A nonrandomized controlled study of sacral giant cell tumors with preoperative treatment of denosumab

Abstract

The aim of this nonrandomized controlled study (level 3)was to evaluate whether preoperative denosumab treatment can reduce intraoperative blood loss, facilitate surgical treatment, and improve local control of sacral giant-cell tumor (GCT).Surgical treatment of sacral GCT is very difficult due to extensive bone destruction and complex anatomical structures. The huge intraoperative blood loss may interrupt surgical management and judgment of tumor range. Denosumab can inhibit the differentiation of osteoclast-like giant cells and bone destruction by blocking RANKL-RANK pathway.Study group (preoperative denosumab treatment) and control group (no denosumab treatment) were matched for age, gender, tumor site, staging, and tumor size. In study group, enhanced computed tomography (CT) was performed before and after denosumab treatment. The comparison parameters between 2 groups: CT enhancement rate, intraoperative blood loss, and oncologic outcome.The mean preoperative time of denosumab treatment was 5.2 months in study group. The mean CT enhancement rate of study group was 2.60 before treatment and 1.37 after treatment (P = .012). The posttreatment CT enhancement rate of study group was significantly lower than that of control group (P = .007). The mean intraoperative bleeding of study group and control group was 2166.7 and 5240 mL, respectively (P = .040). The mean operative time of study group and control group was 268.3 and 268.5 minutes, respectively (P = .997). The recurrence rate of study group (66.7%) was significantly higher than that of control group (0%) (P = .046).Preoperative denosumab treatment has the tendency to reduce blood supply and intraoperative bleeding of sacral GCT. But the sclerosis and bony separation can increase the difficulty of tumor curettage and lead to high recurrence rate after denosumab treatment. It is necessary to study the best surgical opportunity after denosumab treatment and precise method to judge tumor range.

Pre-operative denosumab is associated with higher risk of local recurrence in giant cell tumor of bone: a systematic review and meta-analysis

“…Several studies have reported the newly formed sclerotic bone and thickened cortex made it difficult to identify surgical margin and to curette. Residue tumor cells may hide within the new bone and thickened cortex and may recur once denosumab is discontinued [22,24,25].Traub et al [25] described that the tumor tissue was replaced by gritty, fibrous-like tissue new bone, they suggested intra-operative fluoroscopy to guide the extent of resection. On the other hand, it is argued that the newly formed peripheral bone rim and hardened tumor tissue reduced the risk of inadvertent contamination [19].…”

“…Complications and others 6 studies [9,13,15,19,21,22] reported denosumab-related complications, in the 388 cases treated with denosumab, no osteo-necrosis of jaw or hypocalcemia was observed. 1 study [13] reported a periapical abscess and a periodontal disease during the course of denosumab administration.…”

“…Cortical discontinuity can be found on X-ray and CT, and extensive edema can be found on MRI, which are considered as prognostic markers for local recurrence [6,28].Sclerosis around and within the lesion tumor after denosumab was reported in most studies. A significant decrease in enhancement in enhanced CT value suggested the decrease of blood supply after denosumab administration [22]. On MRI, marrow replacement by tissue with different signal intensity were reported.…”

“…Administration of denosumab were similar, most studies administered denosumab once a month with 1-3 additional doses during the first month, the duration of administration prior to surgery differs for various reasons. Yang et al [22] reported significant decreased VAS score, intraoperative blood loss and CT enhancement after administration.…”

Pre-operative denosumab is associated with higher risk of local recurrence in giant cell tumor of bone: a systematic review and meta-analysis

“…Six studies [9,13,15,19,21,22] reported denosumabrelated complications, in the 388 cases treated with denosumab, no osteo-necrosis of jaw or hypocalcemia was observed. One study [13] reported a periapical abscess and a periodontal disease during the course of denosumab administration.…”