and malignant bone tumors They are considered benign butcourse GCTre - PDF document

Intr and malignant bone tumors. They are considered benign butcourse. GCTrecur in a high percentage of cases, become Patients and methods Between 1975 and 2002, a total of 46 patients with giant cell bone J Orthopaed Traumatol (2003) 3:126DOI 10.1007/s10195-003-0024-3 M. ValeoR. Trinchi Received: 19 May 2003Accepted: July 2003 L. Di Giorgio (  ) Abstract W Key words Giant cell tumor ¥Bone grafting 127 proximal radius, proximal femur, distal humerus, IVmetacarpus,phalanx of the hand, IVmetatarsus, phalanx of the foot, andastragalus. According to the radiographic parameters considered,replace the subchondral bone infiltrated by the tumor, and theSurgical resection, either marginal or wide, was the primary treat- ment in 14 cases; it was followed by reconstructive surgery withpartmental resection. This was followed by application of a pros- Results months to 13 years at primary treatment (Table 1). Ofafter surgery. Furthermore, 6 (75%) of the 8 patients withcurettage had been associated with radiotherapy. None ofnol or packing of the cavity with cement. Two local recur-been marginal resection, one localized in the distal femur,sisted of marginal resection in 2 cases, wide resection inone case and 3 curettage in the oth

er 4 cases (Table 1). TwoIVmetacarpus, curettage accompanied by radiotherapy inthe onset of malignant fibrous histiocytoma. The patientwho had presented a local recurrence in the IVmetacarpus10 years later. The patient who presented a local recurrencesisted of curettage and radiotherapy, was submitted toresection with grafting. Subsequently, neoplastic transfor- Fig. 1 Localization in the 39 cases studied ( numbers indicate thetotal number of cases in which lesion was reported) 128 Fig. 2a-g Grade II giant cell tumor of distal ulna in a 60-year-old man . a Radiograph ( left ) and MRimage ( right ). MR image shows that the cortical bone is involved by the tumor but not overtaken. b Anteroposterior ( left ) and lateral ( right ) radiographs one month following curettage, phenol cauteriza-tion and methylmethacrylate packing. c MR image 10 months later. Note the cavity filled with cement(low signal). d Anteroposterior radiograph 18 months later. e Radiographs 36 months later. f MR images48 months later: no evidence of recurrence. g Radiographs 48 months lateradgefbc Fig. 3a-c Grade III giant cell tumor of astragalus in a 20-year-old man. a Pre-operative radiograph. b Radiograph 5 years following curet-tage, phenol

cauterization and homologous bone grafting. c abc 129 Table 1 Characteristics of the 8 recurrences of giant cell tumor of the bone CaseLocalizationTime to recurrenceSecondary treatmentOutcome1Proximal tibia5 yearsResection and graftsAmputation 2 months later. No evidence2Proximal tibia9 monthsCurettage and graftsNo recurrence at 20 years3Proximal tibia11 monthsCurettage and graftsNo recurrence at 18 years4Distal femur9 monthsCurettage and graftsNo recurrence at 9 years5Distal femur3 yearsResection and graftsNo recurrence at 9 years6Proximal fibula13 yearsResectionNo recurrence at 9 years7Distal radius12 monthsCurettage and Resection and grafts after 9 yearsradiotheraphyAfter 12 months an amputation8IVMetacarpus12 monthsResection and bone graftCurettage and phenol after 10 months No evidence of disease at 10 years Fig. 4a-i oximal tibia in a 62-year-old woman. a Pre-operative radiographs. b MR image shows involvement ofthe subchondral bone without overtaking articular cartilage. c Macroscopic ( left ) and microscopic ( right ) aspects of the lesion. d MR image 6months after curettage, phenol cauterization, filling the cavity with methylmethacrylate (low signal area) with the apposition of homologousgrafts under ca

rtilage to restore the subchondral bone (hypointense signal in the subchondral area). e months postoperatively. f Radiograph 24 months later. g Radiograph 36 months later. h MR image shows after 48 months that the homologousgraft with cement was fixed. i Radiographs 60 months later ghi 130 Discussion decade of life, local aggressive behavior, a tendency to pro-CTand MR images when available. The radiographictigated by CTand MRI, it was possible to study the exten-sion of the lesion more accurately, paying particular atten-tion to the soft tissues and the adjacent joint. According tothe site, age and radiological grading of the lesion, surgicaltreatment consisted of curettage, marginal resection wideresection, or radical resection, of the tumor. Curettage con- of autologous bone. 45 Gy seems to be an effective soleter. Some authors affirmed that for larger tumors, surgerycombined with postoperative radiotherapy is effective inproducing local control of recurrences [2, 3]. Although localthe percentages vary considerably. In fact, the recurrencetreatment performed (Table 2). Although some authors haveAlthough some authors havewhen giant cell tumors, localized in the distal radius or themetacarpal bones, present a hig

her rate of local recurrencesafter treatment by curettage [6Ð8]. Of the 3 patients with tumor in the distal radius, localrecurrence occurred only in the case treated by curettage,and did not occur in the 2 cases treated by radical resectionand arthrodesis or by wide resection accompanied by recon-struction with grafts. Recurrence also occurred in the onlycase of GCTlocalized in the metacarpus treated by curet-tage. Therefore, these findings confirm a higher percentage Table 2 Local recurrences of giant cell tumor of bone ReferenceCases, nAdjuvant treatmentLocal recurrence rate, %Miller et al. [11]280Curettage, BG45McDonald et al. [16]112Curettage, BG34Campanacci et al. [7]16Curettage, phenol, alcohol13Eckardt, Grogan [17]260Curettage, phenol, alcohol25Marcove [8]100Curettage, LN, BG8Miller, Capanna [9]20Curettage, LN, BG20Miller, Capanna [9]33Curettage, phenol, PMMA3 Miller, Capanna [9]187Curettage, PMMA17 BG , bone grafting; LN , liquid nitrogen; PMMA , polymethylmethacrylate 131 As suggested by Szendroy [8], this difference is proba-tion difficult in a complex anatomical area such as the wrist.In similar sites, whenever MRI or CTdo not show bony con-choice in other sites. In fact, this surgical procedure, whichrate

of local recurrences until recently. The local recurrenceby Goldenberg et al. [9] and 27% in Campanacci et al.g et al. [9] and 27% in Campanacci et al.after en bloc resection in these two series, respectively. TheTheused to fill the cavity [9, 11]. In the patients examined in the present study, the local50%. However, by associating chemical cauterization usingmethylmethacrylate was used to fill the cavity. Phenol orig-0.1 mg/l. At concentrations between 0.1% and 1% phenol isdestruction of cell permeability. Applied directly to tissues This characteristic makes it suitable as an adjuvant to surgi-[12]. Despite the fact that its cytotoxic effect is non-specif-fect is non-specif-In our series, phenol was used in 6 cases. Chemical cau-terization was performed by direct application of cotton tipssoaked in a solution containing 5% phenol as opposed toirrigation of the cavity, and there were no unwanted sideeffects. Currently, in addition to curettage associated withever, we prefer a combination of methylmethacrylate to fill, we prefer a combination of methylmethacrylate to fillas part of the treatment of giant cells tumors, we believe thatlow risk of recurrence is related also to how thoroughly thetumor is removed. Curettag

e must be extensive to be effec-tive and requires a large cortical window that providesstraightforward visualization of the entire tumor cavity, 1.Campanacci M, Baldini N, Boriani Sbone. J Bone Joint Surg Am1142.Rock M (1990) Adjuvant manage-Organi Mov 75[Suppl 1]:1953.Miszczyk L, Wydmanski J, Spindel J(2001) Efficacy of radiotherapy for Refer Patel MR Desai SS, Gordon SLet alhand. J Hand Surg (Am) 12:708.Szendroy M (1990) Giant cell tumortissue recurrence. Chir Organi Movgani MovÐ2439.Goldenberg R, Campbell CJ,of bone. An analysis of 218 cases. JBone Joint Surg Am 52:848 4.McGeoch CM, Varian JP(1985)metacarpal. J Hand Surg (Br)5.Rock M (1990) Curettage of giantChir Organi Movgani MovÐ2056.Mapelli S, Mercuri M, Zucchi Vum. Chir Organi Mov 132 10.Marcove RC (1984) The surgery of11.Miller G, Bettelli G, Fabbri N,cell of bone. Chir Org Movg Mov12.Nair MK, Jyothirmayi R (1999)Oncol Biol Phys 43(5):1065 15.Gambini A, Mastantuono M, DiGiorgio Let al (1999) Rehabilitationation. Chir Org Mov 84:35916.McDonald D, Sim FH, McLeod RA,of bone. JBJS 68(A):23517.Eckardt JJ, Grogan TJ (1986) Giant 13.Quint U, Muller RT, Muller G (1998)Characteristics of phenol. ArchOrthop Trauma Surg 117:4314.Capanna R, Sudanese A, Baldini N,Traum 11(