Giant Cell Tumor (GCT) is a relatively common benign aggressive bone tumor that occurs in the bone end of the limb, accounting for approximately 5-8% of primary bone tumors. Although the local recurrence rate of intracapsular surgery reported in the literature is high, it is still the ideal choice for the initial treatment of Giant Cell Tumor of bone because it can better preserve joint function. The possibility of recurrence and secondary malignancy of recurrent giant cell tumor of bone is further increased, so how to choose an effective treatment plan becomes the key and difficult point in controlling recurrence and preserving joint function.
From 2001.10 to 2007.7, 23 patients with recurrent giant cell tumor of the limb bone with complete follow-up data were admitted to our hospital, and the methods and results of their retreatment are now analyzed to discuss the methods and efficacy of treatment for recurrent giant cell tumor of the limb, so as to further improve their cure rate.
I. General information
There were 23 cases in this group, 14 males and 9 females, aged 19-52 years old, with an average age of 32.2 years. The sites of disease were: distal femur in 9 cases, proximal tibia in 5 cases, distal radius in 4 cases, proximal humerus in 3 cases, and proximal femur in 2 cases. The initial surgery was performed with intracapsular scraping, bone cement filling in 15 cases, and bone grafting in 6 cases. The postoperative recurrence time ranged from 7 months to 6 years and 4 months, with a mean of 25.7 months. Among them, 20 cases recurred within 2 years, accounting for 87% of the total number of patients.
II. Clinical and imaging manifestations
Among the 13 recurrent cases in our hospital, 10 cases had no obvious clinical symptoms, and abnormalities were found during follow-up observation of radiographs. 2 cases showed local swelling with vague pain in the distal radius, and 2 cases were found due to local pain in the distal femur. Among the 10 cases in the external hospital, 6 cases were found during outpatient review of radiographs, and 3 of the other 4 cases were found at the clinic due to local swelling and pain without postoperative review, and 1 case even had a pathological fracture due to recurrence. The imaging manifestations were mainly a more obvious hypodensity area around the cement-filled bone, and irregular hypodensity in and around the bone grafting area in bone grafting, and in some cases, incomplete bone shell with soft tissue shadow. According to the radiological Campanacci classification, there were 1 case of grade I, 14 cases of grade II and 8 cases of grade III.
III. Surgical methods
All 15 re-scraping cases used high-speed grinding drill to grind off a layer of bony capsule wall during lesion treatment, carbolic acid and alcohol to cauterize the capsule wall, and repeatedly flushed the bone wall with a pulse flushing pump, and bone cement to fill the cavity. 6 patients with tumor segment resection + artificial joint reconstruction were confirmed to have recurrence by puncture biopsy before surgery, and the tumor bone was truncated at more than 3 cm above the tumor, and the distal femur was reconstructed by applying a rotating hinge artificial knee joint in 4 cases, and the tumor In two cases of recurrent giant cell tumor of the distal radius, the radius was amputated about 2 cm from the proximal end of the tumor, and the distal radius was reconstructed by taking the proximal end of the opposite fibula.
III. RESULTS
All 23 cases were followed up from 10 months to 78 months, with a mean of 37.6 months. Radiographs were taken every 3 months for 2 years after surgery and every 6 months after 2 years. CT examinations were performed when necessary. 15 cases with re-scraping + cement filling had normal joint function and no local complications. The rate of recurrence was 13.3%. 6 cases of lumpectomy + prosthesis replacement and 2 cases of lumpectomy + autologous fibula graft had no local recurrence, and the excellent rate was 75.3% according to the Enneking limb function reconstruction score. However, one case of incision infection and one case of prosthesis loosening occurred in each of them, with a complication rate of 8.7% (see Table 1).
IV. DISCUSSION
(I) Epidemiology of recurrence
Giant cell tumors (GCT) mostly invade the ends of long bones of the extremities, with the distal femur, proximal tibia, distal radius and proximal humerus being the most frequent. GCT is an osteolytic tumor, and pulmonary metastases can occur in 1% to 6% of patients. 20% to 30% of patients have potentially progressive malignancy, and about 5% have sarcomatous transformation, and metastases can occur without histologic malignancy, and the incidence of pulmonary metastases is 1% to 4%. The incidence of local recurrence after intracapsular curettage was 10%-40%. Guo Wei et al. found that the recurrence rate was 13.5% after bone grafting or bone cement filling after curettage in 128 cases of giant cell tumor of bone.
Balke et al. reported treating 214 patients with giant cell tumor of bone, the average time to first recurrence after surgery was 22 months, and the average number of recurrences per person was 1.4. The recurrence rate was 69.7% within 2 years. The recurrence rate after intracapsular scraping without adjuvant therapy (e.g., bone cement or high-speed grinding drill) was 58.8%, which decreased to 21.7% if adjuvant therapy was applied.
In contrast, a large number of studies have shown that the localization of the lesion is the most important factor associated with recurrence. In recurrent giant cell tumors of the limb bone, the choice of resurfacing or segmental resection remains dependent on the extent of lesion involvement. Almost 70% of recurrent giant cell tumors of bone recur within 2 years. In our group, 20 of 23 (87%) recurrent giant cell tumors of the limb bone occurred within 2 years after the first surgery, which is higher than the 70% in the literature, and may be related to the lack of standardization of the initial treatment.
The following factors may have influenced the early recurrence cases.
1, incomplete scraping;
2, failure to apply a high-speed grinding drill to expand and polish the bone shell around the tumor;
3.No application of chemical or physical adjuvant measures;
4. Inadequate assessment of local anatomical structures, etc.
The above factors may be the elements that need careful evaluation and attention when treating patients at first diagnosis.
(B) The importance of early diagnosis and follow-up of relapse
Usually, very few early recurrence cases have clinical symptoms, and only a few present with pathological fractures or local pain and are seen, so early follow-up after initial treatment is crucial. Regular radiographs should be taken for review, and MRI should be performed early if recurrence is suspected. In most of the cases, recurrence can be detected by imaging examination. If worm-like or pinhole-like bone changes appear again on the edge of the original tumor scraping lesion on X-ray, or if the osteolytic area is enlarged or small p-point osteolytic changes appear on the edge of the implant after healing, or soft tissue swelling shadow around it, recurrence should be suspected and the diagnosis can be confirmed by MRI examination or pathological biopsy. In our group, 16 cases were found to have local recurrence during radiographic review, which was confirmed by MRI or biopsy. This provides a reliable guarantee for the choice of later treatment.
The possibility of sarcomatous transformation after recurrence of giant cell tumor of bone has been reported in the literature, and no such cases were found in this group, which may be related to the small total number of cases. Also there was no case of pulmonary metastasis in this group. Therefore, it is important to follow up the patient closely after surgery, and the X-ray should be reviewed every three months. If the patient develops new pain, swelling or suspicious manifestations on X-ray, MRI should be done for the patient. In order to detect whether recurrent giant cell tumor of bone is accompanied by lung metastasis in time, lung CT examination should be performed after recurrence.
(C) Patient assessment and choice of treatment plan after recurrence
Treatment options are usually intracapsular scraping with adjuvant high-speed grinding and polishing, liquid nitrogen freezing and bone cement filling, and if possible adjuvant chemotherapy, including hydrogen peroxide, zinc chloride and phenol. The goal of treatment for recurrent giant cell tumor of bone remains to control recurrence and to maximize preservation of limb function. The majority of recurrent cases detected early are Companacci grade I or II, which accounted for 65.2% (15/23) of cases in our group. Although re-expansion scraping does not yet completely resolve the problem of local recurrence, almost completely normal limb function can be preserved compared to tumor segment resection. Moreover, if the lesion is adequately exposed and thoroughly scraped intraoperatively, the rate of recurrence can be significantly reduced by applying a high-speed grinding drill to abrade the bone crest and then treating the bone wall with chemical agents (carbolic acid, alcohol).
The clinical evaluation of recurrent giant cell tumor should be considered from all aspects, including the initial treatment (whether scraping and bone grafting, bone cement filling, or artificial prosthesis reconstruction), the extent of the tumor after recurrence, and the imaging (such as the size of the tumor, whether the cortical bone is intact or not, and whether the soft tissues are invaded or not), in order to make a more realistic clinical judgment and provide a basis for clinical treatment. In recurrent cases of giant cell tumor of bone, it is also important to perform an aspiration biopsy before reoperation to determine whether the tumor is accompanied by sarcomatous changes. The choice of surgical method can be based on the Companacci classification. Intracapsular resection with local chemistry or other methods is suitable for Campanacci grade I and II giant cell tumors, which is in line with the principles of tumor treatment, with low local recurrence rate, postoperative complications and good postoperative function.
Segmental resection is suitable for Campanacci grade III giant cell tumor, which has a lower local recurrence rate compared with intracapsular resection, but a higher postoperative complication rate. In recurrent giant cell tumor, it is inadvisable to insist on either focal scraping or segmental resection. The extent of the lesion and the local bone residue should be determined by radiographs, CT and MRI findings. If conditions permit, lesion scraping should be considered first. Among the 23 patients with recurrent giant cell tumor of bone in our group, 15 patients with Campanacci grade I and II were treated with intracapsular scraping and bone grafting or bone cement filling, and there were two cases of recurrence after surgery, with a recurrence rate of 13.3% and good clinical outcome and functional recovery.
Although the proximal femur is prone to recurrence due to incomplete scraping of the tumor because of the anatomical relationship, the recurrence in this group occurred in the distal femur, which is not related to the anatomical structure, but may be related to the biological characteristics of the tumor itself, and the recurrence in these two cases may be caused by the aggressiveness of the tumor. For the recurrence cases in this group, most of the patients were Campanacci grade I and II, and good results could still be achieved by performing intracapsular scraping again. In addition to the application of high-speed grinding drill, phenol and alcohol during the surgery, we also applied a pulse flushing gun to perform high-pressure flushing during the grinding process to enhance the removal of tumor cells and preserve the function of the joint. Compared with joint fusion or artificial prosthesis reconstruction after enlarged resection, lesion scraping with bone cement filling better preserved joint function.
Although, bone cement filling is a more desirable method for treating giant cell tumor of bone, it may cause damage to the articular cartilage surface and pain in the late stage due to the high strength of the bone cement itself and the fact that it is not absorbed by the body. An appropriate amount of autologous or allogeneic bone is filled in close to the joint and cement is applied, and premature weight-bearing is avoided after surgery. This prevents the joint surface from collapsing and preserves the original joint function. Balke et al. reported no increase in local recurrence with subchondral bone grafting.
In comparison, Cheng CY et al. found that the lesion scraping group had good function, while the resection group had a significant decrease in joint range of motion and grip strength, and the recurrence rate was similar; it is believed that if the lesion does not involve the wrist joint surface, destroys less than 50% of the bone cortex, or does not form a soft tissue mass, scraping can be considered, and if the lesion is large and the joint surface and soft tissue are seriously involved, the distal radius can be selected. If the scope of the lesion is large and the involvement of the articular surface and soft tissues is serious, resection of the distal radius tumor segment and reconstruction of the contralateral fibula graft can be chosen. In our group, two patients underwent reconstructive surgery with contralateral fibula graft, and the short-term postoperative function was poor, with obvious swelling of the joint area and prerotation and postrotation dysfunction. However, after 1 year postoperative review, the patient’s wrist function improved significantly.
(IV) Treatment of recurrence
In case of recurrence of giant cell tumor of the limb, the treatment options are basically the same as those for the initial recurrence, and the treatment plan is decided according to the extent of tumor invasion at the recurrence site, soft tissue involvement, and the specific situation of subchondral bone near the joint end. Some patients still have the opportunity to choose intracapsular curettage. In our data, there were two cases of recurrence. One of them was treated with resection of the tumor segment for prosthetic reconstruction, and the other one was treated with intracapsular curettage for cement filling, with good postoperative results.
Balke et al. reported a 21.7% recurrence rate of recurrent giant cell tumor in bone scraped with high-speed grinding and cement filling. Balke et al. suggested that the recurrence rate was related to the site of the lesion, with the highest recurrence rate in the distal radius, followed by the distal tibia and proximal humerus.
Therefore, we believe that intracapsular curettage of giant cell tumors in bone, although still at risk of recurrence, can preserve joint function better and should be the first choice for the treatment of recurrent giant cell tumors in the limb. The use of segmental resection and functional reconstruction for radiological Companacci grade III recurrent osteoblastic tumors can effectively reduce the local recurrence rate with satisfactory recent results.