Prognostic factors for local recurrence in extremity-located giant cell tumours of bone with pathological fracture

Abstract

Aims The aim of this paper was to investigate the prognostic factors for local recurrence in patients with pathological fracture through giant cell tumours of bone (GCTB). Patients and Methods A total of 107 patients presenting with fractures through GCTB treated at our institution (Royal Orthopaedic Hospital, Birmingham, United Kingdom) between 1995 and 2016 were retrospectively studied. Of these patients, 57 were female (53%) and 50 were male (47%).The mean age at diagnosis was 33 years (14 to 86). A univariate analysis was performed, followed by multivariate analysis to identify risk factors based on the treatment and clinical characteristics. Results The initial surgical treatment was curettage with or without adjuvants in 55 patients (51%), en bloc resection with or without reconstruction in 45 patients (42%), and neoadjuvant denosumab, followed by resection (n = 3, 3%) or curettage (n = 4, 4%). The choice of treatment depended on tumour location, Campanacci tumour staging, intra-articular involvement, and fracture displacement. Neoadjuvant denosumab was used only in fractures through Campanacci stage 3 tumours. Local recurrence occurred in 28 patients (25%). Surgery more than six weeks after the fracture did not affect the risk of recurrence in any of the groups. In Campanacci stage 3 tumours not treated with denosumab, en bloc resection had lower local recurrences (13%), compared with curettage (39%). In tumours classified as Campanacci 2, intralesional curettage and en bloc resections had similar recurrence rates (21% and 24%, respectively). After univariate analysis, the type of surgical intervention, location, and the use of denosumab were independent factors predicting local recurrence. Further surgery was required 33% more often after intralesional curettage in comparison with resections (mean 1.59, 0 to 5 vs 1.06, 0 to 3 operations). All patients treated with denosumab followed by intralesional curettage developed local recurrence. Conclusion In patients with pathological fractures through GCTB not treated with denosumab, en bloc resection offers lower risks of local recurrence in tumours classified as Campanacci stage 3. Curettage or resections are both similar options in terms of the risk of local recurrence for tumours classified as Campanacci stage 2. The benefits of denosumab followed by intralesional curettage in these patients still remains unclear.

Similar local recurrence but better function with curettage versus resection for bone giant cell tumor and pathological fracture at presentation

“…There is no clear information regarding the optimal surgical treatment of GCTB presenting with a pathological fracture. 10,12,22,29,36 Therefore, we performed this study to evaluate the local recurrence rates, function, and complications after curettage versus resection for GCTB presenting with pathological fractures. Our results showed similar local recurrence and complication rates but better function with curettage versus resection.…”

“…Giant cell tumor of bone (GCTB) accounts for approximately 5% of all primary bone tumors . The rate of pathological fracture at presentation in these patients is 4% to 50% . In the presence of a pathological fracture, treatment with curettage may be difficult and may lead to a higher local recurrence rate because of tumor contamination of adjacent soft tissues and joint by the hematoma .…”

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

“…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]. Although we did not acquire sufficient data to conduct pooled-analysis on the outcome of denosumab combining curettage and local adjuvant, it is strongly recommended in many studies to use local adjuvant and high speed burr [3,24,26,27].Most studies included in our analysis applied various methods of local adjuvant in most patients except for one study specified that no local adjuvant was used [20].…”

“…Surgical choice was taken into account by comparing cases underwent curettage with denosumab and curettage alone in 4 studies [9,[16][17][18](OR: 2.13, 95% CI: 0.95 to 4.76, p=0.07, I 2 =29%)( Figure 3), though the result was not statistically significant. 7 studies [9,[15][16][17][18][19][20] reported outcome on primary lesions, which also suggest significantly higher risk of local recurrence in the denosumab group(OR: 1.91, 95% CI: 1.17 to 3.09, p=0.009, I 2 =36%)( Figure 4).…”

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

“…3), though the result was not statistically significant. Seven studies [9,[15][16][17][18][19][20] reported outcome on primary lesions, which also suggest significantly higher risk of local recurrence in the denosumab group (OR: 1.91, 95% CI: 1.17 to 3.09, p = 0.009, I 2 = 36%)( Fig. 4).…”