Date Published: August 25, 2012
Publisher: Informa Healthcare
Author(s): L van der Heijden, MA van de Sande, PD Dijkstra.
Risk factors for local recurrence of giant-cell tumor of bone (GCTB) have mostly been studied in heterogeneous treatment groups, including resection and intralesional treatment. The aim of the study was the identification of individual risk factors after curettage with adjuvants in GCTB.
Of 147 patients treated for primary GCTB between 1981 and 2009, 93 patients were included in this retrospective single-center study. All patients were treated with curettage and polymethylmethacrylate (PMMA) with (n = 75) or without (n = 18) phenol. Mean follow-up was 8 (2–24) years. Recurrence-free survival was assessed for treatment modalities. Age, sex, tumor location, soft tissue extension, and pathological fractures were scored for every patient and included in a Cox regression analysis.
The recurrence rate after the first procedure was 25/93. Recurrence-free survival for PMMA and phenol and for PMMA alone was similar. Eventually, local control was achieved using 1 or multiple intralesional procedures in 85 patients. Resection was required in 8 patients. A higher risk of local recurrence was found for soft tissue extension (HR = 5, 95% CI: 2–12), but not for age below 30, sex, location (distal radius vs. other), or pathological fracture.
Curettage with adjuvants is a feasible first-choice treatment option for GCTB, with good oncological outcome and joint preservation. Soft tissue extension strongly increased the risk of local recurrence, whereas age, sex, location, and pathological fractures did not.
In this retrospective single-center study, we identified 147 patients with primary GCTB who had been treated at our tertiary referral center for orthopedic oncology between 1981 and 2009 (Figure 1). All patients had a minimum follow-up of 2 years. As primary treatment, curettage with adjuvants (n = 113, 77%), en bloc resection (n = 28, 19%), or other treatment (n = 6, 4%) was performed. We did not evaluate patients who were primarily treated with resection (n = 28); nor did we evaluate patients primarily treated with curettage without PMMA (n = 10), with bisphosphonates (n = 2), with denosumab (n = 2), with radiotherapy (n = 1), or with arterial embolization (n = 1) because it was not standard treatment protocol. There was no statistically significant difference in the patient characteristics or tumor characteristics of excluded patients and of those who were included.
25 of the 93 patients with primary GCTB had a local recurrence. Mean time to first recurrence was 19 (4–78) months. Overall recurrence-free survival rates at 2 and 5 years were 0.82 and 0.74, respectively, and for recurrent GCTB they were 0.63 and 0.45 (Table 2). 4 patients died after 4–9 years, all for reasons unrelated to GCTB. None of these patients had local recurrence or metastases at final follow-up. Local control was achieved using 1 or multiple intralesional procedures in 85 of the 93 patients at 5 years postoperatively. Recurrence-free survival was similar in both primary and recurrent tumors that were treated with or without phenol in addition to PMMA (Figures 2 and 3).
This study demonstrates that curettage with adjuvants is a feasible first-choice treatment option for GCTB, even in the case of soft tissue extension or pathologic fracture. We performed intralesional treatment in the majority of GCTBs with soft tissue extension, either alone or combined with pathological fractures. This would explain the relatively high local recurrence rate, but if we only consider GCTB without a soft tissue component, the local recurrence rate is comparable to that reported in the recent literature (Table 4). However, the risk of a second recurrence after repeat curettage was relatively high (47%).