Recurrence of Giant Cell Tumor of the Spine after Resection: A Report of 10 Cases

Abstract

Objective: To review the clinical details and further treatments for recurrent spinal giant cell tumors (SGCT), and to analyze the risk factors of recurrence and shed new light on the treatment options and prognosis of recurrent SGCT.

Methods: A retrospective analysis of recurrent SGCT between April 2003 and January 2014 was performed. A total of 10 patients comprising 3 men and 7 women with a mean age of 28.9 years (range, 21-40 years) were included in the study. All complete clinical data, radiographs, CT, MRI, scans and pathological data were reviewed. The tumor locations and the regions involved were evaluated by CT and MRI. The blood supply of the tumors was evaluated by enhanced CT and MRI. The mean follow-up was 81.3 months (range, 35.7-172.1 months).

Results: All patients had Enneking stage 3 tumors; 9 (90%) of them had different extents of spinal canal involvement in the primary time period. All patients underwent intralesional resection during their first surgery. Only 1 patient received local adjuvant treatments; no patient underwent selective arterial embolization or used denosumab at that time. Only 1 patient underwent adjuvant radiotherapy postoperatively, and another patient used bisphosphonates. After recurrence, 1 patient was cured using denosumab, and 2 patients' disease was controlled through use of other medical treatments or adjuvant treatments. There were 3 repeated recurrences and 7 repeated surgical procedures were performed in 5 patients. There were 6 intralesional excisions and 1 decompression surgery. The mean relapse-free time after the first surgery was 32.3 months (range, 10.5-62.6 months). The overall mean relapse-free time was 40.2 months (range, 10.5-157 months). No distant metastasis was found in our series. At the final follow-up, 4 patients were disease free, 3 patients' disease was under control, 2 has progressive disease aggravation, while 1 patient died as a result of progression of disease 133.9 months after first surgery.

Conclusion: Intralesional excision for recurrent spinal giant cell tumors is an effective option that may have satisfactory prognosis. However, the excision and the inactivation of the lesion should be carried out carefully and thoroughly without missing any corners. Early diagnosis of recurrence may be associated with better prognosis. Adjuvant treatments perioperatively and systemic medical treatments can decrease recurrence rates and can have therapeutic effects in the recurrent SGCT.

Keywords: Giant cell tumor; Prognosis; Recurrence; Spinal giant cell tumor; Spine.

Figure 1

This graph shows the time taken for a recurrence to develop after the first surgery in 10 patients, expressed as a percentage of the total number of recurrences.

Figure 2

Case 3, (A, B) Preoperative anteroposterior and lateral plain radiographs showing a lesion with pathological fracture at L₁. (C, D) Postoperative anteroposterior and lateral plain radiographs showing the position of the instruments. (E) Sagittal CT showing that the lesion was resected by intralesional curettage and reconstructed by titanium cage filled with bone graft. (F, G) T1‐weighted sagittal and axial MR images showing a local recurrence of spinal giant cell tumors at L₁ 26.8 months postoperatively. (H, I) Axial and coronal CT showing the vertebral osteolysis around titanium cage at L₁. (J) Pathological examination confirmed the recurrence of giant cell tumors. HE staining; magnification ×20. (K, L) Axial and coronal CT angiograms showing the resection of the tumo; bone cement was packed in the cavity.

Figure 3

Case 4, (A, B) T1‐weighted sagittal and T2‐weighted axial MR images showing a soft tissue mass with spinal canal involved at T_5–6 11.4 months after the first intralesional curettage of spinal giant cell tumors. (C, D) Sagittal and axial CT showing that the left vertebral pedicles of T_5–6 were affected by the mass. (E, F) Sagittal and axial CT showing that the lesion was resected by intralesional curettage. (G, H) Postoperative anteroposterior and lateral plain radiographs showing the position of the instruments. (I) Pathological examination confirmed the recurrence of giant cell tumors. HE staining; magnification ×20. (J) T2‐weighted axial MR image showing no evidence of recurrence 1 year after the repeated surgery. (K) T2‐weighted axial MRI showing a moderate signal intensity of mass nearby the vertebral body of T_5–6 38.3 months after the repeated surgery. (L) T2‐weighted axial MR image showing that the mass has no further growth at 17 months follow‐up.

Figure 4

Overall recurrence‐free survival through Kaplan–Meier analysis for patients (case 1–5) at first recurrence and their repeated recurrences. Number of patients: 5. No statistically significant difference was noted between first and repeated recurrences (P = 0.115).