Journal of Orthopaedic Surgery 2014;22(1):108-10
Risk factors for recurrence of giant cell tumours of bone Mashfiqul A Siddiqui, Chusheng Seng, Mann Hong Tan
Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
ABSTRACT Purpose. To determine the risk factors for recurrence of giant cell tumours (GCTs) of bone. Methods. Medical records of 29 men and 29 women (mean age, 34 years) treated for primary (n=53) or recurrent (n=5) GCTs of bone and followed up for a mean of 40.2 months were reviewed. The tumours were located in the distal femur (n=18), proximal tibia (n=10), proximal femur (n=8), distal radius (n=7), proximal fibula (n=4), distal ulna (n=3), calcaneum (n=3), sacrum (n=2), vertebra (n=1), metatarsal (n=1), and distal humerus (n=1). 26 patients had pathological fractures, 12 had cortical break, and 20 had neither. The Campanacci grades of the tumours were I (n=1), II (n=18), and III (n=33); the grades of the remaining 6 tumours were unknown because radiographs were unavailable. The Enneking stages of the tumours were 1 (n=51), 2 (n=6), and 3 (n=1). Treatment included curettage and cementation (n=29), curettage, cementation, and adjuvant treatment with distilled water or liquid
nitrogen for bones without fracture (n=18), wide resection for extensive soft tissue involvement (n=9), and amputation (n=2) for a recurrent GCT of the distal femur and a primary GCT of the calcaneus. Reconstruction included cementation (n=27), bone grafting (n=7), cementation/bone grafting with internal fixation (n=14), reconstruction with endoprosthesis (n=3), and none (n=7). Results. 19 patients had recurrence after a mean of 23.1 months. The overall recurrence-free survival at years 1, 2, and 3 were 86%, 79%, and 72%, respectively. Recurrence did not correlate with patient age (p=0.20), primary or recurrent tumour at presentation (p=0.12), Campanacci grade (p=0.10), Enneking stage (p=0.54), or presence of pathological fracture (p=0.28). Compared to GCTs at other locations, GCTs in the proximal tibia were more likely to recur (27% vs. 60%, p=0.04). Conclusion. GCTs of the proximal tibia are more likely to recur than those at other locations. Key words: giant cell tumor of bone; neoplasm recurrence, local
Address correspondence and reprint requests to: Chusheng Seng, Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road, Singapore 169608. Email: [email protected]
Vol. 22 No. 1, April 2014
Risk factors for recurrence of giant cell tumours of bone 109
INTRODUCTION Giant cell tumour (GCT) of bone is common in East and South-East Asia.1–4 Treatment has evolved from amputation to wide resection and to curettage followed by cementation with polymethyl methacrylate with or without adjuvants.1,5–8 This study aimed to determine the risk factors for recurrence of GCT of bone. MATERIALS AND METHODS Medical records of 29 men and 29 women (mean age, 34 years; standard deviation [SD], 12 years) treated for primary (n=53) or recurrent (n=5) GCTs of bone between 1990 and early 2008 and followed up for a mean of 40.2 (SD, 40) months were reviewed. One patient died of causes unrelated to the disease 30.2 months after initial surgery. The tumours were located in the distal femur (n=18), proximal tibia (n=10), proximal femur (n=8), distal radius (n=7), proximal fibula (n=4), distal ulna (n=3), calcaneum (n=3), sacrum (n=2), vertebra (n=1), metatarsal (n=1), and distal humerus (n=1). 26 patients had pathological fractures (detected by radiographs), 12 had cortical break (detected by magnetic resonance imaging or intra-operatively), and 20 had neither. The Campanacci grades9 of the tumours were 1 (n=1), II (n=18), and III (n=33); the grades of the remaining 6 were unknown because radiographs were unavailable. The Enneking stages10 of the tumours were 1 (n=51), 2 (active) [n=6], and 3 (aggressive) [n=1].
Treatment included curettage and cementation (n=29), curettage, cementation, and adjuvant treatment with distilled water or liquid nitrogen for bones without fracture (n=18), wide resection for extensive soft tissue involvement (n=9), and amputation (n=2) for a recurrent GCT of the distal femur and a primary GCT of the calcaneus. Reconstruction included cementation (n=27), bone grafting (n=7), cementation/bone grafting with internal fixation (n=14), reconstruction with endoprosthesis (n=3), and none (n=7). Chi-square test was used to analyse recurrence in terms of primary/recurrent tumours, Campanacci grade, Enneking stage, presence of a pathological fracture, tumour locations, and treatment type. GCTs of the proximal tibia were compared with GCTs at other locations to determine if there was any confounder that may be responsible for the higher recurrence in GCTs of the proximal tibia. A p value of 20 years after initial surgery have been reported.12,13 Thus, long-term follow-up is necessary. Patients should be informed that GCTs can transform to malignancy, as in 3 of our patients. One limitation of this study was the small sample size and small number of proximal tibia tumours. CONCLUSION GCTs of the proximal tibia are more likely to recur than those at other locations. DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Ward WG Sr, Li G 3rd. Customized treatment algorithm for giant cell tumor of bone: report of a series. Clin Orthop Relat Res 2002;397:259–70. 2. Yip KM, Leung PC, Kumta SM. Giant cell tumor of bone. Clin Orthop Relat Res 1996;323:60–4. 3. Lim YW, Tan MH. Treatment of benign giant cell tumours of bone in Singapore. Ann Acad Med Singapore 2005;34:235–7. 4. Sung HW, Kuo DP, Shu WP, Chai YB, Liu CC, Li SM. Giant-cell tumor of bone: analysis of two hundred and eight cases in Chinese patients. J Bone Joint Surg Am 1982;64:755–61. 5. Balke M, Schremper L, Gebert C, Ahrens H, Streitbuerger A, Koehler G, et al. Giant cell tumor of bone: treatment and outcome of 214 cases. J Cancer Res Clin Oncol 2008;134:969–78. 6. Kivioja AH, Blomqvist C, Hietaniemi K, Trovik C, Walloe A, Bauer HC, et al. 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. 7. 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;81:811–20. 8. Eger W, Schörle C, Zeiler G. Giant cell tumor of the distal fibula: fifteen-year result after en bloc resection and fibula reconstruction. Arch Orthop Trauma Surg 2004;124:56–9. 9. Campanacci M, Baldini N, Boriani S, Sudanese A. J Bone Joint Surg Am 1987;69:106–14. 10. Enneking WF. Staging tumors. In: musculoskeletal tumor surgery. New York: Churchill Livingstone; 1983:87–8. 11. Arbeitsgemeinschaft Knochentumoren, Becker WT, Dohle J, Bernd L, Braun A, Cserhati M, et al. Local recurrence of giant cell tumor of bone after intralesional treatment with and without adjuvant therapy. J Bone Joint Surg Am 2008;90:1060–7. 12. Mori Y, Tsuchiya H, Karita M, Nonomura A, Nojima T, Tomita K. Malignant transformation of a giant cell tumor at 25 years after initial treatment. Clin Orthop Relat Res 2000;381:185–91. 13. Weinzweig J, Watson HK. Recurrent giant cell tumor over a 23-year period. Ann Plast Surg 1997;39:659–61.
Risk factors for recurrence of giant cell tumours of bone Mashfiqul A Siddiqui, Chusheng Seng, Mann Hong Tan
Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
ABSTRACT Purpose. To determine the risk factors for recurrence of giant cell tumours (GCTs) of bone. Methods. Medical records of 29 men and 29 women (mean age, 34 years) treated for primary (n=53) or recurrent (n=5) GCTs of bone and followed up for a mean of 40.2 months were reviewed. The tumours were located in the distal femur (n=18), proximal tibia (n=10), proximal femur (n=8), distal radius (n=7), proximal fibula (n=4), distal ulna (n=3), calcaneum (n=3), sacrum (n=2), vertebra (n=1), metatarsal (n=1), and distal humerus (n=1). 26 patients had pathological fractures, 12 had cortical break, and 20 had neither. The Campanacci grades of the tumours were I (n=1), II (n=18), and III (n=33); the grades of the remaining 6 tumours were unknown because radiographs were unavailable. The Enneking stages of the tumours were 1 (n=51), 2 (n=6), and 3 (n=1). Treatment included curettage and cementation (n=29), curettage, cementation, and adjuvant treatment with distilled water or liquid
nitrogen for bones without fracture (n=18), wide resection for extensive soft tissue involvement (n=9), and amputation (n=2) for a recurrent GCT of the distal femur and a primary GCT of the calcaneus. Reconstruction included cementation (n=27), bone grafting (n=7), cementation/bone grafting with internal fixation (n=14), reconstruction with endoprosthesis (n=3), and none (n=7). Results. 19 patients had recurrence after a mean of 23.1 months. The overall recurrence-free survival at years 1, 2, and 3 were 86%, 79%, and 72%, respectively. Recurrence did not correlate with patient age (p=0.20), primary or recurrent tumour at presentation (p=0.12), Campanacci grade (p=0.10), Enneking stage (p=0.54), or presence of pathological fracture (p=0.28). Compared to GCTs at other locations, GCTs in the proximal tibia were more likely to recur (27% vs. 60%, p=0.04). Conclusion. GCTs of the proximal tibia are more likely to recur than those at other locations. Key words: giant cell tumor of bone; neoplasm recurrence, local
Address correspondence and reprint requests to: Chusheng Seng, Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road, Singapore 169608. Email: [email protected]
Vol. 22 No. 1, April 2014
Risk factors for recurrence of giant cell tumours of bone 109
INTRODUCTION Giant cell tumour (GCT) of bone is common in East and South-East Asia.1–4 Treatment has evolved from amputation to wide resection and to curettage followed by cementation with polymethyl methacrylate with or without adjuvants.1,5–8 This study aimed to determine the risk factors for recurrence of GCT of bone. MATERIALS AND METHODS Medical records of 29 men and 29 women (mean age, 34 years; standard deviation [SD], 12 years) treated for primary (n=53) or recurrent (n=5) GCTs of bone between 1990 and early 2008 and followed up for a mean of 40.2 (SD, 40) months were reviewed. One patient died of causes unrelated to the disease 30.2 months after initial surgery. The tumours were located in the distal femur (n=18), proximal tibia (n=10), proximal femur (n=8), distal radius (n=7), proximal fibula (n=4), distal ulna (n=3), calcaneum (n=3), sacrum (n=2), vertebra (n=1), metatarsal (n=1), and distal humerus (n=1). 26 patients had pathological fractures (detected by radiographs), 12 had cortical break (detected by magnetic resonance imaging or intra-operatively), and 20 had neither. The Campanacci grades9 of the tumours were 1 (n=1), II (n=18), and III (n=33); the grades of the remaining 6 were unknown because radiographs were unavailable. The Enneking stages10 of the tumours were 1 (n=51), 2 (active) [n=6], and 3 (aggressive) [n=1].
Treatment included curettage and cementation (n=29), curettage, cementation, and adjuvant treatment with distilled water or liquid nitrogen for bones without fracture (n=18), wide resection for extensive soft tissue involvement (n=9), and amputation (n=2) for a recurrent GCT of the distal femur and a primary GCT of the calcaneus. Reconstruction included cementation (n=27), bone grafting (n=7), cementation/bone grafting with internal fixation (n=14), reconstruction with endoprosthesis (n=3), and none (n=7). Chi-square test was used to analyse recurrence in terms of primary/recurrent tumours, Campanacci grade, Enneking stage, presence of a pathological fracture, tumour locations, and treatment type. GCTs of the proximal tibia were compared with GCTs at other locations to determine if there was any confounder that may be responsible for the higher recurrence in GCTs of the proximal tibia. A p value of 20 years after initial surgery have been reported.12,13 Thus, long-term follow-up is necessary. Patients should be informed that GCTs can transform to malignancy, as in 3 of our patients. One limitation of this study was the small sample size and small number of proximal tibia tumours. CONCLUSION GCTs of the proximal tibia are more likely to recur than those at other locations. DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Ward WG Sr, Li G 3rd. Customized treatment algorithm for giant cell tumor of bone: report of a series. Clin Orthop Relat Res 2002;397:259–70. 2. Yip KM, Leung PC, Kumta SM. Giant cell tumor of bone. Clin Orthop Relat Res 1996;323:60–4. 3. Lim YW, Tan MH. Treatment of benign giant cell tumours of bone in Singapore. Ann Acad Med Singapore 2005;34:235–7. 4. Sung HW, Kuo DP, Shu WP, Chai YB, Liu CC, Li SM. Giant-cell tumor of bone: analysis of two hundred and eight cases in Chinese patients. J Bone Joint Surg Am 1982;64:755–61. 5. Balke M, Schremper L, Gebert C, Ahrens H, Streitbuerger A, Koehler G, et al. Giant cell tumor of bone: treatment and outcome of 214 cases. J Cancer Res Clin Oncol 2008;134:969–78. 6. Kivioja AH, Blomqvist C, Hietaniemi K, Trovik C, Walloe A, Bauer HC, et al. 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. 7. 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;81:811–20. 8. Eger W, Schörle C, Zeiler G. Giant cell tumor of the distal fibula: fifteen-year result after en bloc resection and fibula reconstruction. Arch Orthop Trauma Surg 2004;124:56–9. 9. Campanacci M, Baldini N, Boriani S, Sudanese A. J Bone Joint Surg Am 1987;69:106–14. 10. Enneking WF. Staging tumors. In: musculoskeletal tumor surgery. New York: Churchill Livingstone; 1983:87–8. 11. Arbeitsgemeinschaft Knochentumoren, Becker WT, Dohle J, Bernd L, Braun A, Cserhati M, et al. Local recurrence of giant cell tumor of bone after intralesional treatment with and without adjuvant therapy. J Bone Joint Surg Am 2008;90:1060–7. 12. Mori Y, Tsuchiya H, Karita M, Nonomura A, Nojima T, Tomita K. Malignant transformation of a giant cell tumor at 25 years after initial treatment. Clin Orthop Relat Res 2000;381:185–91. 13. Weinzweig J, Watson HK. Recurrent giant cell tumor over a 23-year period. Ann Plast Surg 1997;39:659–61.
