accessioned between 1958 and 1983, were reviewed. There were 77 osteosarcomas, 3 fibrosarcomas, 1 chondrosarcoma, and 1 giant cell tumor. The male/female ratio was 2:1. The age distribution was 18%, 29%, 36%, and 17% for the groups less than 51 years, 51-60 years, 61-70 years, and greater than 70 years, respectively. The femur was involved by tumor in 22%; the humerus in 21%; the pelvis in 21%; the calvarium in 12%; the tibia in 10%; and other bones in 15% of the cases. There were 48% survivors after 1 year; 17% after two; and 5% after three and five years; two additional patients with tumor lived for more than seven and 11 years. Radiographs available for simultaneous study in 43 cases revealed predominant tumor patterns that were mixed in 69%, osteoblastic in 21%, and osteolytic in 10%. Other radiographic data and the clinical and histopathologic data are in agreement with five earlier major studies. While the prognosis of neoplasms arising in Paget's disease generally is not good, a small fraction of long-term survivors after aggressive therapy makes this complication a challenge for timely radiographic diagnosis and histopathologic confirmation.

[Immuno-oncologic monitoring of patients with bronchial carcinoma. IV. Aspects of the immunocompetence system]

Some aspects of the immunocompetent system are tested in 84 lung cancer patients at time of diagnosis and during the natural course of the disease. Results show no significant variations for many immunological tests during the course of the neoplasia. Significant alterations are observed in T-lymphocyte and macrophage evaluation. Moreover, some immunological data are related to lung cancer post-surgical survival.

[Prognostic value of various factors in the treatment of patients with primary malignant tumors of the pelvic bones]

The time of life of 219 patients with primary malignant tumors of bones of the pelvis were analyzed in order to study the influence of different factors on the survival rate of the patients. It was shown that a considerable improvement of some results in the treatment of chondrosarcomas and chordomas was achieved after ablative removal of tumors, in reticulosarcoma and Ewing sarcoma--after a combined chemo-radial treatment with prophylactic courses of the therapy during 2 years. The combination of operation and radiotherapy for the treatment of chordomas gave a reliably higher survival of the patients within 5 years of observation. Prognosis in osteogenic sarcoma and angiosarcoma are extremely unfavorable regardless of the method of treatment.

Giant cell carcinoma of the thyroid gland: long survival after combination chemotherapy

A 41-year-old white woman had undifferentiated giant cell carcinoma of the thyroid, unsuccessfully treated with local cobalt therapy. She was given a five-drug combination of chemotherapy, responding rapidly with marked improvement, abatement of symptoms, resolution of the tumor, and eight-year survival to date.