31.9.23 Examine the Outcomes of Surgical Procedures in Patients with Giant Cell Tumors

Original Article

 

Surgical Procedures in Patients with Giant Cell Tumors

Examine the Outcomes of Surgical Procedures in Patients with Giant Cell Tumors

Muhammad Ishaq1, Karim Bakhsh2 and Attiq-ur-Rehman2

ABSTRACT

Objective: To examine the outcomes of different surgical procedures in patients with giant cell tumor also determine the frequency of involved bone required surgical treatment.

Study Design: Retrospective study.

Place and Duration of Study: This study was conducted at the Department of Orthopedic & Traumatology, Qazi Hussain Ahmad Medical Complex Nowshera from January 2018 to March 2020.

Materials and Methods: Sixteen patients of both genders presented with biopsy proven giant cell tumor were analyzed in this study. Patients detailed demographic including age, sex and residence were recorded after written consent. Types of bones and different surgical procedures for the treatment were examined. Outcomes of surgical treatment were examined by Musculo Skeletal Tumor Society score (MSTS). Follow-up was taken at 1 year after surgery.

Results: Ten (62.5%) patients were males and 6 (37.5%) were females. 3 (18.75%) patients were ages less than 20 years, 11 (68.75%) patients were ages 20 to 40 years and 2 (12.5%) patients had ages above 40 years. Pain and swelling was commonly found symptom in 8 (50%) patients. Distal femur was the commonest site in 5(31.25%) patients followed by proximal tibia in 4 (25%) patients. Curettage and bone cementation was the commonly performed surgical procedure in 5 (31.25%), followed by wide excision of bone and cementation and implant in 4 (25%) patients, 3 (18.75%) patients received curettage and bone grafting, 2 (12.5%) had received disarticulation, 1 (6.25%) patient were received arthroplasty and amputation was done in 1 (6.25%) patient. Recurrence was found in 1 patient with curettage and bone grafting and 2 with curettage and bone cementation. The mean MSTS score was 26.2 out of 30.

Conclusion: Giant cell tumor is commonly found in patients with 3rd and 4th decade of life. Distal femur and proximal tibia were the most common site of bones involved and curettage and cementation was the commonly performed surgical procedure. Patients with giant cell tumor were on high risk of recurrence after surgical treatment.

Key Words: Giant cell tumor, Site of bones, Surgical techniques, Outcomes.

Citation of article: Ishaq M, Bakhsh K, Rehman A. Examine the Outcomes of Surgical Procedures in Patients with Giant Cell Tumors. Med Forum 2020;31(9):94-97.

 

 

INTRODUCTION

Cooper in 1818 first described Giant cell tumors (GCT) of the bone. Later Nelaton showed their local aggressiveness, and Virchow revealed their malignant potential.1 The term “giant cell tumor” implies that the multinucleated giant cells are responsible for the proliferative capacity of this tumor, there is evidence that the stromal cells, the major components
of the mononuclear cell population, represent the true

 

 

1. Department of Orthopaedic & Traumatology, Qazi Hussain Ahmad Medical Complex Nowshera, KPK.

2. Department of Orthopaedic, Bolan Medical College Hospital, Quetta.

 

 

Correspondence: Dr. Muhammad Ishaq, Head of Department, Orthopaedic & Traumatology, Qazi Hussain Ahmad Medical Complex Nowshera, KPK.

Contact No: 0300-5924169

Email: wamiqishaq@yahoo.com

 

 

Received:    May, 2020

Accepted:    July, 2020

Printed:        September, 2020

 

 

neoplastic components of giant cell tumor of the bone (GCTB).2

It accounts for 5% of primary skeletal tumors and 21% of all benign bone tumors.3 The disease is more common in China and India, where it constitutes approximately 20% of all primary bone tumours. Most lesions develop in the long bones (75-90%), with most cases (50–65%) occurring near the knee.4 Approximately 1% of cases present as multiple synchronous or metachronous lesions.5

It primarily occurs in young adults between the ages of 20 and 40 years and paediatric cases of GCT are even less frequent and are believed to comprise only 1.7% of all cases of GCTB. Although usually benign tumors, GCTB frequently recurs locally after surgical resection.6 Muramatsu et al7 reported a recurrence rate of 34% after intra-lesional excision, 7% after marginal excision, and none after wide excision.

Secondary transformation, which follows radiation therapy or less commonly surgical intervention, accounts for approximately 70% of malignant GCT. Primary malignant GCT, which arise de novo along-side typical GCT, make up the remainder of malignant cases.8 The incidence of metastases is estimated to be from 1-6%. The metastatic lesions are histologically identical to the primary lesions, showing no tendency to differentiate. The majority of metastatic lesions are to the lung. Solitary metastasis to regional lymph nodes, the mediastinum and the pelvis have been reported, as has involvement of the scalp, bone and para-aortic nodes. The mean interval between the onset of the tumor and the detection of lung metastases is about four to five years.9

Treatment often involves curettage, with or without bone filler or adjuvants such as polymethylmethacrylate (PMMA) or phenol.8 Early treatment methods of GCT involved simple curettage with or without a bone graft and the consequent recurrence rate was approximately 40%. In 1969, Vidal et al10 introduced reconstruction with bone cement after thorough intralesional curettage.

MATERIALS AND METHODS

This retrospective case series study was conducted at Department of Orthopaedic & Traumatology, Qazi Hussain Ahmad Medical Complex Nowshera from 1st January 2018 to 31st March 2020. A total of 16 patients of both genders presented with biopsy proven giant cell tumor were analyzed in this study. Patients detailed demographic including age, sex and symptoms were recorded. Patients with recurrence, patients with lost their follow-up and those with no consent were excluded. All the patients were received biopsy and the lesions were staged according to the grading system by Campanacci et al11, Grade I, II and III. Different sites of involved bones and different surgical procedures for the treatment were examined. Functional outcomes of surgical treatment were examined by Musculo-Skeletal Tumor Society score (MSTS) including pain, function, walking ability, walking aids, emotional acceptance and gait. Recurrence rate was also examined. Follow-up was taken at 1 year after surgery. All the data was analyzed by SPSS 24.0. P-value <0.05 was considered as significant.

RESULTS

Out of 16 patients, 10 (62.5%) patients were males and 6 (37.5%) were females. 3 (18.75%) patients were ages less than 20 years, 11 (68.75%) patients were ages 20 to 40 years and 2 (12.5%) patients had ages above 40 years. Pain and swelling was commonly found symptom in 8 (50%) patients followed by only pain 4 (25%), only swelling in 2 (12.5%) patients and 2 patients were with fracture. 4 (25%) patients had Grade I tumor, 9 (56.25%) patients had Grade II and 3 (18.75%) patients had Grade III tumor (Table 1). Distal femur was the commonest site in 6(37.5%) patients followed by proximal tibia in 5 (31.25%) patients, 2 (12.5%) had proximal humerus and 3 (18.75%) patients had other bones involved (Table 2).

Curettage and bone cementation was the commonly performed surgical procedure in 5 (31.25%), followed by wide excision of bone and cementation and implant in 4 (25%) patients, 3 (18.75%) patients received curettage and bone grafting, 2 (12.5%) had received disarticulation, 1 (6.25%) patient were received arthroplasty and amputation was done in 1 (6.25%) patient (Table 3). Recurrence was found in 1 patient with curettage and bone grafting and 2 with curettage and bone cementation. The mean MSTS score was 26.2 out of 30 (Table 4).

Table No.1: Demographical details of all the patients

Variable

No.

%

Gender

Male

10

62.5

Female

6

37.5

Age (years)

< 20

3

18.75

20 -40

11

68.75

> 40

2

12.5

Clinical presentation

Pain and Swelling

8

50

Pain

4

25

Swelling

2

12.5

Fracture

2

12.5

Tumor grade

Grade I

4

25

Grade II

9

56.25

Grade III

3

18.75

 

Table No.2: Site of bones involved

Site

No.

%

Distal femur

6

37.5

Proximal tibia

5

31.25

Proximal humerus

2

12.5

Other

3

18.75

 

Table No.3: Different surgical procedure performed

Procedure

No.

%

Curettage and bone cementation

5

31.5

Wide excision of bone, cementation and implant

4

25

Curettage and bone grafting

3

18.75

Disarticulation

2

12.5

Arthroplasty

1

6.25

Amputation

1

6.25

 

 

 

 

 

Table No.4: Outcomes of different surgical procedures

Variables

Curettage and bone cementation
(n=5)

Wide excision of bone, cementation and implant (n=4)

Curettage and bone grafting
(n=3)

Disarticulation
(n=2)

Arthroplasty
(n=1)

Amputation
(n=1)

Yes

2

0

1

0

0

0

No

3

0

2

0

0

0

MSTS score

Mean value

0-30

26.2

 

 

DISCUSSION

Giant cell tumor is one of the common life’s threatening malignant disorder with high rate of morbidity. Patients received surgical treatment reported poor quality of life, it is due to delay in visiting hospital, inaccurate diagnoses, self-medication and unawareness of the disease.12-14 Many of studies have been conducted regarding surgical outcomes of giant cell tumor. Present study was also conducted to determine the surgical outcomes of different surgical procedures for the treatment of giant cell tumor of bones. In present study 10 (62.5%) patients were males and 6 (37.5%) were females. 3 (18.75%) patients were ages less than 20 years, 11 (68.75%) patients were ages 20 to 40 years and 2 (12.5%) patients had ages above 40 years. These results showed similarity to some previous studies in which male patients were high in number as compared to females.15,16 Some of other studies reported that female patients had high incidence rate of giant cell tumors 60 to 80% [9-15]. Several previous studies regarding giant cell tumor demonstrated that the incidence rate of giant cell tumor was high in patients with ages 3rd or 4th decades of their lives.18,19

In this study we found that pain and swelling was commonly found symptom in 8 (50%) patients followed by only pain 4 (25%), only swelling in 2 (12.5%) patients and 2 patients were with fracture. Distal femur was the commonest site in 6(37.5%) patients followed by proximal tibia in 5 (31.25%) patients, 2 (12.5%) had proximal humerus and 3 (18.75%) patients had other bones involved. A study conducted by Ahmad et al20 regarding outcomes of different surgical procedures in patients with giant cell tumor, in which they reported pain and swelling combine was the most common presented symptom 42.6% followed by only pain. But in contrast to our study Ahmad et al20 also reported proximal tibia was the commonest site of bone 29.63% followed by distal femur 18.52%.

In the present study, we found recurrence in 3 patients in which 1 patient was treated with curettage and bone grafting and 2 patients were received curettage and bone cementation. The mean MSTS score was 26.2 out of 30. These results showed similarity to some previous studies in which recurrence rate was high in patients treated with bone grafting and cementation.21,22.

CONCLUSION

Giant cell tumor is one of the common life’s threatening malignant disorder. Early diagnosis and better treatment modality may help to reduce the mortality and morbidity rate. It is concluded that giant cell tumor is commonly found in patients with 3rd and 4th decade of life. Distal femur and proximal tibia were the most common site of bones involved and curettage and cementation was the commonly performed surgical procedure. Patients with giant cell tumor were on high risk of recurrence after surgical treatment.

Author’s Contribution:

Concept & Design of Study:

Muhammad Ishaq

Drafting:

Karim Bakhsh

Data Analysis:

Attiq-ur-Rehman

Revisiting Critically:

Muhammad Ishaq, Karim Bakhsh

Final Approval of version:

Muhammad Ishaq

Conflict of Interest: The study has no conflict of interest to declare by any author.

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