Top

Clinical Orthopaedics and Related Research®

Published in:

01-03-2013 | Symposium: Papers Presented at the 2011 ISOLS Meeting in Beijing, China

Giant Cell Tumor With Pathologic Fracture: Should We Curette or Resect?

Authors: Lizz van der Heijden, MSc, P. D. Sander Dijkstra, MD, PhD, Domenico A. Campanacci, MD, PhD, C. L. Max H. Gibbons, MD, PhD, Michiel A. J. van de Sande, MD, PhD

Published in: Clinical Orthopaedics and Related Research® | Issue 3/2013

Abstract

Background

Approximately one in five patients with giant cell tumor of bone presents with a pathologic fracture. However, recurrence rates after resection or curettage differ substantially in the literature and it is unclear when curettage is reasonable after fracture.

Questions/Purposes

We therefore determined: (1) local recurrence rates after curettage with adjuvants or en bloc resection; (2) complication rates after both surgical techniques and whether fracture healing occurred after curettage with adjuvants; and (3) function after both treatment modalities for giant cell tumor of bone with a pathologic fracture.

Methods

We retrospectively reviewed 48 patients with fracture from among 422 patients treated between 1981 and 2009. The primary treatment was resection in 25 and curettage with adjuvants in 23 patients. Minimum followup was 27 months (mean, 101 months; range, 27–293 months).

Results

Recurrence rate was higher after curettage with adjuvants when compared with resection (30% versus 0%). Recurrence risk appears higher with soft tissue extension. The complication rate was lower after curettage with adjuvants when compared with resection (4% versus 16%) and included aseptic loosening of prosthesis, allograft failure, and pseudoarthrosis. Tumor and fracture characteristics did not increase complication risk. Fracture healing occurred in 24 of 25 patients. Mean Musculoskeletal Tumor Society score was higher after curettage with adjuvants (mean, 28; range, 23–30; n = 18) when compared with resection (mean, 25; range, 13–30; n = 25).

Conclusions

Our observations suggest curettage with adjuvants is a reasonable option for giant cell tumor of bone with pathologic fractures. Resection should be considered with soft tissue extension, fracture through a local recurrence, or when structural integrity cannot be regained after reconstruction.

Level of Evidence

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

Aponte-Tinao L, Farfalli GL, Ritacco LE, Ayerza MA, Muscolo DL. Intercalary femur allografts are an acceptable alternative after tumor resection. Clin Orthop Relat Res. 2012;470:728–734.PubMedCrossRef

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;134:969–978.PubMedCrossRef

Becker WT, Dohle J, Bernd L, Braun A, Cserhati M, Enderle A, Hovy L, Matejovsky Z, Szendroi M, Trieb K, Tunn PU. Local recurrence of giant cell tumor of bone after intralesional treatment with and without adjuvant therapy. J Bone Joint Surg Am. 2008;90:1060–1067.PubMedCrossRef

Blackley HR, Wunder JS, Davis AM, White LM, Kandel R, Bell RS. Treatment of giant-cell tumors of long bones with curettage and bone-grafting. J Bone Joint Surg Am. 1999;81:811–820.PubMedCrossRef

Campanacci M, Baldini N, Boriani S, Sudanese A. Giant-cell tumor of bone. J Bone Joint Surg Am. 1987;69:106–114.PubMed

Deheshi BM, Jaffer SN, Griffin AM, Ferguson PC, Bell RS, Wunder JS. Joint salvage for pathologic fracture of giant cell tumor of the lower extremity. Clin Orthop Relat Res. 2007;459:96–104.PubMedCrossRef

Dreinhöfer KE, Rydholm A, Bauer HC, Kreicbergs A. Giant-cell tumours with fracture at diagnosis. Curettage and acrylic cementing in ten cases. J Bone Joint Surg Br. 1995;77:189–193.PubMed

Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res. 1993;286:241–246.PubMed

Errani C, Ruggieri P, Asenzio MA, Toscano A, Colangeli S, Rimondi E, Rossi G, Longhi A, Mercuri M. Giant cell tumor of the extremity: a review of 349 cases from a single institution. Cancer Treat Rev. 2010;36:1–7.PubMedCrossRef

10.

Gaston CL, Bhumbra R, Watanuki M, Abudu AT, Carter SR, Jeys LM, Tillman RM, Grimer RJ. Does the addition of cement improve the rate of local recurrence after curettage of giant cell tumours in bone? J Bone Joint Surg Br. 2011;93:1665–1669.PubMed

11.

Ghert MA, Rizzo M, Harrelson JM, Scully SP. Giant-cell tumor of the appendicular skeleton. Clin Orthop Relat Res. 2002;400:201–210.PubMedCrossRef

12.

Henderson ER, Groundland JS, Pala E, Dennis JA, Wooten R, Cheong D, Windhager R, Kotz RI, Mercuri M, Funovics PT, Hornicek FJ, Temple HT, Ruggieri P, Letson GD. Failure mode classification for tumor endoprostheses: retrospective review of five institutions and a literature review. J Bone Joint Surg Am. 2011;93:418–429.PubMedCrossRef

13.

Jeys LM, Grimer RJ, Carter SR, Tillman RM. Periprosthetic infection in patients treated for an orthopaedic oncological condition. J Bone Joint Surg Am. 2005;87:842–849.PubMedCrossRef

14.

Jeys LM, Suneja R, Chami G, Grimer RJ, Carter SR, Tillman RM. Impending fractures in giant cell tumours of the distal femur: incidence and outcome. Int Orthop. 2006;30:135–138.PubMedCrossRef

15.

Kivioja AH, Blomqvist C, Hietaniemi K, Trovik C, Walloe A, Bauer HC, Jorgensen PH, Bergh P, Folleras G. Cement is recommended in intralesional surgery of giant cell tumors: a Scandinavian Sarcoma Group study of 294 patients followed for a median time of 5 years. Acta Orthop. 2008;79:86–93.PubMedCrossRef

16.

Klenke FM, Wenger DE, Inwards CY, Rose PS, Sim FH. Giant cell tumor of bone: risk factors for recurrence. Clin Orthop Relat Res. 2011;469:591–599.PubMedCrossRef

17.

Kostenuik PJ, Nguyen HQ, McCabe J, Warmington KS, Kurahara C, Sun N, Chen C, Li L, Cattley RC, Van G, Scully S, Elliott R, Grisanti M, Morony S, Tan HL, Asuncion F, Li X, Ominsky MS, Stolina M, Dwyer D, Dougall WC, Hawkins N, Boyle WJ, Simonet WS, Sullivan JK. Denosumab, a fully human monoclonal antibody to RANKL, inhibits bone resorption and increases BMD in knock-in mice that express chimeric (murine/human) RANKL. J Bone Miner Res. 2009;24:182–195.PubMedCrossRef

18.

Lindeman JH, Hanemaaijer R, Mulder A, Dijkstra PDS, Szuhai K, Bromme D, Verheijen JH, Hogendoorn PCW. Cathepsin K is the principal protease in giant cell tumor of bone. Am J Pathol. 2004;165:593–600.PubMedCrossRef

19.

McDonald DJ, Sim FH, McLeod RA, Dahlin DC. Giant-cell tumor of bone. J Bone Joint Surg Am. 1986;68:235–242.PubMed

20.

O’Donnell RJ, Springfield DS, Motwani HK, Ready JE, Gebhardt MC, Mankin HJ. Recurrence of giant-cell tumors of the long bones after curettage and packing with cement. J Bone Joint Surg Am. 1994;76:1827–1833.PubMed

21.

Prosser GH, Baloch KG, Tillman RM, Carter SR, Grimer RJ. Does curettage without adjuvant therapy provide low recurrence rates in giant-cell tumors of bone? Clin Orthop Relat Res. 2005;435:211–218.PubMedCrossRef

22.

Shehadeh A, Noveau J, Malawer M, Henshaw R. Late complications and survival of endoprosthetic reconstruction after resection of bone tumors. Clin Orthop Relat Res. 2010;468:2885–2895.PubMedCrossRef

23.

Su YP, Chen WM, Chen TH. Giant-cell tumors of bone: an analysis of 87 cases. Int Orthop. 2004;28:239–243.PubMedCrossRef

24.

Szendroi M. Giant-cell tumour of bone. J Bone Joint Surg Br. 2004;86:5–12.PubMed

25.

Thomas D, Henshaw R, Skubitz K, Chawla S, Staddon A, Blay JY, Roudier M, Smith J, Ye Z, Sohn W, Dansey R, Jun S. Denosumab in patients with giant-cell tumour of bone: an open-label, phase 2 study. Lancet Oncol. 2010;11:275–280.PubMedCrossRef

26.

Turcotte RE. Giant cell tumor of bone. Orthop Clin North Am. 2006;37:35–51.PubMedCrossRef

27.

Turcotte RE, Wunder JS, Isler MH, Bell RS, Schachar N, Masri BA, Moreau G, Davis AM. Giant cell tumor of long bone: a Canadian Sarcoma Group study. Clin Orthop Relat Res. 2002;397:248–258.PubMedCrossRef

28.

Werner M. Giant cell tumour of bone: morphological, biological and histogenetical aspects. Int Orthop. 2006;30:484–489.PubMedCrossRef

Title: Giant Cell Tumor With Pathologic Fracture: Should We Curette or Resect?
Authors: Lizz van der Heijden, MSc
P. D. Sander Dijkstra, MD, PhD
Domenico A. Campanacci, MD, PhD
C. L. Max H. Gibbons, MD, PhD
Michiel A. J. van de Sande, MD, PhD
Publication date: 01-03-2013
Publisher: Springer-Verlag
Published in: Clinical Orthopaedics and Related Research® / Issue 3/2013
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-012-2546-6

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Giant Cell Tumor With Pathologic Fracture: Should We Curette or Resect?

Abstract

Background

Questions/Purposes

Methods

Results

Conclusions

Level of Evidence

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Questions/Purposes

Methods

Results

Conclusions

Level of Evidence

Please log in to get access to this content

Other articles of this Issue 3/2013

Prophylactic Stabilization for Bone Metastases, Myeloma, or Lymphoma: Do We Need to Protect the Entire Bone?

Surgical Technique: Iliosacral Reconstruction With Minimal Spinal Instrumentation

Surgery Quality and Tumor Status Impact on Survival and Local Control of Resectable Liposarcomas of Extremities or the Trunk Wall

Locking Buttons Increase Fatigue Life of Locking Plates in a Segmental Bone Defect Model

The Classic: Case of Osteo-Sarcoma of Tibia, Recurring in Stump of Thigh, and Probably Affecting the Lung

Reply to Letter to the Editor: Combined Anterior-Posterior Surgery is the Most Important Risk Factor for Developing Proximal Junctional Kyphosis in Idiopathic Scoliosis