Adjuvant treatment of non-malignant active and aggressive bone tumors

Abstract

Aggressive but nonmalignant bone tumors often pose a difficult therapeutic dilemma for orthopaedic oncologists. Intralesional surgery usually is the modality of choice to lessen the morbidity associated with a marginal or wide excision. With more aggressive tumors, such as giant cell tumor of bone, chondroblastoma or aneurysmal bone cysts, high recurrence rates after curettage alone present a challenge to the surgeon. Adjuvant therapies provide an additional means of clearing the cavity of tumor cells after aggressive intralesional resection. The addition of adjuvants then is able to extend the margins beyond that which is visible to a marginal excision, removing microscopic disease. Clinically, this yields lower recurrence rates, with different methods having better efficacy. With the less aggressive yet still active lesions, injections and percutaneous methods may be preferred.This article discusses some of the more common as well as emerging trends in adjuvant therapy for active and aggressive nonmalignant bone tumors. Broad categories included are mechanical (burring), hypothermic or hyperthermic (cryotherapy, argon beam, cementation), chemical (phenol, hydrogen peroxide), and biologic modalities (bisphosphonates). Injectable materials also are discussed. Current literature regarding these adjuvants (focusing on the past 2 years) is presented, with an eye on clinical recommendations.

Joint Salvage Using Sandwich Technique for Giant Cell Tumors around Knee

“…However, the management protocol was similar in all patients. Finally, the time for follow-up in our study was relatively short 3.4 years, although various studies have shown that most of the local recurrences occur before 2 years, 6,11,14,32,42 there have been reports of late recurrence of GCT. 25,43 Also, degenerative changes in joint may take a longer time to develop.…”

“…The use of high-speed bur is accepted worldwide by all surgeons and it has shown to decrease recurrence after curettage to 25%. 6,7,18,23,24 Algawahmed et al in their metaanalysis compared recurrence rates in GCT following intralesional curettage and high-speed burring with a cohort of patients who underwent the same procedure plus a chemical or thermal adjuvant. They concluded that meticulous surgical technique including high-speed burring and not the use of adjuvants is the most important step in reducing recurrence rates in GCT of bone.…”

“…25,26 The use of cement in packing the cavity has been proposed to be advantageous. 13,14 The exothermic heat of polymerization for bone cement is 54.4 kJ/mol, which induces thermal necrosis at the bone cement interface and a few millimeters to the adjacent articular cartilage, 6,[27][28][29] while at the same time, there is also a direct toxic effect of the methyl methacrylate monomer that induces adjacent hypoxia. 6,13 Few studies have reported that a recurrence rate less than 25% when cement was used for cavity filling as compared with more than 50% recurrence rate when other cavity filling was used, 14,23 while others conclude that the use of cement as an adjuvant does not decrease the recurrence rate, if curettage has been done meticulously.…”

“…13,14 The exothermic heat of polymerization for bone cement is 54.4 kJ/mol, which induces thermal necrosis at the bone cement interface and a few millimeters to the adjacent articular cartilage, 6,[27][28][29] while at the same time, there is also a direct toxic effect of the methyl methacrylate monomer that induces adjacent hypoxia. 6,13 Few studies have reported that a recurrence rate less than 25% when cement was used for cavity filling as compared with more than 50% recurrence rate when other cavity filling was used, 14,23 while others conclude that the use of cement as an adjuvant does not decrease the recurrence rate, if curettage has been done meticulously. 23 Although it has been proposed that cement can be tolerated close to the joint surface, 30 there are reports suggesting that cement can induce heat necrosis, a few millimeters to the adjacent articular cartilage and the long-term presence of cement in a weight-bearing subchondral location can induce degenerative changes in the articular surface.…”

The Sandwich Technique in the Management of Periarticular Giant Cell Tumour of the Knee

“…The adjuncts include phenol, liquid nitrogen and bone cement/PMMA, which is the most widely used adjunct either in combination or in isolation. Polymethyl methacryllate is formed by an exothermic reaction and induces thermal tumour necrosis and also hypoxic tumour necrosis induced by its monomer (16). Balke et al showed that statistically the use of bone cement significantly decreased the recurrence rate by a factor of eight when compared to high-speed burring used in isolation (13).…”