Recurrence Rates and Risk Factors for Primary Giant Cell Tumors around the Knee: A Multicentre Retrospective Study in China

Abstract

Giant cell tumors of the bone (GCTBs) are commonly diagnosed in Asian populations, usually around the knee. Herein, we aimed to determine the clinical characteristics, local recurrence rates, and relevant risk factors of primary GCTB around the knee. Univariate and multivariate survival analyses were used to identify the risk factors for local recurrence. Four hundred ten patients with primary GCTB around the knee, treated between March 2000 and June 2014, were recruited from 7 institutions in China. The overall local recurrence rate was 23.4%, but was higher in patients aged 20-39 years (28.5%; P = 0.039). The local recurrence rate was the highest in patients treated with intralesional curettage (53.4%), and the lowest in those treated with resection (4.9%). We found a higher risk of tumor recurrence in the proximal fibula compared to the distal femur (hazard ratio: 28.52, 95% confidence interval: 5.88-138.39; P < 0.0001), and in patients treated with curettage compared to those treated with resection (hazard ratio: 12.07, 95% confidence interval: 4.99-29.18; P < 0.0001). Thus, the tumor location must be considered when selecting the optimal surgical treatment approach to reduce the risk of local recurrence and preserve joint function, especially in young patients.

Figure 1. Kaplan-Meier curve of the cumulative rate without local recurrence by tumor location.

Reference as tumor located distal femur, the HR (95% CI) of local recurrence was 21.54 (4.89, 94.78) in tumor located in fibular head, P < 0.0001.

Figure 2. Kaplan-Meier curve of the cumulative rate without local recurrence by surgical approach.

Reference as en-bloc resection and marginal resection, there was a HR (95% CI) of 11.25 (4.69, 26.97) in intracystic curettage, and 5.85 (2.45, 13.96) in resection partly with intracystic curettage, all P < 0.0001.

Figure 3

The diagrammatic drawing of intracystic curettage: (a) Indications: with a localized lesion, no broken or mild broken the cortical bone, without obvious soft tissue mass. (b) A window in the cortical bone was made. (c) To remove mass using a series of curettes of various sizes. (d) To polish the residual tumor cavity with a high-speed burring until reaching the normal cortical bone. (e) To fill the residual tumor cavity with allogenic particle bone graft and covered the windowed cortical bone.

Figure 4

The diagrammatic drawing of curettage combined with resection: (a) Indications: with an extensive lesion, with around soft tissue mass, the part broken cortical bone without possible of reserve, with a tumor involved the articular cavity or cruciate ligament. (b) To remove the cortical bone and soft tissue mass without possible of reserve, and continued to dispose the tumor cavity using curette and a high-speed burr. (c) To fill the cavitary bone defects with allogenic particle bone graft, and internal fixation using an anatomical bone plate.

Figure 5

The diagrammatic drawing of en bloc marginal resection: (a) Indications: with extensive bone cortex lesions together with around large soft tissue mass. An osteotomy plane was confirmed based on preoperative magnetic resonance imaging (dashed line indicated the osteotomy plane). (b) To resect the en bloc tumor, and to reconstruct the knee using an articulated prosthesis.

Figure 6. Flow chat of patients’ selection.

Of the 410 included patients, 304 completed ≥12 months of follow-up (response rate, 74.1%), with a median follow-up time of 55 months (range, 12–188 months). Of these patients, 252 (82.9%) received face-to-face follow-up with physical and radiological examinations at the 7 participating hospitals; 52 (17.1%) were also contacted via telephone, with their physical and radiological examinations performed at local hospitals.