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The Recurrent Giant Cell Tumour
Dr. A. Srinivasa RaoM.S.(Orth); Fellow Ortho. Path. (USA)
Emeritus Professor, Gandhi Medical CollegeHyderabadHonorary Fellow, IOAConsultant, Orthopedic Oncology,KIMS, Secunderabad
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Incidence
In USA 5% of Primary bone tumorsIn Asian Countries 20 – 30 %
More common in South India
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W.H.O
GCT is an Aggressive potentially Malignant lesion
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Natural Course of Disease
Lytic lesion in bone Destructive expansion with periosteal new bone forming shellThin shell – “egg shell crackling”Shell broken – still has soft tissue cover – pseudo capsuleIf left alone – breaks into sub cut. tissue and
later skin – fungates
Aggressive Still Benign
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A small percentage of them are malignant
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Surgery
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Histology – frankly malignant
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Recurrence
The other disturbing, most challenging complication in the management of GCT
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Terms used in Management of GCT
Curettage (intra lesional)
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Terms used for Management
Curettage (intra lesional)Aggressive Curettage (curettage + adjuvant)
Adjuvants – Procedures or Packing
materials
Procedures - Phenol - H2O2 Lavage - Cryosurgery (Liquid Nitrogen)
Packing Materials - Bone Graft (auto / allo)
- Bone Cement High speed Burr
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Terms used for Management
Curettage (intra lesional)Aggressive Curettage (curettage + adjuvant)
Adjuvants – Procedures or Packing
materials
Extended CurettageMarginal excision
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Terms used for Management
Curettage (intra lesional)Aggressive Curettage (curettage + adjuvant)
Adjuvants – Procedures or Packing
materials
Extended CurettageMarginal excisionEn bloc excisionResectionWide resection
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Extended Curettage - thoroughMr.PK., Ext.Curettage, Auto Fibula & Allocancellous grafting
ACL seenThroughcavity
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Mr.PK; 3 yr FU
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Extended Curettage, H2O2 adjuvant
Bone Grafting - Auto Fibula & Allo Cancellous Case 2
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2 yr Post op
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Clinical FU 3 yrs
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Extended CurettageH2O2 AdjuvantBone Graft – Auto Fibula & Allo Cancellous
Case 3
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Case 3 – 28 mths FU
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Recurrence
Campannacchi 1987 51 local recurrences 90% appeared in 3 yrs
In a large series Majority recurred by 2 years
Very few recurred by 3 yrs Single recurrence by 6 yrs
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Aim of Treatment of GCT
To reduce the incidence of local recurrence while preserving maximal joint function
- Curettage preserves joint function; but risk of recurrence - Resection and Reconstruction minimises recurrence;
but joint function jeopardised - Custom Mega Prosthesis preserves joint function &
minimises recurrence; but risk of failure in long run
Benefit –Risk Ratio to be assessed
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Recurrence Curettage
25 % Klenka et.al. Mayo Clinic; CORR 2011
34 % McDonald JBJS 1986
42.9 % Durr et.al.; Eur. J Surg Onc. 1999
49 % Becker et.al JBJS 2008
49 % Knochentumoren JBJS 2008
58.8 % Balke et.al Cancer Res Clin Onc 2009
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Recurrence Burr & Bone graft
32.5 % Malek et.al., Int. Orthop.,2006
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Recurrence PMMA Cementation
14 % Kirschen CORR 1996
22 % Becker et.al. JBJS 2008
22 % Knochentumoren JBJS 2008
15 % Chanchairujira et al J Med Ass Thai 2011
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RecurrencePhenol
9.1 % Durr et.al. Eur J Surg Onc 1999
15 % Becker et.al. JBJS 2008
No effect on Recurrence Klenka et.al CORR, 2011
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Recurrence Liquid Nitrogen
7.9 % Malawar, CORR 1991
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RecurrenceWide Resection
7 % McDonald JBJS 1986
0 % Chanchairujira et al J Med Ass Thai 2011
5 % Klenka et.al. Mayo Clinic; CORR 2011
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Recurrent GCT Campannacchi JBJS 1987
Intralesional procedures 27 %Marginal Excision 8 %Radical procedures 0 %
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Recurrence After Pathological fracture
Does not increase rate of Recurrence JBJS 1995
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Recurrence Summary of Statistics
Adjuvants do reduce Recurrence rateRecurrence can occur after any adjuvant treatment Incidences are not consistent & vary widelyType of adjuvant used / nature of filling material had no effect on recurrence rate Turcotte et.al. CORR 2002
It is likely that the adequacy of removal of tumour determines the outcome rather than the use of adjuvant modalitiesExtended curettage ( marginal excision) has least recurrence rate
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Predictors of Recurrence / Prognosis ?
Best treatment of these tumours & Risk factors for recurrence -
Controversial
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Predictors of Recurrence / Prognosis ?
Radiology Histology VEGF & MMP-9 expression
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Radiology – Campanacchi Grading
1 2 3
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Radiology
Difference of opinionGrade 3 – increased rate of recurrence
Posser et.al. CORR 2005
Turcotte OCNA 2006
Recurrence rates are independent of Campanacchi grading Ramedios JBJS 1997
No significant relation between radiology & recurrence Sishir Rastogi IJO 2007
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Campanacchi Grade 1
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Campanacchi Grade 3
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Campanacchi Giant Cell Tumour, Bone & Soft tissue Tumours,; Springer Verlog 1990
Unpredictable behaviour of GCT is not always related to Radiographic & Histological appearances
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Histology
Benign & Malignant can be differentiatedGrading is not valid Prediction of clinical behaviour of GCT based on Histology is impossible Cancer 1980
Rough guide – No. of Giant cells & No. of Nuclei in each Giant Cell
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VEGF & MMP-9 Kumta et.al. Life Sciences 2003
VEGF (Vascular Endothelial Growth Factor)MMP-9 (Matrix Metalloprotease)
Their expressions were more in Recurrent GCTs This could be a prognostic factor Kumta et.al. Life Sciences; Aug 2003
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Recurrence Management
Recurettage & adjuvant usageCustomary to deal more radically –
Resection & ReconstructionCustom Mega ProsthesisAmputation
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9 mths
Case 1. SARITHA 23 yr F
2 yrs
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Saritha - 3 yrs FU
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Saritha - 4 yrs FU
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6 yrs FU – No Recurrence
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12/04
2/05(2 mo)
Case 2. Sravan 25 yr M
9/06(1½ yrs)
4/07 (7 mths) 1/09 (27 mths)
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5 yrs P.O.Total 7 yr FU
No RecurrenceSatisfactory Function
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Case 3. Custom Mega Prosthesis
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2 yrs FU; Benefit-Risk Ratio
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Case. 4 Recurrent GCT Distal Radius
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Resection & ReconstructionSkin sloughed out - Amputation
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Recurrent GCT Case 5 after Enneking Resection Arthrodesis
Recurrence & Path. Fr in 3 months
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Enneking Resection Arthrodesis
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Resection Arthrodesis – Enneking typeRecurrence proximal shaft – excision & graft
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Resection Arthrodesis – Enneking type
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Message
Recurrences may be managed with appropriate surgeriesNo Amputation unless
- the tumour is frankly malignant - is too big for conservative management - tumour recurred more than twice
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Summary
GCT is an aggressive tumourCurettage & bone grafting preserves joint function; Recurrence is a problemAdjuvants minimise recurrence; Nothing to choose between different adjuvantsAdequacy of tumour removal determines outcome“Extended curettage”, H2O2 adjuvant & allo cancellous bone grafting is economical; has least recurrence rate
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Summary (contd)
Radiology & Histology cannot predict RecurrenceVEGF & MMP-9 may predict aggressiveness of tumourRecurrences can be recuretted; but excision & reconstruction preferredAmputation for malignant GCT or for tumours too large to be conserved
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a s rao