Giant cell, cementing, recurrence, reconstruction, en-block excision, literature

1. Giant cell tumours
Current Concepts in surgical management
Vinod Naneria, G. Yeotikar, A. Wadhwani
Choithram Hospital & Research Centre,
Indore, India

2. Three basic principle
• Removal of tumor.
• Supportive therapy.
• Reconstruction.

3. Complete removal of tumor mass
• Intra-lesional Curettage
• En-block Excision
• Radiation for inaccessible sites (spine)

4. Adjuvant Therapy
• Pulse Lavage
• H2O2
• Phenol
• Alcohol
• Liquid nitrogen
• Electric cauterization
• Laser

5. Reconstruction/Restoration
• Bone grafts
• Allografts
• Cementing
• Cementing with metal supports.
҉ Not MRI computable – Followup MRI for
early detection - difficult
• A combination of bone graft + cement.
҉ Sandwich technique.

6. The Crux of Tx
• Curettage + Curettage + Curettage.
• Wide Window.
• Dental Burr.
• Electric Cauterization.
• Adjuvant therapy – H2O2 / phenol / Liquid
Nitrogen /Argon beam Laser / Alcohol.
• Cementing / Bone grafting.
• Radiation for inaccessible sites.
• Bisphosphonates.

7. Why Cement?
• It is simple.
• there is no need for bone grafting.
• Immediate fixation and stabilization is
obtained.
• joint function is preserved.
• local control is better by thermal & cyto-toxic
effect of cement.
• local recurrence is easily to detect.

8. Cement is recommended
Acta Orthop. 2008 Feb
Intralesional surgery should be the first choice
in most giant cell tumors, even in the
presence of a pathological fracture. After
thorough evacuation, the cavity should be
filled with cement.
Acta Orthop. 2008 Feb;79(1):86-93.
Cement is recommended in intralesional surgery of giant cell
tumors: a Scandinavian Sarcoma Group study of 294 patients
followed for a median time of 5 years.
Kivioja AH, Blomqvist C, Hietaniemi K, Trovik C, Walloe A,
Bauer HC, Jorgensen PH, Bergh P, Follerås G.

9. Cement as Adjuvant Therapy
J Bone Joint Surg Am. 2008 May
Use of polymethylmethacrylate as an adjuvant
appears to be the therapy of choice for
primary as well as recurrent giant cell tumors
of bone.
J Bone Joint Surg Am. 2008 May;90(5):1060-7.
Local recurrence of giant cell tumor of bone after intralesional
treatment with and without adjuvant therapy.
Arbeitsgemeinschaft Knochentumoren, Becker WT, Dohle J, Bernd L,
Braun A, Cserhati M, Enderle A, Hovy L, Matejovsky Z, Szendroi M, Trieb
K, Tunn PU.

10. Complications - Cement
• May form a radiolucent zone at the bone-
cement interface up to 2.5 mm in width.
• Osteoarthritis of the knee joint in patient with
an intraarticular fracture at initial
presentation.
• A stress fracture of the shaft.
J Orthop Sci. 2002;7(2):194-8.
Complications associated with bone cementing for the
treatment of giant cell tumors of bone.
Wada T, Kaya M, Nagoya S, Kawaguchi S, Isu K, Yamashita T,
Yamawaki S, Ishii S.

11. Complications associated with bone cementing
A retrospective review 15 GCT treated between
1984 and 1998. Aggressive curettage + large
bone window + acrylic cement. Mean follow-up
time of 46 months (range, 24-188 months).
All the patients showed a non progressive
radiolucent zone up to 2.5mm at the bone-
cement interface in the first 6 months after
operation.
One patient developed Osteoarthritis of the knee
joint after 14 years.
One patient had stress fracture in a large
tumour.

12. Complications associated with bone cementing
In summary:
No evidence that the long-term presence
of cement close to the knee joint was
associated with the development of
degenerative osteoarthritis.
Wada T, Kaya M, Nagoya S, Kawaguchi S, Isu K,
Yamashita T, Yamawaki S, Ishii S. Department of
Orthopaedic Surgery, Sapporo Medical University, South-1,
West-16, Sapporo 060-8543, Japan. J Orthop Sci.
2002;7(2):194-8.

13. Cementing & O.A.Knee
Follow up of nine patients at a mean period of
11 years (6 to 16) after curettage and cementing
of a giant-cell tumour around the knee showed
no evidence that the long-term presence of
cement close to the knee joint was associated
with the development of degenerative
osteoarthritis.
J Bone Joint Surg Br. 2007 Mar;89(3):361-5.
Giant-cell tumour of the knee: the condition of the cartilage after
treatment by curettage and cementing.
von Steyern FV, Kristiansson I, Jonsson K, Mannfolk P, Heinegård
D, Rydholm A. Department of Orthopaedics, Centre for Medical Imaging and Physiology,
Lund University Hospital, Lund, Sweden.

14. Comparison of the degenerative changes
Comparison of the degenerative changes in weight-bearing
joints following cementing or grafting techniques in giant
cell tumour patients: medium-term results. - Szalay K, Antal
I, Kiss J, Szendroi M. ; Orthopaedic Clinic of Semmelweis
University, Budapest, Hungary.
Eighty patients were included in this follow-up study, 44 of
whom underwent curettage followed by bone grafting, and 36
who had curettage followed by cementation. At the 24-month
post-operative examination, significantly less degenerative
change was found in patients with bone cement than in those
with bone grafting.
Int Orthop. 2006 Dec;30(6):505-9. Epub 2006 Sep

15. Heat Of Polymerization of Cement
Arch Orthop Trauma Surg (1993)
Heat above 60 ° produced during
polymerization lasted for about 10 min.
After heat treatment at 60 ° for 10 min, no
cells could have survived. This study has
clarified the tumoricidal effect of methyl
methacrylate by hyperthermia from the
heat caused by polymerization.
Cementation in the treatment of giant cell tumor of bone S. Komiya and A.
Inoue; Department of Orthopaedic Surgery, Kurume University School of
Medicine, Kurume, Japan, Arch Orthop Trauma Surg (1993) 112:51-55

16. Intralesional Curettage
Curettage, high-speed burring with added
phenol/liquid nitrogen treatment and cementation
is a useful and safe method in the treatment of
giant cell tumors. The advantages include a low
recurrence rate, as well as immediate stabilization
allowing early mobilization. Patients who have
Campanacci grade I tumors have the highest
chance of being disease-free after the first
operation.
Ann Acad Med Singapore. 2005 Apr;34(3):235-7.
Treatment of benign giant cell tumors of bone in Singapore.
Lim YW, Tan MH.
Department of Orthopaedic Surgery, Changi General Hospital, Singapore.
yeow_1@yahoo.com

17. A 30yr, female with biopsy proved Giantcell tumour

19. Post-op X-ray

20. 1997

22. 1998 recurrence at bone graft site

23. Treatment of local recurrences of giant cell tumour in
long bones after curettage and cementing. A
Scandinavian Sarcoma Group study.
We retrospectively studied local recurrence of GCT in long bones following
curettage and cementing in 137 patients.
The median follow-up time was 60 months (3 to 166).
A total of 19 patients (14%) had at least one local recurrence, the first was
diagnosed at a median of 17 months (3 to 29) after treatment of the
primary tumour.
There were 13 patients with a total of 15 local recurrences who were
successfully treated by further curettage and cementing.
Two patients with a second local recurrence were consequently treated
twice. At the last follow-up, at a median of 53 months (3 to 128) after the
most recent operation, all patients were free from disease.
Vult von Steyern F, Bauer HC, Trovik C, Kivioja A, Bergh P, Holmberg
Jörgensen P, Follerås G, Rydholm A; Scandinavian Sarcoma Group.
Department of Orthopaedics, Lund University Hospital, SE-221 85 Lund,
Sweden.

24. 2006

25. Functional results 10 yrs. P.O. in 2006

26. Functional results 10 yrs. P.O. in 2006

27. Sept.2011

28. Functional result in Sept. 2011 – 14 yrs. P.O.

29. 2005

33. Six month Post -op

35. Curettage +Cementing is not contra indicated in fractures

37. GCT
Curetting + bone grafting
Recurrence

41. A case of Recurrence of GCT
• 30 years old Female.
• Pain & swelling lower femur & knee 6 months.
• Open biopsy – GCT – June 2010
• Curettage + Bone graft + Calcium sulphate.
• Recurrence in Oct.2010
• Serial x-rays and operative and clinical photos

42. Recurrence Feb 2011

43. March 2011

44. Curetted bone Bone graft posterior cortex
Knee Shaft
Graft
Shaft
Knee Exposed medial
Curetted bone articular cartilage

45. March 2011
Immediate Post Op

47. 2000

48. Curettage + cementingg

49. 2006

51. 2009

52. F
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53. Feb 2012

54. June 2009
35 / M

55. Confirmation of cement spill over

57. Feb 2012

58. Feb 2012

59. En block excision

61. 25 years Female
2006

63. Articular cartilage is clearly visible

65. Post op Six month later

70. 40 Yrs/ M/ 2006

71. Curettage + Bone graft

72. Recurrence after bone graft

75. 2008

77. 2009

81. Talus

82. Curettage + cement

83. 1991, 35/ M, Pathological fracture
THR + cement

84. Recurrence
1993 1 year post radiation
Re-curettage
+ Radiation

85. 2003 – 12 years post surgery

86. Pathological Fracture neck femur - 2006

87. Six month post operative
functional status

88. 21 years old Female gradual deterioration since July 2009
Leading to pathological fracture neck femur

91. Lesser Trochanter
Calcer femoris

92. Eaten away head of femur

94. Post Operative

95. 24 / F / GCT / 2003

97. Post op X-ray One year later

100. 25 years Male, Feb - 2011

103. 3 months P.O.

106. Six months post op

107. At 3 months
At 6 months

108. At 3 months
At 6 months

109. 30 / female / swelling shoulder 1 year

110. Wide Window

112. Function After 3 years -Dec 2012

113. 1987 – a case of GCT upper end humerus
Rx by curettage + bone graft.
Follow up at 2006

114. 18 years old female

115. Curettage + Bone graft + G bone

116. Curettage + G bone

124. Developed recurrence in the
transplanted graft suggested
and adjacent metacarpal.
Patient refused further
reconstruction /limited
amputation of fingers.
Metacarpals and phalanges
have 100% recurrence in our

125. 35 / F/ 2003 GCT lower end radius

126. Bone grafting

127. Recurrence

131. Aug 2002 Nov 2002

132. Recurrence after 5 years in a transplanted Fibula

135. Lost from Follow up

136. 35 / F/ 2000 June

137. Curettage + Bone grafting

138. Recurrence

143. 2008

144. Reconstruction was done
in Nov 2000.
2006 – six years later

145. Developed GCT of Tendon
Aug 2010 – 10 years later

146. The Key To Success - literature
• Adequate removal of the tumour seems
to be a more important predictive factor
for the outcome of surgery than the use
of phenol as an adjuvant therapy.
Eur J Surg Oncol. 2001 Mar;27(2):200-2.
Recurrence of curetted and bone-grafted giant-cell tumours with and without
adjuvant phenol therapy.
Trieb K, Bitzan P, Lang S, Dominkus M, Kotz R.

147. Curettage is the key - literature
• CONCLUSIONS: Curettage plus cement
reconstruction is safe and effective in treating
local GCT of limbs. The key of the method is
aggressive curettage of the lesion via a bone
window. Cement is adjuvant therapy only.
Zhonghua Wai Ke Za Zhi. 1999 Dec;37(12):730-2.
[Curettage plus cement reconstruction for treating giant cell tumor of limbs]
Zhang Q, Cai Y, Niu X, Hao L.
Department of Orthopaedic Oncology, Beijing Jishuitan Hospital, Beijing 100035.

148. Prevention of recurrence – literature
The most important factor for local recurrence appeared
to be inadequate curettage with similar recurrence rates
regardless of the type of bone graft used. A careful
approach to the surgical margin including use of a dental
burr and local adjuvant treatment with phenol, the rate of
local recurrence may be decreased.
Changgeng Yi Xue Za Zhi. 1996 Mar;19(1):16-23.
Treatment of giant cell tumor of long bone.
Shih HN, Chen YJ, Huang TJ, Ho WP, Hsueh S, Hsu RW. Department of Orthopedic
Surgery, Chang Gung Medical College, Taoyuan, Taiwan, R.O.C.

149. Prevention of recurrence -
literature
• Use of polymethylmethacrylate as an adjuvant significantly
reduces the recurrence rate following intralesional treatment
of benign giant cell tumors, and it appears to be the therapy
of choice for primary as well as recurrent giant cell tumors of
bone.
J Bone Joint Surg Am. 2008 May;90(5):1060-7.
Local recurrence of giant cell tumor of bone after intralesional treatment with
and without adjuvant therapy.
Arbeitsgemeinschaft Knochentumoren, Becker WT, Dohle J, Bernd L, Braun A,
Cserhati M, Enderle A, Hovy L, Matejovsky Z, Szendroi M, Trieb K, Tunn PU.
Orthopädische Klinik Volmarstein, Universität Witten/Herdecke, Wetter, Germany.
w.becker@gmx.com

150. Recommendation - literature
This study demonstrates that either curettage and
packing with cement or wide resection are
effective in treatment of giant cell tumor of bone.
There is, however, a better functional result after
curettage and packing with cement than following
wide resection. We recommend curettage and
cement packing for giant cell tumor of bone
whenever it is technically feasible
Changgeng Yi Xue Za Zhi. 1998 Mar;21(1):37-43.
Treatment of giant cell tumor of bone: a comparison of local curettage and wide
resection.
Liu HS, Wang JW.

151. DISCLAIMER
Information contained and transmitted by this presentation is
based on personal experience and collection of cases at
Choithram Hospital & Research centre, Indore, India, during
last 25 years. It is intended for use only by the students of
orthopaedic surgery. Views and opinion expressed in this
presentation are personal opinion. Depending upon the x-
rays and clinical presentations viewers can make their own
opinion. For any confusion please contact the sole author for
clarification. Every body is allowed to copy or download and
use the material best suited to him. I am not responsible for
any controversies arise out of this presentation. For any
correction or suggestion please contact naneria@yahoo.com