Treatment of giant-cell tumors of long bones with curettage and bone-grafting.
01 Jun 1999-Journal of Bone and Joint Surgery, American Volume (J Bone Joint Surg Am)-Vol. 81, Iss: 6, pp 811-820
TL;DR: The results of the present study suggest that the risk of local recurrence after curettage with a high-speed burr and reconstruction with autogenous graft with or without allograft bone is similar to that observed after use of cement and other adjuvant treatment.
Abstract: Background: The use of curettage, phenol, and cement is accepted by most experts as the best treatment for giant-cell tumor of bone. The present study was performed to evaluate whether equivalent results could be obtained with curettage with use of a high-speed burr and reconstruction of the resulting defect with autogenous bone graft with or without allograft bone. Methods: The prospectively collected records of patients who had a giant-cell tumor of a long bone were reviewed to determine the rate of local recurrence after treatment with curettage with use of a high-speed burr and reconstruction with autogenous bone graft with or without allograft bone. All of the patients were followed clinically and radiographically, and a biopsy was performed if there were any suspicious changes. Results: Fifty-nine patients met the criteria for inclusion in the study. According to the grading system of Campanacci et al., two patients (3 percent) had a grade-I tumor, twenty-nine (49 percent) had a grade-II tumor, and twenty-eight (47 percent) had a grade-III tumor. Seventeen patients (29 percent) had a pathological fracture at the time of presentation. The mean duration of follow-up was eighty months (range, twenty-eight to 132 months). Seven patients (12 percent) had a local recurrence. Six of these seven were disease-free at the latest follow-up examination after at least one additional treatment with curettage or soft-tissue resection (one patient). One patient had resection and reconstruction with a prosthesis after a massive local recurrence and pulmonary metastases. Conclusions: Despite the high rates of recurrence reported in the literature after treatment of giant-cell tumor with curettage and bone-grafting, the results of the present study suggest that the risk of local recurrence after curettage with a high-speed burr and reconstruction with autogenous graft with or without allograft bone is similar to that observed after use of cement and other adjuvant treatment. It is likely that the adequacy of the removal of the tumor rather than the use of adjuvant modalities is what determines the risk of recurrence.
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01 Jan 2014
TL;DR: Lymphedema is a common complication after treatment for breast cancer and factors associated with increased risk of lymphedEMA include extent of axillary surgery, axillary radiation, infection, and patient obesity.
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TL;DR: The radiologic features of giant cell tumor (GCT) and giant cell reparative granuloma (GCRG) of bone often strongly suggest the diagnosis and reflect their pathologic appearance, and recognition of the spectrum of radiologic appearances of GCT and GCRG is important in allowing prospective diagnosis, guiding therapy, and facilitating early detection of recurrence.
Abstract: The radiologic features of giant cell tumor (GCT) and giant cell reparative granuloma (GCRG) of bone often strongly suggest the diagnosis and reflect their pathologic appearance. At radiography, GCT often demonstrates a metaepiphyseal location with extension to subchondral bone. GCRG has a similar appearance but most commonly affects the mandible, maxilla, hands, or feet. Computed tomography and magnetic resonance (MR) imaging are helpful in staging lesions, particularly in delineating soft-tissue extension. Cystic (secondary aneurysmal bone cyst) components are reported in 14% of GCTs. However, biopsy must be directed at the solid regions, which harbor diagnostic tissue. These solid components demonstrate low to intermediate signal intensity at T2-weighted MR imaging, a feature that can be helpful in diagnosis. Multiple GCTs, although rare, do occur and may be associated with Paget disease. Malignant GCT accounts for 5%–10% of all GCTs and is usually secondary to previous irradiation of benign GCT. Treat...
433 citations
TL;DR: The combination of all adjuncts (PMMA, burring, H2O2 − 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 andTherefore, if the tumor reaches close to the articulating surface a subchondral bone graft can be performed without risking a higher recurrence rate.
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.
352 citations
Cites background from "Treatment of giant-cell tumors of l..."
...With this procedures the local recurrence rate ranges from 10 to 40% (Blackley et al. 1999; Campanacci et al. 1987; Goldenberg et al. 1970; Lausten et al. 1996; Malek et al. 2006), but...
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...This can be accomplished by physical adjuncts such as cryotherapy, hyperthermia or high-speed burring (Blackley et al. 1999; Demichev 1994; Fan et al. 1996; Malawer et al. 1999; Malek et al. 2006) or chemical substances with cytotoxic eVects such as phenol, alcohol, H2O2 or methotrexate (Blackley…...
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...Bone cement The use of bone cement is reported as a safe and eVective procedure that provides local adjuvant therapy and immediate stability (Bini et al. 1995; Blackley et al. 1999; Malek et al. 2006; Rooney et al. 1993; Szendroi 1992)....
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...…Fan et al. 1996; Malawer et al. 1999; Malek et al. 2006) or chemical substances with cytotoxic eVects such as phenol, alcohol, H2O2 or methotrexate (Blackley et al. 1999; Durr et al. 1999; Goldenberg et al. 1970; Jones et al. 2006; Kirchen et al. 1996; Lausten et al. 1996; Masui et al. 1998;…...
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...With this procedures the local recurrence rate ranges from 10 to 40% (Blackley et al. 1999; Campanacci et al. 1987; Goldenberg et al. 1970; Lausten et al. 1996; Malek et al. 2006), but exact statistical data on the individual eVects of the diVerent adjuncts and of the subchondral bone graft is…...
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TL;DR: Giant cell tumour (GCT) is still one of the most obscure and intensively examined tumours of bone; and there are still many unanswered questions with regard to both its treatment and prognosis.
Abstract: Giant cell tumour (GCT) is still one of the most obscure and intensively examined tumours of bone. Its histogenesis is uncertain. The histology does not predict the clinical outcome; and there are still many unanswered questions with regard to both its treatment and prognosis. The World Health Organisation has classified GCT as “an aggressive, potentially malignant lesion”, 1 which means that its evolution based on its histological features is unpredictable. Statistically, 80% of GCTs have a benign course, with a local rate of recurrence of 20% to 50%. About 10% undergo malignant transformation at recurrence and 1% to 4% give pulmonary metastases even in cases of benign histology.
340 citations
TL;DR: Results from the Musculoskeletal Tumor Society rating from 1987 were significantly lower in patients who sustained a displaced fracture and results from the bodily pain section of the Short Form-36 also were found to be lower when a pathologic fracture was present.
Abstract: A multicentric retrospective study of giant cell tumor of bone was conducted among Canadian surgeons. The hypothesis was that no differences would be found in health status, function, or recurrence rate irrespective to the nature of filling material or adjuvant used in patients treated with curettage. One hundred eighty-six cases were collected. There were 96 females and 90 males. The mean age of the patients was 36 years (range, 14-72 years), the minimum followup was 24 months, and the median followup was 60 months. Sixty-two percent of the tumors involved the knee region. One hundred fifty-eight were primary tumors and 28 were recurrences. Campanacci grading was as follows: Grade 1, seven patients; Grade 2, 100 patients; Grade 3, 76 patients; and unknown in three patients. Fifty-six patients had a pathologic fracture. Resection was done in 38 patients and 148 patients had curettage. The latter was supplemented with high speed burring in 135 patients, cement in 64 patients, various combinations of autograft or allograft bone in 61 patients, phenol in 37 patients, and liquid nitrogen in 10 patients. Structural allografts were used in 25 patients. The overall recurrence rate was 17%, 18% after curettage, and 16% after resection. Patients with primary tumors treated with curettage had a 10% recurrence rate. For recurrent lesions treated by curettage, the recurrence rate was 35%. The nature of the filling material used or the type of adjuvant method used or any combination of both failed to show any statistical impact on the recurrence risk. The results from the Musculoskeletal Tumor Society rating from 1987 were significantly lower in patients who sustained a displaced fracture. Results from the bodily pain section of the Short Form-36 also were found to be lower when a pathologic fracture was present. Results from the Musculoskeletal Tumor Society Rating 1987, the Short Form-36, and the Toronto Extremity Salvage Score did not show differences when either cement or bone graft were used after curettage.
338 citations
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TL;DR: Of the fifty-one local recurrences that were seen after treatment at the Istituto Rizzoli, 90 per cent appeared in the first three years after surgery, and these results did not correlate with the radiographic grade of the lesion.
Abstract: Of 327 patients who had a giant-cell tumor of bone and were seen at the Istituto Rizzoli, 293 were treated at the Institute, and 280 of these were followed for two to forty-four years. The distribution according to sex and age of the patient and site of the tumor was similar to the distributions in major reports of large series. The tumor usually involved the metaphysis and the epiphysis, but was occasionally limited to the metaphysis, and in only 2 per cent of the patients was it adjacent to an open growth plate. The tumor on occasion invaded the articular space, also involving the ligaments and the synovial membrane. Extension to an adjacent bone through the joint occurred in 5 per cent of the tumors. Our radiographic grading, which is roughly comparable with the staging system of Enneking et al., was Grade I in 4 per cent, II in 74 per cent, and III in 22 per cent of 266 patients before treatment. A pathological fracture was apparent on the first radiograph in 9 per cent of the patients. In the 280 patients with adequate follow-up, 331 surgical procedures were performed. The rate of local recurrence was 27 per cent in the 151 intralesional procedures, 8 per cent in the 122 marginal excisions, and zero in the fifty-eight wide or radical procedures. These results did not correlate with the radiographic grade of the lesion. Of the fifty-one local recurrences that were seen after treatment at our institution, 90 per cent appeared in the first three years after surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
1,255 citations
TL;DR: The treatment of the tumors in this series was performed by many surgeons and varied considerably, and success in the treatment of recurrences was observed after a second curettage with or without bone-grafting, and the success of surgical treatment appeared to depend on the completeness with which the tumor was removed.
Abstract: Two hundred and twenty-two tumors in 218 patients were collected from different institutions and doctors. Eight patients had died less than eighteen months after the diagnosis was made, one of an unrelated disease, the others as a result of their tumor. The remaining 210 patients with 214 tumors were followed for an average of 9.9 years, the range being two to thirty-four years.
In each case, skeletal maturity, location of the lesion, roentgenographic findings, histological characteristics, and treatment were analyzed. Skeletal maturity, as evidenced by closure of the epiphyses, was present in all patients. This observation may explain the predominance of females (27:11) in the patients less than twenty years old. More than half (55 per cent) of the lesions were located in the lower end of the femur, the upper part of the tibia, and the lower end of the radius. Other sites were the sacrum, pelvis, proximal end of the femur and fibula, and the small bones of the hands and feet.
The roentgenographic findings were sufficiently characteristic to be helpful but not diagnostic. They were influenced by previous treatment of fracture.
The histological features permitted grading as suggested by Jaffe, Lichtenstein, and Portis30. However, the grading was not of prognostic value although it did serve to alert the surgeon to the possibility that the tumor was malignant. A consistently accurate prediction as to local recurrence or pulmonary metastasis could not be made on the basis of the histological grade.
The treatment of the tumors in this series was performed by many surgeons and varied considerably. All patients had a preliminary biopsy. The primary surgical treatment ranged from curettage or excision, with or without bone-grafting, to amputation. The success of surgical treatment, whether by curettage or resection, appeared to depend on the completeness with which the tumor was removed.
After primary curettage, thirty-five of forty-five tumors recurred; whereas, after primary curettage combined with bone-grafting, twenty-two of the ninety-one tumors recurred. After primary resection, ten of the forty-four tumors recurred, whereas, after primary resection combined with bone-grafting, four of twenty-two tumors recurred. Primary amputation was performed for ten tumors none of which recurred. After primary irradiation, six of ten tumors recurred. Ninety-seven per cent of the recurrences occurred within two years of the time that the initial diagnosis was made.
At the time of this study, 189 of the 218 patients were alive and well, and twenty-nine had died. Of the 189 who were alive and well, 121 had had no recurrence after primary treatment and sixty-eight had required secondary procedures. Of the twenty-nine patients who had died, fourteen had died of their tumor, three of postirradiation sarcoma, and twelve of unrelated disease. Eighteen of the twenty-nine dead patients had recurrent lesions.
In the whole series, 180 secondary procedures were performed, 140 on sixty-eight patients who survived and forty on the twenty-nine patients who died.
Of the 140 procedures on surviving patients, eighteen were for infection, five for lung metastases, four for fracture or non-union of a bone graft, and 113 for fifty-nine recurrences.
The forty procedures done on the patients who died included one for infection, one for fracture of the bone graft, two for lung metastases, and thirty-six for recurrences.
Of the seventy-seven patients who had recurrent lesions, fifty-six had one recurrence; sixteen, two recurrences; and four, three recurrences.
Success in the treatment of recurrences was observed after a second curettage with or without bone-grafting in nine of sixteen patients, after secondary resection with or without bone-grafting in sixteen of thirty-five patients, after secondary irradiation in five of thirty-six patients, and after amputation in thirty-nine of forty-six patients.
Irradiation, used for ten primary and thirty-six secondary tumors, was clearly beneficial in eight, possibly helpful in nine, and clearly ineffective in twenty-nine. Three of the patients so treated had postirradiation sarcoma. The average follow-up of patients who had radiotherapy was 9.2 years (the range four months to thirty-four years).
In five of the six patients with pulmonary metastases, lobectomy was successful.
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468 citations
TL;DR: The nine-year experience with sixty patients who had had a giant-cell tumor of a long bone was reviewed to determine the rate of recurrence after treatment with curettage and packing with polymethylmethacrylate cement.
Abstract: The nine-year experience with sixty patients who had had a giant-cell tumor of a long bone was reviewed to determine the rate of recurrence after treatment with curettage and packing with polymethylmethacrylate cement. The demographic characteristics, including the age and sex of the patient and the site of the tumor, were similar to those that have been reported for other large series. An average of four years (range, two to ten years) after the operation, the over-all rate of initial local recurrence was 25 per cent (fifteen of sixty patients). Patients who had had a tumor of the distal aspect of the radius had a higher rate of recurrence (five of ten) than those who had had a tumor of the proximal aspect of the tibia (seven [28 per cent] of twenty-five) or of the distal part of the femur (three [13 per cent] of twenty-three). Higher rates of recurrence were also noted for patients who had had a pathological fracture (three of six), those who had had a Stage-III tumor according to the classification of Campanacci et al. (six of sixteen), and those who had not had adjuvant treatment with either a high-speed burr or phenol (eight of nineteen). Patients who had had an initial recurrence after packing with cement had a low rate of secondary recurrence when the initial recurrence had been treated with a wide resection or a second intralesional procedure (zero of ten and one of five patients, respectively), after an average of three years (range, ten months to eight years). No patient had a multicentric tumor or metastasis.(ABSTRACT TRUNCATED AT 250 WORDS)
406 citations
TL;DR: The authors' experience involving 221 consecutive patients with giant-cell tumor who were treated from 1960 to 1982 is reported, and curettage and bone-grafting, with preservation of function of the joint, is the preferred treatment for most patients.
Abstract: Our experience involving 221 consecutive patients with giant-cell tumor who were treated from 1960 to 1982 is reported. Of one group of 146 patients, twenty-seven who were initially treated by wide resection and 112 who had thorough curettage had a recurrence rate of 23 per cent after an average length of follow-up of seven years. All thirty-three recurrences were noted less than six years after operation, and twenty-seven were noted within the first three years postoperatively. Over-all, the type of surgical removal was the most significant factor in recurrence. The recurrence rate was 34 per cent in the patients who had curettage of the lesion and 7 per cent in those who had a wide resection. In a second group of seventy-five patients, initially treated by us for a recurrent tumor, there were fifteen subsequent recurrences, after an average length of follow-up of seven years. Curettage and bone-grafting, with preservation of function of the joint, is the preferred treatment for most patients.
366 citations