|Year : 2022 | Volume
| Issue : 3 | Page : 1549-1554
Functional and oncological outcomes after extended curettage of giant cell tumor around the knee
Bahaa M Hasan, Abdallah I Algarf, Ismail T Badr
Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||13-Mar-2022|
|Date of Decision||14-Apr-2022|
|Date of Acceptance||17-Apr-2022|
|Date of Web Publication||29-Oct-2022|
Abdallah I Algarf
Source of Support: None, Conflict of Interest: None
To evaluate the functional and oncological outcomes after extended curettage of giant cell tumor (GCT) around the knee joint.
GCT is a relatively common benign bone tumor. The peak incidence is at the middle age. It usually involves the ends of long bones around the knee joint. Although many patients usually present with mild to moderate symptoms, the effect of the GCT on individual well-being can be significant.
Patients and methods
This is a prospective and retrospective nonrandomized study that included 20 patients with GCT around the knee joint. Patients were managed surgically with extended curettage with or without internal fixation. High-speed burr and bone cement were used in all cases. Plate and screws were used in eight patients (40% of cases), two (10%) patients were augmented with rush pins, and one (5%) patient was augmented with K-wires. Complications and oncological and functional outcomes were evaluated and analyzed.
A total of 17 (85%) patients had no complications. One (5%) case had mild knee osteoarthritis. One (5%) case had a recurrence. One (5%) case had a soft tissue recurrence with osteoarthritis. No cases had lung metastasis. The mean total musculoskeletal tumor society score preoperatively was 20.4 ± 2.58 and postoperatively was 28.9 ± 1.17. The mean follow-up period was 25.75 ± 15.47 months.
Surgical treatment of GCT with extended curettage using high-speed burr and bone cement as adjuvant improves the patient's functional outcome and decreases GCT recurrence rate.
Keywords: extended curettage, functional outcome, giant cell tumor, oncological outcome, polymethyl-methacrylate
|How to cite this article:|
Hasan BM, Algarf AI, Badr IT. Functional and oncological outcomes after extended curettage of giant cell tumor around the knee. Menoufia Med J 2022;35:1549-54
|How to cite this URL:|
Hasan BM, Algarf AI, Badr IT. Functional and oncological outcomes after extended curettage of giant cell tumor around the knee. Menoufia Med J [serial online] 2022 [cited 2023 Feb 4];35:1549-54. Available from: http://www.mmj.eg.net/text.asp?2022/35/3/1549/359529
| Introduction|| |
Giant cell tumor (GCT) is a benign tumor with locally aggressive behavior, and it can metastasize to the lung in ∼1–9% of cases,. GCT is a relatively common benign tumor with its peak incidence at middle age. It usually involves the ends of long bones, for example, distal femur.
Patients present with pain, soft tissue mass or lump, limited range of motion, joint effusion, or even synovitis. Some patients may present with pathological fracture, which indicates a more aggressive form of tumor.
Radiographic characteristics include a skeletally mature patient with eccentric, epiphyso-metaphyseal, well-circumscribed, lytic lesion with a narrow zone of transition. Usually, there is no sclerotic rim at the margin of the tumor or visible mineralization inside it.
Campanacci et al. classified the tumor into three grades based on its radiographic appearance and tumor aggressiveness.
Treatment of GCT is mainly surgical and usually includes extended curettage (burr + adjuvant) or wide resection. A high-speed burr is used to provide a properly clean cavity after tumor curettage without endangering vital structures such as the articular cartilage. Moreover, adjuvants such as polymethyl-methacrylate, phenol, hydrogen peroxide, cryotherapy, and alcohol are used, which ultimately aims to ensure complete removal of the tumor and reduce the chance of tumor recurrence. Recently, the rate of recurrence after extended curettage (burr + adjuvant as cement) is greatly reduced and mostly the recurrence of the GCT occurs within the first 2 years after the surgical procedure,. This study aims to evaluate the functional and oncological outcome after extended curettage of GCT around the knee joint.
| Patients and methods|| |
With the approval of the ethical committee, a retrospective and prospective nonrandomized study was conducted of clinical data of 20 patients diagnosed with GCT around the knee and treated surgically with extended curettage with or without internal fixation at Menoufia University Hospital and Kasr-Alainy Hospital between July 2019 and August 2021. Informed consent was obtained from all patients in the study. Patients diagnosed with GCT around the knee joint were included. Patients with GCT in axial skeleton or sites other than around the knee joint or who received denosumab alone or as adjuvant before surgery, as well as patients who had lung metastasis or were treated with en-block resection were excluded. All patients were evaluated and analyzed for the demographic data, clinical picture, and laboratory and radiological investigations. Intraoperative data such as the use of tourniquet, the approach, biopsy collection, the use of high-speed burr, the type of chemical adjuvant (e.g., hydrogen peroxide), the use of a filling material (e.g., cement), the use of internal fixation method (e.g., plate and screws), and complications were collected. Postoperative data including complications, period of follow-up, radiographic evaluation, functional evaluation using musculoskeletal tumor society (MSTS) score, and presence of local recurrence were collected. The operative technique included the application of a tourniquet at the base of the affected limb, then the limb was sterilized, and skin incision of a proper length was applied according to the tumor size and location. The tumor was then accessed through a proper approach respecting contemporary guidelines of tumor surgery, providing an adequately large bone window for full visualization and curettage of the entire tumor mass. Different size curettes were then used to evacuate the cavity out of the tumor mass followed by using a high-speed burr to ensure adequate curettage of the lesion [Figure 1]. Hydrogen peroxide and extensive jet lavage were used, which added to the quality of the curettage. Bone cement was then used to fill the tumor cavity either alone or augmented with an internal fixation method such as plate and screws. The wound was sutured back after the application of a drain. Clinical and radiological follow-up was done every 3 months in the first year and then every 6 months for 2 years. The functional outcomes of patients were collected according to the MSTS score.
|Figure 1: Intraoperative images of GCT of the distal femur of a 36-year-old woman. The images show the cavity of GCT before and after using a high-speed burr for curettage (case no. 17). GCT, giant cell tumor.|
Click here to view
Data were fed to the computer and analyzed using IBM SPSS software package, version 20.0. (IBM Corp., Armonk, New York, USA). Qualitative data were described using numbers and percentages. The Kolmogorov–Smirnov test was used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, and SD. The significance of the obtained results was judged at the 5% level.
Data were coded, entered, and analyzed using SPSS (statistical package for social sciences), version 20 and GraphPad Prism 8. Descriptive statistics was done for the study regarding all collected variables.
The level of significance (P value) was set as follows:
- P value more than 0.05: nonsignificant.
- P value less than 0.05: significant.
- P value less than 0.01: highly significant.
| Results|| |
A total of 20 patients (11 males and nine females) were included. The mean age was 33.3 ± 9.71 years (range, 17–53 years). All of the patients were skeletally mature [Table 1].
|Table 1: Demographic data distribution, duration, follow-up, treatment, complications, and treatment of complication in all of the study population|
Click here to view
The duration of symptoms was ∼6 months, and the mean follow-up period after our surgical intervention was about 25.75 ± 15.47 months [Table 1].
Regarding the method of fixation, plate and screws were used in eight (40%) cases, two (10%) cases were augmented with rush pins, and one (5%) case was augmented with K-wires. Bone cement was used in 20 (100%) cases. A total of five (25%) cases needed immobilization for 1 month. Partial weight-bearing was permitted after 1 week in 15 (75%) cases and after 4 weeks in five (25%) cases [Table 1].
Regarding oncological outcomes, two (10%) cases had a local recurrence. No cases had lung metastasis [Table 2].
The mean total MSTS score preoperatively was 20.4 ± 2.58 and postoperatively was 28.9 ± 1.17, with a P value less than 0.0001, indicating high statistical significance [Table 3].
|Table 3: Total musculoskeletal tumor society score data distribution in all study population|
Click here to view
Regarding complications, 17 (85%) patients had no complications. One (5%) case had mild knee osteoarthritis alone treated with analgesics. One (5%) case had a recurrence and was treated by resection with prosthetic replacement of the knee joint. One (5%) case had a soft tissue recurrence accompanied by mild knee osteoarthritis and was treated by removal of the soft tissue mass [Table 2].
| Discussion|| |
The most common site of affection of GCT is around the knee joint, which is a crucial joint for everyday activities and hence for leading a normal life, so various surgical methods and technique enhancements were described over the years aiming to optimize the functional and oncological outcome following surgical treatment of the GCT. Surgical treatment can be done either by resection of the affected area followed by joint reconstruction or by curettage of the GCT.
In this study, 20 cases of GCT around the knee were treated with extended curettage (11 male and nine female), which showed slight male predominance. Some studies coincided with this study as in the study by Ayerza et al., where 22 patients were reviewed, of which 16 were males and six were females. This is contrary to most literature studies, which indicate a slight female predominance of GCT, as in the study by Caubère et al., where 19 patients were reviewed, comprising eight males and 11 females.
In this study, the mean age of patients was 33.3 ± 9.71 years (range 17–53 years), which is slightly higher than the mean age of patients in the study by Ayerza et al. (mean age of patients was 31 years), but it is lower than the mean age of patients in the study by Caubère et al. (mean age of the patients was 46 years old).
In the literature, GCT usually affects the patients around the third and fourth decade of life,,. In this study, the mean age of patients was 33.3 ± 9.71 years old, which is a relatively young age. As the most affected site of GCT is around the knee joint, the intralesional curettage method aims to get rid of the GCT without compromising the integrity of the natural adjacent knee joint while maintaining an adequate functional outcome. The main disadvantage of the intralesional curettage method is that it does not always ensure a complete rid of the tumor and hence it has a high recurrence rate.
Most studies,,,, agree that ensuring complete removal of the tumor is the most important predictive factor for local recurrence of the GCT. As adjuvants cannot compensate for bad techniques, better techniques have been developed over the years to improve the ability of the curettage to ensure complete eradication of the remnants of GCT. Using a high-speed burr, as we did in all cases of this study, is one of these promising techniques. It is used to extend the curettage and to deepen the GCT cavity after the evacuation of the GCT mass. Moreover, a high-speed burr enables the removal of the remaining bony septa and crista to eliminate any interior cavity space that could be inaccessible during manual curettage and could act as potential hideouts for tumor remnants,,.
Although using adjuvants in GCT is still controversial in literature,, a combination of multiple modalities such as high-speed burr and local adjuvant such as cement is usually recommended to further extend the margin of curettage and ensure complete elimination of the tumor remnants to minimize the risk of local recurrence. Bone cement is thought to extend the margins of the curettage by exploiting its necrotic thermal effect on tissues. In addition, the direct toxic effect of the cement monomer on the adjacent bone is thought to induce hypoxia, all of which could contribute to the elimination of any microscopic remnants of the tumor cells that could be present beyond the tumor's proper area,,,.
In all cases of this study, we used bone cement as a local adjuvant after completion of the intralesional curettage using the high-speed burr. Depending on the size of the GCT cavity and integrity of its cortical walls, bone cement was used either alone or accompanied by internal fixation. A total of nine (45%) cases were filled with bone cement alone [Figure 2], as in these cases, the residual cavity after the curettage was relatively small, and the cortical walls and the subchondral bone supporting the joint cartilage were of sufficient thickness. In cases of the large residual cavity with thin cortical cavity walls, the bone cement was augmented by internal fixation in the form of plate and screws, as we did in eight (40%) cases, or rush pins, as we did in two (10%) cases, or even k-wires, as we did in one (5%) case.
|Figure 2: (a and b) Preoperative radiograph of the left knee (anteroposterior and lateral) showing osteolytic meta-epiphyseal expansile bony lesion GCT of the proximal tibia. (c and d) Postoperative radiograph of the knee showing filling of GCT bony cavity with cement after extended curettage. (e and f) Six-month postoperative radiograph of the knee showing the GCT cavity filled with cement after extended curettage, healing of cortical window, and no radiolucent zones around the cement, indicating no recurrence. GCT, giant cell tumor.|
Click here to view
The bone cement either alone or with internal fixation provides immediate mechanical stability which reduces the need for prolonged immobilization and enables early weight-bearing. In this study, 15 (75%) patients did not need immobilization, and only five (25%) patients needed immobilization for 1 month. In addition, partial weight-bearing was permitted for 15 (75%) patients after 1 week postoperatively and for five (25%) patients after 4 weeks postoperatively.
There was one (5%) case of pathological fracture treated by extended curettage, cementation, and internal fixation with plate and screws. This patient was immobilized for 4 weeks and then partial weight-bearing was permitted. The functional outcome was satisfactory for the patient, and there were no signs of recurrence at the latest follow-up.
The recurrence rate in this study is 10% which is an accepted range compared with most studies,,,. Such results support our hypothesis that extended curettage of GCT around the knee achieves a good oncological outcome while preserving a satisfactory functional outcome of the knee joint.
In this study, 18 (90%) cases were disease free at an average of about 25.75 ± 15.47 months (range, 6–60 months) postoperatively. Recurrence occurred in two (10%) cases. One (5%) case had the recurrence in the form of an osteolytic lesion around the bone cement 12 months after surgery and was treated surgically by hardware removal, as well as resection with prosthetic replacement of the knee joint. One (5%) case had the recurrence in the form of soft tissue GCT around the distal femur which occurred 17 months postoperatively and was treated with removal of the GCT soft tissue mass.
In this study, recurrences occurred within one and half years postoperatively (the first recurrence occurred after 12 months, and the longest after 17 months). Most studies,, suggest that GCT recurrence occurs within 2 years postoperatively. The mean follow-up period in this study was 25.75 ± 15.47 months which is supposedly enough to indicate recurrence tendency after treatment of GCT with extended curettage.
Regarding other complications, two (10%) cases showed symptoms of osteoarthritis. The first case was an old age patient (53 years). The second case was a young age patient (26 years old) who had a soft tissue recurrence mass; hence, the knee osteoarthritis could be more attributed to the effects of other factors such as old age and recurrence, rather than the surgical technique and use of cement.
The mean total MSTS score preoperatively was 20.4 ± 2.58 and postoperatively was 28.9 ± 1.17, with a P value less than 0.0001, indicating high statistical significance. The functional outcome was considered satisfactory as it showed an average MSTS score of 28.9 ± 1.17 points, which was similar to the MSTS score in the study by Ayerza et al..
Limitations of this study include the relatively small number of patients; some cases were analyzed retrospectively, which might lead to bias; and not all cases were done by the same surgeon or at the same institute. Finally, results should be considered preliminary as a longer period of follow-up is recommended.
| Conclusion|| |
Surgical treatment of GCT around the knee joint with extended curettage, using high-speed burr, and bone cement as an adjuvant improves the functional outcome of the patients and decreases the recurrence rate of GCT.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mavrogenis AF, Igoumenou VG, Megaloikonomos PD, Panagopoulos GN, Papagelopoulos PJ, Soucacos PN. Giant cell tumor of bone revisited. SICOT J 2017; 3
Siebenrock KA, Unni KK, Rock MG. Giant-cell tumour of bone metastasising to the lungs: a long-term follow-up. J Bone Joint Surg Br 1998; 80
López-Pousa A, Broto JM, Garrido T, Vázquez J. Giant cell tumour of bone: new treatments in development. Clin Transl Oncol 2015; 17
van der Heijden L, Dijkstra PDS, van de Sande MAJ, Kroep JR, Nout RA, van Rijswijk CSP, et al
. The clinical approach toward giant cell tumor of bone. Oncologist 2014; 19
Campanacci M, Baldini N, Boriani S, Sudanese A. Giant-cell tumor of bone. J Bone Joint Surg Am 1987; 69
Li D, Zhang J, Li Y, Xia J, Yang Y, Ren M, et al
. Surgery methods and soft tissue extension are the potential risk factors of local recurrence in giant cell tumor of bone. World J Surg Oncol 2016; 14
Amelio JM, Rockberg J, Hernandez RK, Sobocki P, Stryker S, Bach BA, et al
. Population-based study of giant cell tumor of bone in Sweden (1983–2011). Cancer Epidemiol 2016; 42
Ayerza MA, Aponte-Tinao LA, Farfalli GL, Restrepo CAL, Muscolo DL. Joint preservation after extensive curettage of knee giant cell tumors. Clin Orthop Relat Res 2009; 467
Caubère A, Harrosch S, Fioravanti M, Curvale G, Rochwerger A, Mattei JC. Does curettage–cement packing for treating giant cell tumors at the knee lead to osteoarthritis?. Orthop Traumatol Surg Res 2017; 103
Saibaba B, Chouhan DK, Kumar V, Dhillon MS, Rajoli SR. Curettage and reconstruction by the sandwich technique for giant cell tumours around the knee. J Orthop Surg 2014; 22
Balke M, Schremper L, Gebert C, Ahrens H, Streitbuerger A, Koehler G, et al
. Giant cell tumor of bone: treatment and outcome of 214 cases. J Cancer Res Clin Oncol 2008; 134
Trieb K, Bitzan P, Lang S, Dominkus M, Kotz R. Recurrence of curetted and bone-grafted giant-cell tumours with and without adjuvant phenol therapy. Eur J Surg Oncol 2001; 27
Kivioja AH, Blomqvist C, Hietaniemi K, Trovik C, Walloe A, Bauer HCF, et al
. Cement is recommended in intralesional surgery of giant cell tumors: a Scandinavian Sarcoma Group study of 294 patients followed for a median time of 5 years. Acta Orthop 2008; 79
Hu P, Zhao L, Zhang H, Yu X, Wang Z, Ye Z, et al
. Recurrence rates and risk factors for primary giant cell tumors around the knee: a multicentre retrospective study in China. Sci Rep 2016; 6
Ghert M, Algawahmed H, Turcotte R, Farrokhyar F. High-speed burring with and without the use of surgical adjuvants in the intralesional management of giant cell tumor of bone: a systematic review and meta-analysis. Sarcoma 2010; 2010
Prosser GH, Baloch KG, Tillman RM, Carter SR, Grimer RJ. Does curettage without adjuvant therapy provide low recurrence rates in giant-cell tumors of bone?. Clin Orthop Relat Res 2005; 435
Intralesional W, Ebeid WA, Hasan BZ, Badr IT. Functional and oncological outcome after treatment. J Pediatr Orthop 2019; 39
Tsukamoto S, Mavrogenis AF, Tanzi P, Leone G, Akahane M, Tanaka Y, et al
. Curettage as first surgery for bone giant cell tumor: adequate surgery is more important than oncology training or surgical management by high volume specialized teams. Eur J Orthop Surg Traumatol 2020; 30
Saiz P, Virkus W, Piasecki P, Templeton A, Shott S, Gitelis S. Results of giant cell tumor of bone treated with intralesional excision. Clin Orthop Relat Res 2004; 424
Lackman RD, Hosalkar HS, Ogilvie CM, Torbert JT, Fox EJ. Intralesional curettage for grades II and III giant cell tumors of bone. Clin Orthop Relat Res 2005; 438
Chakarun CJ, Forrester DM, Gottsegen CJ, Patel DB, White EA, Matcuk GR. Giant cell tumor of bone: review, mimics, and new developments in treatment. Radiographics 2013; 33
Co HL, Wang EHM. Giant cell tumor of the small bones of the foot. J Orthop Surg 2018; 26
Müller DA, Beltrami G, Scoccianti G, Campanacci DA, Franchi A, Capanna R. Risks and benefits of combining denosumab and surgery in giant cell tumor of bone – a case series. World J Surg Oncol 2016; 14
Movahedinia S, Shooshtarizadeh T, Mostafavi H. Secondary malignant transformation of giant cell tumor of bone: is it a fate?. Iran J Pathol 2019; 14
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]