The Recurrent Giant Cell Tumour

Dr. A. Srinivasa RaoM.S.(Orth); Fellow Ortho. Path. (USA)

Emeritus Professor, Gandhi Medical CollegeHyderabadHonorary Fellow, IOAConsultant, Orthopedic Oncology,KIMS, Secunderabad

Incidence

In USA 5% of Primary bone tumorsIn Asian Countries 20 – 30 %

More common in South India

W.H.O

GCT is an Aggressive potentially Malignant lesion

Natural Course of Disease

Lytic lesion in bone Destructive expansion with periosteal new bone forming shellThin shell – “egg shell crackling”Shell broken – still has soft tissue cover – pseudo capsuleIf left alone – breaks into sub cut. tissue and

later skin – fungates

Aggressive Still Benign

A small percentage of them are malignant

Surgery

Histology – frankly malignant

Recurrence

The other disturbing, most challenging complication in the management of GCT

Terms used in Management of GCT

Curettage (intra lesional)

Terms used for Management

Curettage (intra lesional)Aggressive Curettage (curettage + adjuvant)

Adjuvants – Procedures or Packing

materials

Procedures - Phenol - H2O2 Lavage - Cryosurgery (Liquid Nitrogen)

Packing Materials - Bone Graft (auto / allo)

- Bone Cement High speed Burr

Terms used for Management

Curettage (intra lesional)Aggressive Curettage (curettage + adjuvant)

Adjuvants – Procedures or Packing

materials

Extended CurettageMarginal excision

Terms used for Management

Curettage (intra lesional)Aggressive Curettage (curettage + adjuvant)

Adjuvants – Procedures or Packing

materials

Extended CurettageMarginal excisionEn bloc excisionResectionWide resection

Extended Curettage - thoroughMr.PK., Ext.Curettage, Auto Fibula & Allocancellous grafting

ACL seenThroughcavity

Mr.PK; 3 yr FU

Extended Curettage, H2O2 adjuvant

Bone Grafting - Auto Fibula & Allo Cancellous Case 2

2 yr Post op

Clinical FU 3 yrs

Extended CurettageH2O2 AdjuvantBone Graft – Auto Fibula & Allo Cancellous

Case 3

Case 3 – 28 mths FU

Recurrence

Campannacchi 1987 51 local recurrences 90% appeared in 3 yrs

In a large series Majority recurred by 2 years

Very few recurred by 3 yrs Single recurrence by 6 yrs

Aim of Treatment of GCT

To reduce the incidence of local recurrence while preserving maximal joint function

- Curettage preserves joint function; but risk of recurrence - Resection and Reconstruction minimises recurrence;

but joint function jeopardised - Custom Mega Prosthesis preserves joint function &

minimises recurrence; but risk of failure in long run

Benefit –Risk Ratio to be assessed

Recurrence Curettage

25 % Klenka et.al. Mayo Clinic; CORR 2011

34 % McDonald JBJS 1986

42.9 % Durr et.al.; Eur. J Surg Onc. 1999

49 % Becker et.al JBJS 2008

49 % Knochentumoren JBJS 2008

58.8 % Balke et.al Cancer Res Clin Onc 2009

Recurrence Burr & Bone graft

32.5 % Malek et.al., Int. Orthop.,2006

Recurrence PMMA Cementation

14 % Kirschen CORR 1996

22 % Becker et.al. JBJS 2008

22 % Knochentumoren JBJS 2008

15 % Chanchairujira et al J Med Ass Thai 2011

RecurrencePhenol

9.1 % Durr et.al. Eur J Surg Onc 1999

15 % Becker et.al. JBJS 2008

No effect on Recurrence Klenka et.al CORR, 2011

Recurrence Liquid Nitrogen

7.9 % Malawar, CORR 1991

RecurrenceWide Resection

7 % McDonald JBJS 1986

0 % Chanchairujira et al J Med Ass Thai 2011

5 % Klenka et.al. Mayo Clinic; CORR 2011

Recurrent GCT Campannacchi JBJS 1987

Intralesional procedures 27 %Marginal Excision 8 %Radical procedures 0 %

Recurrence After Pathological fracture

Does not increase rate of Recurrence JBJS 1995

Recurrence Summary of Statistics

Adjuvants do reduce Recurrence rateRecurrence can occur after any adjuvant treatment Incidences are not consistent & vary widelyType of adjuvant used / nature of filling material had no effect on recurrence rate Turcotte et.al. CORR 2002

It is likely that the adequacy of removal of tumour determines the outcome rather than the use of adjuvant modalitiesExtended curettage ( marginal excision) has least recurrence rate

Predictors of Recurrence / Prognosis ?

Best treatment of these tumours & Risk factors for recurrence -

Controversial

Predictors of Recurrence / Prognosis ?

Radiology Histology VEGF & MMP-9 expression

Radiology – Campanacchi Grading

1 2 3

Radiology

Difference of opinionGrade 3 – increased rate of recurrence

Posser et.al. CORR 2005

Turcotte OCNA 2006

Recurrence rates are independent of Campanacchi grading Ramedios JBJS 1997

No significant relation between radiology & recurrence Sishir Rastogi IJO 2007

Campanacchi Grade 1

Campanacchi Grade 3

Campanacchi Giant Cell Tumour, Bone & Soft tissue Tumours,; Springer Verlog 1990

Unpredictable behaviour of GCT is not always related to Radiographic & Histological appearances

Histology

Benign & Malignant can be differentiatedGrading is not valid Prediction of clinical behaviour of GCT based on Histology is impossible Cancer 1980

Rough guide – No. of Giant cells & No. of Nuclei in each Giant Cell

VEGF & MMP-9 Kumta et.al. Life Sciences 2003

VEGF (Vascular Endothelial Growth Factor)MMP-9 (Matrix Metalloprotease)

Their expressions were more in Recurrent GCTs This could be a prognostic factor Kumta et.al. Life Sciences; Aug 2003

Recurrence Management

Recurettage & adjuvant usageCustomary to deal more radically –

Resection & ReconstructionCustom Mega ProsthesisAmputation

9 mths

Case 1. SARITHA 23 yr F

2 yrs

Saritha - 3 yrs FU

Saritha - 4 yrs FU

6 yrs FU – No Recurrence

12/04

2/05(2 mo)

Case 2. Sravan 25 yr M

9/06(1½ yrs)

4/07 (7 mths) 1/09 (27 mths)

5 yrs P.O.Total 7 yr FU

No RecurrenceSatisfactory Function

Case 3. Custom Mega Prosthesis

2 yrs FU; Benefit-Risk Ratio

Case. 4 Recurrent GCT Distal Radius

Resection & ReconstructionSkin sloughed out - Amputation

Recurrent GCT Case 5 after Enneking Resection Arthrodesis

Recurrence & Path. Fr in 3 months

Enneking Resection Arthrodesis

Resection Arthrodesis – Enneking typeRecurrence proximal shaft – excision & graft

Resection Arthrodesis – Enneking type

Message

Recurrences may be managed with appropriate surgeriesNo Amputation unless

- the tumour is frankly malignant - is too big for conservative management - tumour recurred more than twice

Summary

GCT is an aggressive tumourCurettage & bone grafting preserves joint function; Recurrence is a problemAdjuvants minimise recurrence; Nothing to choose between different adjuvantsAdequacy of tumour removal determines outcome“Extended curettage”, H2O2 adjuvant & allo cancellous bone grafting is economical; has least recurrence rate

Summary (contd)

Radiology & Histology cannot predict RecurrenceVEGF & MMP-9 may predict aggressiveness of tumourRecurrences can be recuretted; but excision & reconstruction preferredAmputation for malignant GCT or for tumours too large to be conserved

a s rao