Surgical challenges, novel techniques, and systemic treatment of giant cell tumour of bone of the distal radius

Abstract

Aims Giant cell tumour of bone (GCTB) treatment changed since the introduction of denosumab from purely surgical towards a multidisciplinary approach, with recent concerns of higher recurrence rates after denosumab. We evaluated oncological, surgical, and functional outcomes for distal radius GCTB, with a critically appraised systematic literature review. Methods We included 76 patients with distal radius GCTB in three sarcoma centres (1990 to 2019). Median follow-up was 8.8 years (2 to 23). Seven patients underwent curettage, 38 curettage with adjuvants, and 31 resection; 20 had denosumab. Results Recurrence rate was 71% (5/7) after curettage, 32% (12/38) after curettage with adjuvants, and 6% (2/31) after resection. Median time to recurrence was 17 months (4 to 77). Recurrences were treated with curettage with adjuvants (11), resection (six), or curettage (two). Overall, 84% (38/45) was cured after one to thee intralesional procedures. Seven patients had 12 months neoadjuvant denosumab (5 to 15) and sixmonths adjuvant denosumab; two recurred (29%). Twelve patients had six months neoadjuvant denosumab (4 to 10); five recurred (42%). Two had pulmonary metastases (2.6%), both stable after denosumab. Complication rate was 18% (14/76, with 11 requiring surgery). At follow-up, median MusculoSkeletal Tumour Society score was 28 (18 to 30), median Short Form-36 Health Survey was 86 (41 to 95), and median Disability of Arm, Shoulder, and Hand was 7.8 (0 to 58). Conclusion Distal radius GCTB treatment might deviate from general GCTB treatment because of complexity of wrist anatomy and function. Novel insights on surgical treatment are presented in this multicentre study and systematic review. Intralesional surgery resulted in high recurrence-rate for distal radius GCTB, also with additional denosumab. The large majority of patients however, were cured after repeated curettage. Cite this article: Bone Jt Open 2022;3(7):515–528.

Giant cell tumour of bone

“…our study also showed that larger tumour size, higher campanacci grade, and the presence of a soft-tissue mass or a pathological fracture did not affect the rate of LR when evaluated across the entire cohort of 354 patients or the 267 treated by curettage. pathological fracture and campanacci stage were correlated with lr in other studies, 8,25,27,28 which differs from our observation, and may be related to population-based differences or technical aspects of surgical management. However, the presence of a pathological fracture or soft-tissue mass, factors which together define Campanacci grade 3 disease, are likely to contribute to surgical decision-making as their presence can make tumour removal by curettage and joint salvage more difficult, thereby pushing the treatment decision towards resection.…”

“…Even when joint sparing may be possible, GCTB of the distal radius carries the highest risk of LR, such that marginally salvageable joints may often best be treated with resection and fusion instead. 25,26 Not surprisingly, in this study, curettage of a GCTB in the distal radius had the highest rate of LR (33.3%) compared to all other sites combined (10.7%) (p = 0.043, Figure 7). By comparison, when GCTB involves expendable bones, the decision to proceed directly to resection is easier since this gives a low risk of recurrence with minimal associated morbidity.…”

“…younger age, distal radial location, and intralesional curettage were all associated with a higher risk of lr on univariate analysis. 25 By comparison, tumour size, campanacci grade, soft-tissue extension, presence of pathological fracture, and patient sex were not associated with the risk of lr. Multivariate analysis showed that curettage rather than resection was the only independent risk factor for lr.…”

“…patients treated with denosumab at our centre were excluded from this study since it has been directly linked to a higher rate of lr after curettage and joint salvage, 18,20 and would otherwise introduce bias. However, denosumab has a role in the management of metastatic disease and in locally advanced cases can be used to facilitate joint salvage even though the risk of lr may be increased, 18,25,32 or even to delay or possibly avoid surgical treatment. nevertheless, case reports of bone sarcoma arising in GctB following denosumab treatment are concerning.…”