Radiol med DOI 10.1007/s11547-014-0396-x

DIAGNOSTIC IMAGING IN ONCOLOGY

In-depth analysis of local recurrence of giant cell tumour of bone with soft tissue extension after intralesional curettage Liang Chen • Xiao-Yi Ding • Chengs-Sheng Wang Ming-Jue Si • Lian-Jun Du • Wei-Bin Zhang • Yong Lu



Received: 23 January 2013 / Accepted: 22 November 2013 Ó Italian Society of Medical Radiology 2014

Abstract Purpose The aim of this study was to assess the local recurrence rate of giant cell tumour of bone (GCTB) with soft tissue extension, to identify characteristics of the soft tissue extension that can best indicate recurrence of GCTB after intralesional curettage. Materials and methods A total of 48 cases of GCTB with soft tissue extension after intralesional curettage were recruited. Patients were divided into two groups based on various objective features of soft tissue extension including

L. Chen  X.-Y. Ding (&)  C.-S. Wang  M.-J. Si  L.-J. Du  Y. Lu Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin 2nd Road, Shanghai 200025, China e-mail: [email protected] L. Chen e-mail: [email protected] C.-S. Wang e-mail: [email protected] M.-J. Si e-mail: [email protected]

size, number, margins, involvement of adjacent tissues, signal intensity, static enhancement and Jaffe grade. The local recurrence rate was compared using the Chi-square test and Chi-square value correction for continuity. Risk factors were assessed by multivariate logistic regression analysis. Results The local recurrence rate was significantly different according to soft tissue extension size, number and margins (p \ 0.05). There was no significant difference in the groups of adjacent tissue involvement and Jaffe grade (p [ 0.05). Size, number and margins of the soft tissue extension were independent risk factors of local recurrence of GCTB after intralesional curettage (p \ 0.05). Conclusions The local recurrence rate of GCTB with soft tissue extension after intralesional curettage is higher if the soft tissue extension is large, multiple and lacking bone envelope integrity. For cases with the above-mentioned features, we suggest that the higher recurrence rate can be taken into full consideration when choosing appropriate surgical procedures. Keywords Giant cell tumour  Curettage  Recurrence  Magnetic resonance

L.-J. Du e-mail: [email protected] Y. Lu e-mail: [email protected] L. Chen Department of Radiology, Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, No. 110, Ganhe Road, Shanghai 200437, China W.-B. Zhang Department of Orthopedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin 2nd Road, Shanghai 200025, China

Introduction Giant tumour of bone (GCTB) is a benign bone lesion most often found in the extremities of bones [1, 2]. Tumours arise in the meta-epiphyseal region of long bones, predominantly in the distal femur and the proximal tibia, but they can occur in the entire skeleton [2]. Histologically, these tumours are classified as a benign neoplastic lesion consisting of three cell types: mononuclear histiocytic cells, multinucleated giant cells that resemble osteoclasts,

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and neoplastic stromal cells [3]. The biological behaviour of GCTB ranges from latent, active to locally aggressive forms and occasionally distant metastasis [1, 2, 4]. Surgery is the mainstay of treatment for GCTB. En bloc resection has been recommended for aggressive tumours [2]. Although complete removal of the lesion provides a low recurrence rate, wide resection requires complex reconstruction of the adjacent joints, which increases the rate of surgical complications and disabilities [4, 5]. Intralesional curettage with adjuvants is a feasible first-choice treatment option for GCTB, with good oncological outcome and joint preservation [2–5]. Nevertheless, the recurrence rate remains relatively high [4, 6, 7]. Risk factors for local recurrence of GCTB after intralesional curettage have been previously studied in depth [1, 8– 11]. Some studies demonstrated that demographic factors (age, gender) and disease-related factors (location, pathological fractures and soft tissue extension) did not influence the risk of recurrence [1, 8]. However, van der Heijden [12] reported that soft tissue extension strongly increased the risk of local recurrence, whereas age, sex, location and pathological fractures did not. The prognostic relevance of soft tissue extension of GCTB remains controversial [8]. Magnetic resonance imaging (MRI) appears to be more sensitive than computed tomography (CT) and radiography in detecting soft tissue extension of GCTB for its excellent soft tissue contrast which allows for easier identification of the tumour and its extent. In addition, MRI can provide visualisation of the number and margins of soft tissue extension and involvement of adjacent tissues, as well as depicting liquefaction and necrosis with the use of intravenous gadolinium injection [8–12]. To our knowledge, all previous studies investigated the soft tissue extension of GCTB as one of risk factors for local recurrence. No research has investigated the relationship between the soft tissue extension of GCTB and recurrence rates after intralesional curettage. In this study, we focused on the soft tissue extension of GCTB, with a view to identifying some characteristics that can serve to indicate the recurrence of GCTB after intralesional curettage.

Patients and methods Database A total of 48 patients (22 women and 26 men; average age, 30 years; range 16–46 years) were consecutively enrolled in this study from January 1998 to June 2011. All patients had histopathological confirmation of GCTB with an MRI report of GCTB with soft tissue extension. All cases were referred from the Ruijin Hospital, Shanghai Jiao Tong University School of Medicine. All patients underwent

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Table 1 Location of giant cell tumour of bone (GCTB) with soft tissue extension in 48 patients

Location

No. of patients

Distal femur

15

Proximal femur

3

Femoral shaft

1

Distal tibia Proximal tibia

4 14

Proximal humerus

3

Distal radius

4

Sacrum

4

Total

48

intralesional curettage with PMMA (polymethylmethacrylate), which is the preferred standard treatment for GCTB in our hospital, and were all followed up for over 2 years. Recurrence occurred in 16 (33.33 %) of the 48 cases. The time to recurrence varied from 6 to 32 months (mean 13 months). A summary of lesion location in the 48 patients is given in Table 1. All patients underwent conventional and contrast-enhanced MRI. The MR examinations were carried out after the patients had been fully informed about the procedure and had given their consent. Informed consent was also obtained from all patients for the use of all clinical and imaging data for this study. MR protocols All MR examinations were performed using a 1.5-T superconducting whole-body imager (Signa, General Electric Medical System) with dedicated extremity coils or body phased-array coils. All measurements were performed on a postprocessing workstation (GE Healthcare). The following sequences were obtained: spin-echo T1weighted (TR range/TE range, 450-600/15-20), fast spinecho T2-weighted (TR range/TE range, 3500-4000/80120), fat-suppressed fast spin-echo T2-weighted (TR range/TE range 3,500–4,000/80–120). Contrast-enhanced spin-echo T1-weighted images with or without fat-selective presaturation were obtained using a mechanical power injector after the start of a rapid IV injection at 3 mL/s of gadopentetate dimeglumine (Magnevist Schering), 0.1 mmol/kg of body weight. The field of view varied from 14 to 18 cm. Slice thickness was 5 mm and interslice gap was 0.5 mm. The imaging matrix ranged from 192 9 256 to 256 9 256. The number of acquisitions was 2. Objective features The following characteristics were evaluated in consensus by two observers and the results are given in Table 2.

Radiol med Table 2 MRI findings in 48 patients of GCTB with soft tissue extension Finding

No. of patients

z were the three radii. Each case was calculated three times and the mean value was adopted. When the volume of soft tissue extension exceeded 50 % of the volume of whole tumour, we defined the soft tissue extension as being large.

Size Large

10

Small

38

Number Multiple Single Adjacent tissue involvement Yes No

9 39 34 14

Margins With bone envelope integrity

32

Without bone envelope integrity

16

T1: intermediate/low, heterogeneous T2: high, homogeneous T2: intermediate/high, heterogeneous

When the number of soft tissue extensions was greater than or equal to two, and the extended soft tissues were isolated in consecutive images, we defined the finding as multiple soft tissue extensions. When there was only one soft tissue extension, we defined it as a single soft tissue extension. When the extended soft tissue was expressed as a mass with several lobules, we also defined it as a single soft tissue extension. Adjacent tissue involvement

Signal intensity characteristics T1: low, homogeneous

Number

4 44 4 44

Static enhancement Homogeneous enhancement

4

Heterogeneous enhancement

44

The absence or presence of adjacent soft tissue involvement (such as muscle, ligament, capsula articularis), defined as abnormal signal intensity areas and foci (low on T1-weighted images and high on T2-weighted images with fat suppression) was determined. Soft tissue extension margins

Jaffe grade Grade I Grade II

1 38

Grade III

9

Soft tissue extension

Cortical breach around the soft tissue extension was established when outer cortical integrity was disturbed by the presence of abnormal signal intensity. If continuity of the band of low signal intensity on MR images attributed to marginal scleroses was completely broken off, we defined the bone envelope around the extended soft tissue as not having integrity.

Soft tissue extension was defined as a complete breakthrough of the cortex and additional extension into adjacent soft tissue [12].

Signal intensity characteristics

Size of tumour and soft tissue extension

Signal intensities of soft tissue extension relative to muscle on spin-echo T1-weighted and T2-weighted images (higher, equal, or lower) were determined.

The size of GCTB and soft tissue extension was measured directly on the contrast-enhanced MR images which best depicted them. The diameters of both the tumour and the soft tissue extension were recorded in three axes: anterioposterior, transverse, and craniocaudal. The craniocaudal dimension was measured by counting the number of slices that showed tumour and soft tissue extension multiplied by the slice thickness. To ensure consistency, all measurements were performed by one person. The measurements were then reviewed independently by a second person. Any discrepancies were resolved by consensus. The three measurements from each tumour and soft tissue extension were averaged. The volume of each tumour and soft tissue extension was calculated using the standard equation for the volume of an ellipsoid: V = (4p/3)xyz, in which x, y,

Static enhancement The pattern of soft tissue extension enhancement on T1weighted gadopentetate dimeglumine-enhanced images (homogeneous or heterogeneous) was recorded. Jaffe grade GCTB was originally described by Jaffe et al. [13], who classified the tumour into three categories: grade I (benign) without appreciable atypia of stromal cells, few mitoses, none abnormal; grade II (intermediate) with stromal cells showing only slight or more marked atypia, but not enough to justify a diagnosis of malignancy; and grade III

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(malignant) with obvious features of malignancy. The Jaffe grade results were obtained from the reports of our hospital’s pathology department.

Thirty-nine cases had single soft tissue extension and 10 cases developed recurrence (recurrence rate 25.64 %). v2 = 3.85, p \ 0.05.

Observer study

Adjacent tissue involvement

All MR images were graded in consensus by two radiologists with 10 years experience in musculoskeletal MR imaging. The readers were blinded to the results regarding recurrence at the time of consensus review. The findings were described only when both observers could definitively establish a diagnosis on the basis of the images. On completion of the retrospective review, the MR images were correlated with surgery results.

Involvement of adjacent tissues was observed in 34 cases (Fig. 2b) and 11 cases had recurrence (recurrence rate 32.35 %). Among the 14 cases without adjacent tissue involvement, 5 developed recurrence (recurrence rate 35.71 %). v2 = 0.32, p [ 0.05.

Data analysis Analysis of the local recurrence rate of GCTB with soft tissue extension considered seven aspects including soft tissue extension size, number, margins, adjacent tissue involvement, signal intensity characteristics, static enhancement and Jaffe grade. The difference in local recurrence rates was compared by Chi-square test and Chi-square value correction for continuity. Risk factors were analysed by multivariate logistic regression analysis. The interobserver agreement was evaluated using the interclass correlation coefficients computed from the independent evaluation results. Analysis was performed by SPSS version 13.0 (SPSS, Chicago, IL, USA), and p values of less than 0.05 were considered to indicate a statistically significant difference.

Soft tissue extension margins Thirty-two cases showed bone envelope integrity and seven of them had recurrence (recurrence rate 21.88 %). Among 16 cases lacking bone envelope integrity (Fig. 4), 9 developed recurrence (recurrence rate 56.25 %). v2 = 5.67, p \ 0.05. Signal intensity characteristics Four cases showed homogeneous low signal intensity on T1-weighted images (Fig. 1a) and homogeneous high signal intensity on T2-weighed images (Fig. 1b). Only one case had recurrence (recurrence rate 25 %). Forty-four cases showed heterogeneous signal intensity on T1weighted images (Fig. 4c) and T2-weighted images (Fig. 4b). Fifteen cases developed recurrence (recurrence rate 34.09 %). Static enhancement

Results The reviewers successfully evaluated the images from all patients. Interobserver agreement was good (interclass correlation, 0.88 for size; 0.93 for number; 0.89 for margins; 0.95 for adjacent tissue involvement; 0.96 for signal intensity characteristics of conventional MR images and static enhancement MR images). Tumour and soft tissue extension size Among all the 48 cases, 10 had large soft tissue extension (Fig. 1), of which 7 cases developed recurrence (recurrence rate 70 %). The remaining 38 cases had small soft tissue extension and 9 of them had recurrence (recurrence rate 23.68 %). v2 = 5.70, p \ 0.05. Number Nine cases had multiple soft tissue extensions (Figs. 2, 3) and six cases had recurrence (recurrence rate 66.67 %).

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Intense enhancement was seen in all cases. Four cases showed homogeneous enhancement (Figs. 1c, 3a, b) and only one case had recurrence (recurrence rate 25 %). Fortyfour cases showed heterogeneous enhancement (Fig. 2c, d) and 15 cases had recurrence (recurrence rate 34.09 %). Jaffe grade One case was grade I and did not have recurrence. Thirtyeight cases were grade II (Figs. 1f, 3e, 4f) and 13 cases had recurrence (recurrence rate 34.21 %). Nine cases were Jaffe grade III (Fig. 2f) and three cases had recurrence (recurrence rate 33.33 %). Tests were run between the groups of Jaffe’s grade II and III. v2 = 0.13, p [ 0.05. The results are given in Table 3. A significant difference was found in the groups of soft tissue size, number, and margins (p values were all below 0.05). The local recurrence rate was higher when the soft tissue extension was large, multiple and lacking bone envelope integrity. There was no significant difference in the groups of adjacent

Radiol med

Fig. 1 25-year-old woman of giant cell tumour of bone (GCTB) with large soft tissue extension at the distal tibia. a, b Sagittal spin-echo T1-weighted image and T2-weighted image show GCTB with a large soft tissue extension. Volume of the soft tissue extension was about 140.55 cm3. Volume of the whole tumour was about 241.82 cm3. The ratio was 58.12 %. The soft tissue extension shows homogeneous low signal intensity on T1-weighted image and homogeneous high signal intensity on T2-weighted image. c Sagittal contrast-enhanced T1weighted image with fat suppression shows homogeneous

enhancement of the soft tissue extension. d Axial contrast-enhanced T1-weighted image with fat suppression shows the large soft tissue extension with homogeneous enhancement. e Axial T2-weighted image with fat suppression shows recurrent tumour after intralesional curettage. Time to recurrence was about 8 months. f Photomicrograph of the soft tissue extension which consists of a number of osteoclasttype giant cell and mononuclear stromal cells (Haematoxylin and Eosin 9250). Jaffe grade II

tissue involvement and Jaffe grade (p values were all above 0.05). We did not analyse the difference between the groups of signal intensity characteristics and static enhancement as the number of cases showing homogeneous signal intensity and homogeneous enhancement was too small. The results of multivariate logistic regression analysis are shown in Table 4. Size, number, and margins of the soft tissue extension were regarded as independent risk factors of GCTB with soft tissue extension after intralesional curettage (p \ 0.05). The involvement of adjacent tissues was not an independent risk factor of GCTB with soft tissue extension after intralesional curettage (p [ 0.05).

soft tissue extension of GCTB. When GCTB had large soft tissue extension, multiple soft tissue extensions and lacked integrity of the bone envelope around the extended soft tissue, the local recurrence rate after intralesional curettage was higher. There was no statistically significant difference in the groups of adjacent tissue involvement and Jaffe grade. Giant cell tumour of bone is a benign bone lesion most often found in the extremities of bones [1, 2]. Tumours arise in the meta-epiphyseal region of long bones, predominantly in the distal femur and the proximal tibia, but they can occur in the entire skeleton [2]. The biological behaviour of GCTB ranges from latent, active to locally aggressive forms and occasionally distant metastasis [1, 2, 4]. Surgery is the mainstay of treatment for GCTB. Although en bloc resection provides a low recurrence rate, wide resection requires complex reconstruction of the adjacent joints, which increases the rate of surgical complications and disabilities [4, 5]. Intralesional curettage

Discussion Our study showed that there were statistically significant differences in the group of size, number, and margins of

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Fig. 2 20-year-old man with GCTB with two soft tissue extensions at the sacrum. a Coronal T1-weighted image shows the soft tissue has low/intermediate signal intensity on T1-weighted image. b Coronal T2-weighted image with fat suppression shows intermediate/high signal intensity on T2-weighted image. The image also shows high signal intensity of adjacent tissues around the soft tissue extension. c Axial contrast-enhanced T1-weighted image with fat suppression shows heterogeneous enhancement of the soft tissue extension.

d Sagittal contrast-enhanced T1-weighted image with fat suppression shows the two soft tissue extensions. One is in the front of the sacrum, another is behind the sacrum. e Axial T2-weighted image shows recurrent tumour after intralesional curettage. Time to recurrence was about 6 months. f Photomicrograph of the soft tissue extension shows spindle-shaped cells with slightly atypical nuclei (Haematoxylin and Eosin 9250). Jaffe grade III

with adjuvants is a feasible first-choice treatment option for GCTB, with good oncological outcome and joint preservation [2–5]. Nevertheless, the recurrence rate is relatively high [4, 6, 7]. Risk factors for local recurrence of GCTB after intralesional curettage have been previously studied in depth [1, 8–11]. Some studies demonstrated that demographic factors (age, gender) and disease-related factors (location, pathological fractures and soft tissue extension) did not influence the risk of recurrence [1, 8]. However, van der Heijden [12] reported that soft tissue extension strongly increased the risk of local recurrence, whereas age, sex, location and pathological fractures did not. The prognostic relevance of soft tissue extension of GCTB remains controversial. In this study, we focused on soft tissue extension, to assess the relationship between soft tissue extension of GCTB and the recurrence rate after intralesional curettage. There were significant differences among the groups of size, number, and margins of soft tissue extension. The

recurrence rate of GCTB with large soft tissue extension, multiple soft tissue extensions, and lack of bone envelope integrity was higher. The reason might be that for GCTB with large or multiple soft tissue extension and lack of bone envelope integrity, intralesional curettage proves to be technically more difficult, and is less likely to completely remove the whole tumour. The remaining tumour tissue is an important reason for recurrence. No significant difference was found in the group of adjacent tissue involvement. GCTB is more often found at the extremity of long bone [14]. If GCTB has soft tissue extension, the adjacent tissues are always compressed due to limitation of local space. The compression causes signal changes on the MR images. MR signal changes of 14 cases with adjacent tissue involvement disappeared during the clinical follow-up after intralesional curettage. Therefore, compression of adjacent tissues might be one of reasons for the changes of the MR signal. Other reasons for MR signal changes in adjacent tissues require further study.

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Fig. 3 35-year-old woman with GCTB with two small soft tissue extensions at the femoral shaft. The case did not develop recurrence. a, b Axial contrast-enhanced T1-weighted images show two small soft tissue extensions with homogeneous enhancement (arrow). c,

d Sagittal T2-weighted images image show the two small soft tissue extensions (arrow). e Photomicrograph of the soft tissue extension of GCTB shows a number of osteoclast-type giant cells and mononuclear stromal cells (Haematoxylin and Eosin 9250). Jaffe grade II

MR signal intensities of the GCTB and soft tissue extension are consistently equal to those of skeletal muscle or between those of muscle and fat on T1weighted images. On T2-weighted images, the signal intensities tend to be between those of muscle and fat. Most lesions are inhomogeneous due to bleeding, liquefaction and necrosis especially in large soft tissue extension. On contrast-enhanced MR images, most lesions showed heterogeneous enhancement [15]. In our study, 4 cases showed homogeneous low signal intensity and 44 cases showed heterogeneous intermediate/low signal intensity on T1-weighted images. Four cases showed homogeneous high signal intensity and 44 cases showed heterogeneous intermediate/high signal intensity on T2-weighted images. On contrast-enhanced MR images, 4 cases showed homogeneous enhancement and 44

cases showed heterogeneous enhancement. All these findings are consistent with the results reported by Kitagawa [15]. We could not make a definite classification according to the internal MR signal features on conventional and contrast-enhanced MR images of the soft tissue extension. Further study is necessary with a larger series of cases. There was no significant difference in the groups of Jaffe grade of GCTB. Some cases were Jaffe grade II, but they may have large soft tissue extension, multiple soft tissue extensions and other aggressive characteristic features on MR images. Some cases were Jaffe grade III class but they did not have the above-mentioned features. Jaffe’s grading system proved to be difficult to apply in practice and was unable to predict the clinical behaviour and prognosis of GCTB [16].

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Fig. 4 38-year-old man with GCTB with soft tissue extension at the proximal femur. a–c Axial spin-echo T2-weighted image with fat suppression, T2-weighted image, and T1-weighted image show cortical breach around the soft tissue extension (arrow). The soft tissue extension shows low/intermediate signal intensity on T1weighted images and high/intermediate signal intensity on T2-

weighted images. d, e Coronal T2-weighted image with fat suppression and T1-weighted image show recurrent tumour after intralesional curettage. Time to recurrence was about 7 months. f Photomicrograph of the soft tissue extension shows a number of osteoclast-type giant cells and mononuclear stromal cells (Haematoxylin and Eosin 9250). Jaffe grade II

Intralesional curettage is the least invasive surgical option and usually provides the possibility to save the joint adjacent to the tumour [17]. Intralesional curettage may be combined with the use of local adjuncts, such as PMMA void filling, hydrogen peroxide, phenol, and cryotherapy [9, 17, 18] with the intention to further reduce the risk of local recurrence. More patients prefer intralesional curettage, in particular young patients, because of the good function preservation and lower rates of surgical complications. In our study, among 10 cases of intralesional curettage with large soft tissue extension, 7 developed recurrence, with a mean age of 28.46 ? 10.32 years. We speculated that if all GCTB patients with soft tissue extension received intralesional curettage, the recurrence rate would be higher.

Based on these findings, we can conclude that GCTB with large soft tissue extension, multiple soft tissue extensions and lacking bone envelope integrity have an increased risk of local recurrence after intralesional curettage. Several limitations of this study should be mentioned. First, only a small number of patients were evaluated, which limited the power of the statistical results. More patients and multi-institutional studies are necessary for a confirmation of the results with additional statistical power. Second, we found that several objective features may appear in one case, such as GCTB with large soft tissue extension, MR images of adjacent tissue involvement and a lack of bone envelope integrity. We did not analyse the interrelation of objective features because of the small

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Radiol med Table 3 Comparison of recurrence rate in each group Objective features

No. of pts with recurrence

No. of pts without recurrence

Total

v2

p value

5.70

\0.05

Large soft tissue extension

7

3

10

Small soft tissue extension

9

29

38

Total

16

32

48

With adjacent tissue involvement

11

23

34

5

9

14

16

32

48

6

3

9

Single soft tissue extension

10

29

39

Total

16

32

48

Without adjacent tissue involvement Total Multiple soft tissue extensions

Without bone envelope integrity

9

7

16

With bone envelope integrity Total

7 16

25 32

32 48

Jaffe grade II

13

25

38

3

6

9

16

31

47

Jaffe’s grade III Total

0.32

[0.05

3.85

\0.05

5.67

\0.05

0.13

[0.05

Table 4 Multivariate logistic regression analysis results of GCTB with soft tissue extension Recurrence rate

B

Standard error

Wald

df

Sig.

Exp (B)

95 % confidence interval for exp (B) Lower bound

Upper bound

[Size]

2.434

1.026

5.629

1

0.018*

11.402

1.527

85.143

[Number]

2.121

1.005

4.460

1

0.035*

8.343

1.165

59.759

1.744

0.823

4.491

1

0.034*

5.719

1.140

28.697

-0.864

0.938

0.848

1

0.357

0.421

0.067

2.652

[Margin] [Adjacent]

[Size], [Number], [Margin] represent the size, number and margin of the soft tissue extension, respectively. [Adjacent] represents the adjacent soft tissue involvement around the soft tissue extension * Significant statistical difference (p \ 0.05)

number of cases. Third, the definition and concept of ‘‘large soft tissue extension’’, which played an important role in analysing recurrence rates, might be imperfectly illustrated here. We shall continue this study with further cases. Fourth, we did not sufficiently investigate the relationship between histopathological changes and characters on MR images of GCTB with soft tissue extension, especially as regards changes of adjacent soft tissue involvement in explaining the MR signal changes. Fifth, although we found that the local recurrence rate was higher if GCTB had large soft tissue extension, multiple soft tissue extensions and a lack of bone envelope integrity, we failed to investigate whether there were any other reasons which might affect the recurrence rate following intralesional curettage. All of these will be the focus of our future research. However, this is the first study focusing on soft tissue extension of GCTB. This study could provide new clues to identify the characteristics of the soft tissue extension that

might best predict recurrence of GCTB after intralesional curettage.

Conclusions In summary, the recurrence rate of GCTB with soft tissue extension is higher when the extended soft tissue is large, multiple and lacking bone envelope integrity after intralesional curettage. For cases with the above features, we strongly suggest that a high recurrence rate should be taken into full consideration when choosing the appropriate surgical procedures. Acknowledgments This study was supported by the National Natural Science Foundation of China (Project Number: 81072188). Conflict of interest Liang Chen, Xiao-Yi Ding, Chengs-Sheng Wang, Ming-Jue Si, Lian-Jun Du, Wei-Bin Zhang, Yong Lu declare no conflict of interest.

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In-depth analysis of local recurrence of giant cell tumour of bone with soft tissue extension after intralesional curettage.

The aim of this study was to assess the local recurrence rate of giant cell tumour of bone (GCTB) with soft tissue extension, to identify characterist...
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