Giant cell tumor of bone: risk factors for recurrence

Abstract

Background: Many surgeons treat giant cell tumor of bone (GCT) with intralesional curettage. Wide resection is reserved for extensive bone destruction where joint preservation is impossible or when expendable sites (eg, fibular head) are affected. Adjuvants such as polymethylmethacrylate and phenol have been recommended to reduce the risk of local recurrence after intralesional surgery. However, the best treatment of these tumors and risk factors for recurrence remain controversial.

Questions/purposes: We evaluated the recurrence-free survival after surgical treatment of GCT to determine the influence of the surgical approach, adjuvant treatment, local tumor presentation, and demographic factors on the risk of recurrence.

Methods: We retrospectively reviewed 118 patients treated for benign GCT of bone between 1985 and 2005. Recurrence rates, risk factors for recurrence and the development of pulmonary metastases were determined. The minimum followup was 36 months (mean, 108.4 ± 43.7; range, 36-233 months).

Results: Wide resection had a lower recurrence rate than intralesional surgery (5% versus 25%). Application of polymethylmethacrylate decreased the risk of local recurrence after intralesional surgery compared with bone grafting; phenol application alone had no effect on the risk of recurrence. Pulmonary metastases occurred in 4%; multidisciplinary treatment including wedge resection, chemotherapy, and radiotherapy achieved disease-free survival or stable disease in all of these patients.

Conclusion: We recommend intralesional surgery with polymethylmethacrylate for the majority of primary GCTs. Because pulmonary metastases are rare and aggressive treatment of pulmonary metastases is usually successful, we believe the potential for metastases should not by itself create an indication for wide resection of primary tumors.

Level of evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Fig. 1A–F

(A) AP and (B) lateral views are shown of a GCT of the distal radius at diagnosis. (C) AP and (D) lateral radiographs obtained 6 months after intralesional surgery with polymethylmethacrylate filling are shown. (E) AP and (F) lateral radiographs obtained at the 3-year followup show no signs of recurrence.

Fig. 2

Recurrence-free survival for patients with primary giant cell tumor (GCT) treated with wide resection (A) and intralesional surgery (B) is shown. Treatment subgroups for patients were intralesional surgery included the use of polymethylmethacrylate (PMMA) and phenol (B1), the use of bone grafting and phenol (B2), and intralesional surgery without adjuvants (B3). The estimated cumulative recurrence free survival (95% confidence interval) rates were 0.947 (0.847–0.999) for Group A, 0.747 (0.659–0.835) for Group B, 0.851 (0.741–0.961) for Group B1, 0.656 (0.491–0.821) for Group B2, and 0.682 (0.488–0.876) Group B3.