Novel Strategy of Curettage and Adjuvant Microwave Therapy for the Treatment of Giant Cell Tumor of Bone in Extremities: A Preliminary Study

Abstract

Objectives: To evaluate whether curettage with adjuvant microwave therapy was successful in the treatment of giant cell tumor of the bone (GCTB) in extremities, especially for GCTB with pathological fractures and GCTB of the distal radius.

Methods: This was a retrospective study of 54 cases of GCTB of the extremities treated by curettage with adjuvant microwave therapy between 2007 and 2019. Five patients were lost to follow up and excluded from the study. A total of 33 male and 21 female patients were included in this study. Patients were aged 15-57 years (mean 29.72 ± 10.48 years). Among these patients, there were 10 cases of GCTB with pathological fractures and eight cases of GCTB of the distal radius; one of these cases was combined with a pathological fracture. Comprehensive imaging examinations (X-rays [including lesion site and chest], CT, MRI, emission computed tomography, and pathology examination) of all patients were reviewed. The clinical staging of these patients were evaluated radiologically using the Campanacci classification system based on the extent of spread of the tumor. All patients underwent curettage with adjuvant microwave therapy. Clinical and imaging evaluations were performed in all cases to check for recurrence or metastasis. Lower limb and upper limber function were assessed using the Musculoskeletal Tumor Society score (MSTS), and wrist function was assessed according to the disabilities of the arm, shoulder and hand (DASH) score. Data on surgical-related complications were recorded.

Results: All cases were followed up for 24-126 months (mean 60.69 ± 29.61 months). There were 24 patients with a Campanacci grade of 3 and 30 with a Campanacci grade of 2. The 52 patients were continuously disease-free. The local recurrence rate was 3.70% (2 patients). One patient had recurrence in the proximal femur, and the other developed in soft tissue of the calf muscle. No recurrence occurred for GCTB of the distal radius. One recurrence occurred in a GCTB with pathological fractures. The intervals were 9 and 28 months, respectively. The cases of recurrence all had a Campanacci grade of 3 (8.33%). The median MSTS among the 54 patients was 27.67 ± 3.81. The mean wrist function DASH score was 8.30 ± 2.53. The mean MSTS was 28.67 ± 1.63 and 26.71 ± 5.49 for patients with GCTB of the distal radius and for those with pathological fractures, respectively. In comparing patients with and without pathological fractures, there was no significant difference in the MSTS functional score. Five patients had complications after the surgery.

Conclusion: Curettage with adjuvant microwave ablation therapy provided favorable local control and satisfactory functional outcomes in the treatment of GCTB, especially for cases with pathological fractures and those with GCTB of the distal radius.

Keywords: Distal radius; Giant cell tumor; Microwave ablation; Pathological fracture.

Fig 1

An intraoperative photo of a giant cell tumor of the bone (GCTB) in the proximal tibia. The microwave antennas’ shaft positions were repositioned between ablation cycles. The temperature of the articular cartilage and ligaments was continuously monitored by thermometry needles, and cooled sterilized water was injected into the knee joint to ensure that the temperature was below 43°C. The gauze soaked with ice brine isolates the vascular and nerve bundle from the tumor lesion.

Fig 2

Schematic diagrams (A‐C) of a giant cell tumor in the proximal tibia illustrate the heating and monitoring from three different perspectives. When we ablate the lesion adjacent to the articular surface, we need to pay attention to protect the structure in the articular cavity, and inject ice brine into the articular cavity.Meanwhile, Attention should be paid to the protection of the posterior vascular nerves when we ablate the lesions of adjacent vessels. such as Gauze soaked with ice brine or our hand.(a) Microwave ablation probe. (b) Thermometry needle in the knee joint and adjacent to the lesion. (c) Flow of cryogenic saline cools the articular cavity to protect the normal structure, such as cartilage, meniscus, and cruciate ligament. (d) Gauze soaked with ice brine isolates the vascular and nerve bundle from the tumor lesion. (e) Occassionally, we placed our hand between the tumor lesion and the important vascular nerve to prevent vascular nerve damage. The orange region represents the heating range of the microwave.

Fig 3

An illustrative case of giant cell tumor of the bone (GCTB) with pathological bone fracture. (A, B) Preoperative frontal and lateral X‐rays of the knee, diagnosed with proximal tibial GCTB with pathological fracture. (C, D) Preoperative MRI images of the knee, which indicated the extent of the tumor, Campanacci grade III. (E, F) Postoperative frontal and lateral X‐rays of the knee. During the operation, the ligamentum patellae was cut off and protected and was reconstructed in situ after microwave ablation. (G, H) Postoperative frontal and lateral X‐rays after 2 years; no local recurrence was observed.

Fig 4

An illustrative case of giant cell tumor of the bone (GCTB) of the distal radius. (A, E) This radiograph shows a GCTB of the distal radius, Campanacci II. (B, F) Postoperative frontal and lateral X‐rays; bone cement filled the cavity after curettage. (C, G) 4 years after the operation, no local recurrence was observed. (D, H) 5 years after the operation, there was no local recurrence.

Fig 5

Recurrence‐free survival by site in 54 giant cell tumors of the bone of the long bones (distal radius, distal femur, proximal tibia, proximal femur, other sites, and with pathological fracture).

Fig 6

Mann–Whitney U‐test shows no significant difference in the Musculoskeletal Tumor Society score between lower extremities with and without pathological fractures.

Fig 7

Adverse event survival by site in 54 giant cell tumor of the bone of the long bones. The dots in different colors represent the time of the adverse event. Red point: infection. Green point: subluxation. Blue point: femoral head necrosis. Yellow point: pathological fracture.