giantcell tumour
DESCRIPTION
Giant cell, cementing, recurrence, reconstruction, en-block excision, literatureTRANSCRIPT
Giant cell tumoursCurrent Concepts in surgical management
Vinod Naneria, G. Yeotikar, A. WadhwaniChoithram Hospital & Research Centre,
Indore, India
Three basic principle
• Removal of tumor.• Supportive therapy.• Reconstruction.
Complete removal of tumor mass
• Intra-lesional Curettage• En-block Excision• Radiation for inaccessible sites (spine)
Adjuvant Therapy
• Pulse Lavage• H2O2• Phenol• Alcohol• Liquid nitrogen• Electric cauterization• Laser
Reconstruction/Restoration
• Bone grafts• Allografts• Cementing• Cementing with metal supports.
҉9 Not MRI computable – Followup MRI for early detection - difficult
• A combination of bone graft + cement.҉9 Sandwich technique.
The Crux of Tx• Curettage + Curettage + Curettage.• Wide Window.• Dental Burr.• Electric Cauterization.• Adjuvant therapy – H2O2 / phenol / Liquid
Nitrogen /Argon beam Laser / Alcohol.• Cementing / Bone grafting.• Radiation for inaccessible sites.• Bisphosphonates.
Why Cement?
• It is simple. • there is no need for bone grafting. • Immediate fixation and stabilization is
obtained. • joint function is preserved. • local control is better by thermal & cyto-toxic
effect of cement.• local recurrence is easily to detect.
Intralesional surgery should be the first choice in most giant cell tumors, even in the presence of a pathological fracture. After thorough evacuation, the cavity should be filled with cement.
Acta Orthop. 2008 Feb;79(1):86-93.
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. Kivioja AH, Blomqvist C, Hietaniemi K, Trovik C, Walloe A, Bauer HC, Jorgensen PH, Bergh P, Follerås G.
Cement is recommendedActa Orthop. 2008 Feb
Use of polymethylmethacrylate as an adjuvant appears to be the therapy of choice for primary as well as recurrent giant cell tumors of bone.
J Bone Joint Surg Am. 2008 May;90(5):1060-7.
Local recurrence of giant cell tumor of bone after intralesional treatment with and without adjuvant therapy. Arbeitsgemeinschaft Knochentumoren, Becker WT, Dohle J, Bernd L, Braun A, Cserhati M, Enderle A, Hovy L, Matejovsky Z, Szendroi M, Trieb K, Tunn PU.
Cement as Adjuvant TherapyJ Bone Joint Surg Am. 2008 May
Complications - Cement• May form a radiolucent zone at the bone-
cement interface up to 2.5 mm in width.• Osteoarthritis of the knee joint in patient with
an intraarticular fracture at initial presentation.
• A stress fracture of the shaft.J Orthop Sci. 2002;7(2):194-8.
Complications associated with bone cementing for the treatment of giant cell tumors of bone.
Wada T, Kaya M, Nagoya S, Kawaguchi S, Isu K, Yamashita T, Yamawaki S, Ishii S.
Complications associated with bone cementing
A retrospective review 15 GCT treated between 1984 and 1998. Aggressive curettage + large bone window + acrylic cement. Mean follow-up time of 46 months (range, 24-188 months).
All the patients showed a non progressive radiolucent zone up to 2.5mm at the bone-cement interface in the first 6 months after operation.
One patient developed Osteoarthritis of the knee joint after 14 years.
One patient had stress fracture in a large tumour.
Complications associated with bone cementing
In summary:No evidence that the long-term presence of cement close to the knee joint was associated with the development of degenerative osteoarthritis.
Wada T, Kaya M, Nagoya S, Kawaguchi S, Isu K, Yamashita T, Yamawaki S, Ishii S. Department of Orthopaedic Surgery, Sapporo Medical University, South-1, West 16, Sapporo 060-8543, Japan. J Orthop Sci. 2002;7(2):194-8.
Cementing & O.A.Knee Follow up of nine patients at a mean period of
11 years (6 to 16) after curettage and cementing of a giant-cell tumour around the knee showed no evidence that the long-term presence of cement close to the knee joint was associated with the development of degenerative osteoarthritis.
J Bone Joint Surg Br. 2007 Mar;89(3):361-5.
Giant-cell tumour of the knee: the condition of the cartilage after treatment by curettage and cementing.
von Steyern FV, Kristiansson I, Jonsson K, Mannfolk P, Heinegård D, Rydholm A. Department of Orthopaedics, Centre for Medical Imaging and Physiology, Lund University Hospital, Lund, Sweden.
Comparison of the degenerative changes
Comparison of the degenerative changes in weight-bearing joints following cementing or grafting techniques in giant cell tumour patients: medium-term results. - Szalay K, Antal I, Kiss J, Szendroi M. ; Orthopaedic Clinic of Semmelweis University, Budapest, Hungary.
Eighty patients were included in this follow-up study, 44 of
whom underwent curettage followed by bone grafting, and 36 who had curettage followed by cementation. At the 24-month post-operative examination, significantly less degenerative change was found in patients with bone cement than in those with bone grafting.
Int Orthop. 2006 Dec;30(6):505-9. Epub 2006 Sep
Heat above 60 ° produced during polymerization lasted for about 10 min. After heat treatment at 60 ° for 10 min, no cells could have survived. This study has clarified the tumoricidal effect of methyl methacrylate by hyperthermia from the heat caused by polymerization.
Heat Of Polymerization of CementArch Orthop Trauma Surg (1993)
Cementation in the treatment of giant cell tumor of bone S. Komiya and A. Inoue; Department of Orthopaedic Surgery, Kurume University School of Medicine, Kurume, Japan, Arch Orthop Trauma Surg (1993) 112:51-55
Curettage, high-speed burring with added phenol/liquid nitrogen treatment and cementation is a useful and safe method in the treatment of giant cell tumors. The advantages include a low recurrence rate, as well as immediate stabilization allowing early mobilization. Patients who have Campanacci grade I tumors have the highest chance of being disease-free after the first operation.
Ann Acad Med Singapore. 2005 Apr;34(3):235-7. Treatment of benign giant cell tumors of bone in Singapore. Lim YW, Tan MH. Department of Orthopaedic Surgery, Changi General Hospital, Singapore. [email protected]
Intralesional Curettage
A 30yr, female with biopsy proved Giantcell tumour
Post-op X-ray
1997
1998 recurrence at bone graft site
Treatment of local recurrences of giant cell tumour in long bones after curettage and cementing. A
Scandinavian Sarcoma Group study.
We retrospectively studied local recurrence of GCT in long bones following curettage and cementing in 137 patients.
The median follow-up time was 60 months (3 to 166). A total of 19 patients (14%) had at least one local recurrence, the first was
diagnosed at a median of 17 months (3 to 29) after treatment of the primary tumour.
There were 13 patients with a total of 15 local recurrences who were successfully treated by further curettage and cementing.
Two patients with a second local recurrence were consequently treated twice. At the last follow-up, at a median of 53 months (3 to 128) after the most recent operation, all patients were free from disease.
Vult von Steyern F, Bauer HC, Trovik C, Kivioja A, Bergh P, Holmberg Jörgensen P, Follerås G, Rydholm A; Scandinavian Sarcoma Group.
Department of Orthopaedics, Lund University Hospital, SE-221 85 Lund, Sweden.
2006
Functional results 10 yrs. P.O. in 2006
Functional results 10 yrs. P.O. in 2006
Sept.2011
Functional result in Sept. 2011 – 14 yrs. P.O.
2005
Six month Post -op
Curettage +Cementing is not contra indicated in fractures
GCTCuretting + bone graftingRecurrence
A case of Recurrence of GCT
• 30 years old Female.• Pain & swelling lower femur & knee 6 months.• Open biopsy – GCT – June 2010• Curettage + Bone graft + Calcium sulphate.• Recurrence in Oct.2010• Serial x-rays and operative and clinical photos
Recurrence Feb 2011
March 2011
Curetted bone
Curetted bone
Bone graft posterior cortex
Knee
Shaft
GraftKnee Shaft
Exposed medial articular cartilage
March 2011Immediate Post Op
2000
Curettage + cementingg
2006
2009
Functional result 2009
Feb 2012
June 200935 / M
Confirmation of cement spill over
Feb 2012
Feb 2012
En block excision
25 years Female
2006
Articular cartilage is clearly visible
Post op Six month later
40 Yrs/ M/ 2006
Curettage + Bone graft
Recurrence after bone graft
2008
2009
Talus
Curettage + cement
1991, 35/ M, Pathological fracture
THR + cement
Recurrence1993
Re-curettage + Radiation
1 year post radiation
2003 – 12 years post surgery
Pathological Fracture neck femur - 2006
Six month post operativefunctional status
21 years old Female gradual deterioration since July 2009Leading to pathological fracture neck femur
Lesser Trochanter
Calcer femoris
Eaten away head of femur
Post Operative
24 / F / GCT / 2003
Post op X-ray One year later
25 years Male, Feb - 2011
3 months P.O.
Six months post op
At 3 months
At 6 months
At 3 months
At 6 months
30 / female / swelling shoulder 1 year
Wide Window
Function After 3 years -Dec 2012
1987 – a case of GCT upper end humerusRx by curettage + bone graft.Follow up at 2006
18 years old female
Curettage + Bone graft + G bone
Curettage + G bone
Developed recurrence in the transplanted graft suggested and adjacent metacarpal.Patient refused further reconstruction /limited amputation of fingers.Metacarpals and phalanges have 100% recurrence in our series
35 / F/ 2003 GCT lower end radius
Bone grafting
Recurrence
Aug 2002 Nov 2002
Recurrence after 5 years in a transplanted Fibula
Lost from Follow up
35 / F/ 2000 June
Curettage + Bone grafting
Recurrence
2008
Reconstruction was donein Nov 2000.
2006 – six years later
Developed GCT of TendonAug 2010 – 10 years later
The Key To Success - literature
• Adequate removal of the tumour seems to be a more important predictive factor for the outcome of surgery than the use of phenol as an adjuvant therapy.
Eur J Surg Oncol. 2001 Mar;27(2):200-2.
Recurrence of curetted and bone-grafted giant-cell tumours with and without adjuvant phenol therapy.
Trieb K, Bitzan P, Lang S, Dominkus M, Kotz R.
Curettage is the key - literature
• CONCLUSIONS: Curettage plus cement reconstruction is safe and effective in treating local GCT of limbs. The key of the method is aggressive curettage of the lesion via a bone window. Cement is adjuvant therapy only.
Zhonghua Wai Ke Za Zhi. 1999 Dec;37(12):730-2.
[Curettage plus cement reconstruction for treating giant cell tumor of limbs] Zhang Q, Cai Y, Niu X, Hao L. Department of Orthopaedic Oncology, Beijing Jishuitan Hospital, Beijing 100035.
The most important factor for local recurrence appeared to be inadequate curettage with similar recurrence rates regardless of the type of bone graft used. A careful approach to the surgical margin including use of a dental burr and local adjuvant treatment with phenol, the rate of local recurrence may be decreased.
Changgeng Yi Xue Za Zhi. 1996 Mar;19(1):16-23. Treatment of giant cell tumor of long bone. Shih HN, Chen YJ, Huang TJ, Ho WP, Hsueh S, Hsu RW. Department of Orthopedic Surgery, Chang Gung Medical College, Taoyuan, Taiwan, R.O.C.
Prevention of recurrence – literature
Prevention of recurrence - literature
• Use of polymethylmethacrylate as an adjuvant significantly reduces the recurrence rate following intralesional treatment of benign giant cell tumors, and it appears to be the therapy of choice for primary as well as recurrent giant cell tumors of bone.
J Bone Joint Surg Am. 2008 May;90(5):1060-7. Local recurrence of giant cell tumor of bone after intralesional treatment with and without adjuvant therapy. Arbeitsgemeinschaft Knochentumoren, Becker WT, Dohle J, Bernd L, Braun A, Cserhati M, Enderle A, Hovy L, Matejovsky Z, Szendroi M, Trieb K, Tunn PU. Orthopädische Klinik Volmarstein, Universität Witten/Herdecke, Wetter, Germany. [email protected]
This study demonstrates that either curettage and packing with cement or wide resection are effective in treatment of giant cell tumor of bone. There is, however, a better functional result after curettage and packing with cement than following wide resection. We recommend curettage and cement packing for giant cell tumor of bone whenever it is technically feasible
Changgeng Yi Xue Za Zhi. 1998 Mar;21(1):37-43. Treatment of giant cell tumor of bone: a comparison of local curettage and wide resection. Liu HS, Wang JW.
Recommendation - literature
DISCLAIMER Information contained and transmitted by this presentation is
based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India, during last 25 years. It is intended for use only by the students of orthopaedic surgery. Views and opinion expressed in this presentation are personal opinion. Depending upon the x-rays and clinical presentations viewers can make their own opinion. For any confusion please contact the sole author for clarification. Every body is allowed to copy or download and use the material best suited to him. I am not responsible for any controversies arise out of this presentation. For any correction or suggestion please contact [email protected]