Giant cell tumoursCurrent Concepts in surgical management Vinod Naneria, G. Yeotikar, A. Wadhwani  Choithram Hospital & Re...
Three basic principle• Removal of tumor.• Supportive therapy.• Reconstruction.
Complete removal of tumor mass   • Intra-lesional Curettage   • En-block Excision   • Radiation for inaccessible sites (sp...
Adjuvant Therapy•   Pulse Lavage•   H2O2•   Phenol•   Alcohol•   Liquid nitrogen•   Electric cauterization•   Laser
Reconstruction/Restoration •   Bone grafts •   Allografts •   Cementing •   Cementing with metal supports.     ҉ Not MRI c...
The Crux of Tx• Curettage + Curettage + Curettage.• Wide Window.• Dental Burr.• Electric Cauterization.• Adjuvant therapy ...
Why Cement?• It is simple.• there is no need for bone grafting.• Immediate fixation and stabilization is  obtained.• joint...
Cement is recommended                    Acta Orthop. 2008 FebIntralesional surgery should be the first choicein most gian...
Cement as Adjuvant Therapy                   J Bone Joint Surg Am. 2008 MayUse of polymethylmethacrylate as an adjuvantapp...
Complications - Cement• May form a radiolucent zone at the bone-  cement interface up to 2.5 mm in width.• Osteoarthritis ...
Complications associated with bone cementingA retrospective review 15 GCT treated between 1984 and 1998. Aggressive curett...
Complications associated with bone cementingIn summary:  No evidence that the long-term presence  of cement close to the k...
Cementing & O.A.KneeFollow up of nine patients at a mean period of11 years (6 to 16) after curettage and cementingof a gia...
Comparison of the degenerative changesComparison of the degenerative changes in weight-bearingjoints following cementing o...
Heat Of Polymerization of Cement                  Arch Orthop Trauma Surg (1993)   Heat above 60 ° produced during   polym...
Intralesional CurettageCurettage, high-speed burring with addedphenol/liquid nitrogen treatment and cementationis a useful...
A 30yr, female with biopsy proved Giantcell tumour
Post-op X-ray
1997
1998 recurrence at bone graft site
Treatment of local recurrences of giant cell tumour in    long bones after curettage and cementing. A        Scandinavian ...
2006
Functional results 10 yrs. P.O. in 2006
Functional results 10 yrs. P.O. in 2006
Sept.2011
Functional result in Sept. 2011 – 14 yrs. P.O.
2005
Six month Post -op
Curettage +Cementing is not contra indicated in fractures
GCTCuretting + bone graftingRecurrence
A case of Recurrence of GCT•   30 years old Female.•   Pain & swelling lower femur & knee 6 months.•   Open biopsy – GCT –...
Recurrence Feb 2011
March 2011
Curetted bone            Bone graft posterior cortex                               Knee                        Shaft      ...
March 2011Immediate Post Op
2000
Curettage + cementingg
2006
2009
Functionalresult2009
Feb 2012
June 200935 / M
Confirmation of cement spill over
Feb 2012
Feb 2012
En block excision
25 years Female                  2006
Articular cartilage is clearly visible
Post op Six month later
40 Yrs/ M/ 2006
Curettage + Bone graft
Recurrence after bone graft
2008
2009
Talus
Curettage + cement
1991, 35/ M, Pathological fracture                    THR + cement
Recurrence1993           1 year post radiationRe-curettage+ Radiation
2003 – 12 years post surgery
Pathological Fracture neck femur - 2006
Six month post operativefunctional status
21 years old Female gradual deterioration since July 2009Leading to pathological fracture neck femur
Lesser Trochanter           Calcer femoris
Eaten away head of femur
Post Operative
24 / F / GCT / 2003
Post op X-ray One year later
25 years Male, Feb - 2011
3 months P.O.
Six months post op
At 3 monthsAt 6 months
At 3 months              At 6 months
30 / female / swelling shoulder 1 year
Wide Window
Function After 3 years -Dec 2012
1987 – a case of GCT upper end humerusRx by curettage + bone graft.Follow up at 2006
18 years old female
Curettage + Bone graft + G bone
Curettage + G bone
Developed recurrence in thetransplanted graft suggestedand adjacent metacarpal.Patient refused furtherreconstruction /limi...
35 / F/ 2003 GCT lower end radius
Bone grafting
Recurrence
Aug 2002   Nov 2002
Recurrence after 5 years in a transplanted Fibula
Lost from Follow up
35 / F/ 2000 June
Curettage + Bone grafting
Recurrence
2008
Reconstruction was donein Nov 2000.2006 – six years later
Developed GCT of TendonAug 2010 – 10 years later
The Key To Success - literature• Adequate removal of the tumour seems  to be a more important predictive factor  for the o...
Curettage is the key - literature• CONCLUSIONS: Curettage plus cement  reconstruction is safe and effective in treating  l...
Prevention of recurrence – literatureThe most important factor for local recurrence appearedto be inadequate curettage wit...
Prevention of recurrence -                 literature• Use of polymethylmethacrylate as an adjuvant significantly  reduces...
Recommendation - literatureThis study demonstrates that either curettage andpacking with cement or wide resection areeffec...
DISCLAIMERInformation contained and transmitted by this presentation isbased on personal experience and collection of case...
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Giant cell, cementing, recurrence, reconstruction, en-block excision, literature

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  • 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. 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. The significantly better results following treatment of recurrent tumors without adjuvants compared with the results of the same treatment of primary tumors were probably related to increased surgical thoroughness brought about by the surgeon's awareness of dealing with a riskier tumor.
  • Giantcell tumour

    1. 1. Giant cell tumoursCurrent Concepts in surgical management Vinod Naneria, G. Yeotikar, A. Wadhwani Choithram Hospital & Research Centre, Indore, India
    2. 2. Three basic principle• Removal of tumor.• Supportive therapy.• Reconstruction.
    3. 3. Complete removal of tumor mass • Intra-lesional Curettage • En-block Excision • Radiation for inaccessible sites (spine)
    4. 4. Adjuvant Therapy• Pulse Lavage• H2O2• Phenol• Alcohol• Liquid nitrogen• Electric cauterization• Laser
    5. 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. 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. 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. 8. Cement is recommended Acta Orthop. 2008 FebIntralesional surgery should be the first choicein most giant cell tumors, even in thepresence of a pathological fracture. Afterthorough evacuation, the cavity should befilled with cement. Acta Orthop. 2008 Feb;79(1):86-93.Cement is recommended in intralesional surgery of giant celltumors: a Scandinavian Sarcoma Group study of 294 patientsfollowed 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. 9. Cement as Adjuvant Therapy J Bone Joint Surg Am. 2008 MayUse of polymethylmethacrylate as an adjuvantappears to be the therapy of choice forprimary as well as recurrent giant cell tumorsof bone. J Bone Joint Surg Am. 2008 May;90(5):1060-7.Local recurrence of giant cell tumor of bone after intralesionaltreatment 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, TriebK, Tunn PU.
    10. 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. 11. Complications associated with bone cementingA 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. 12. Complications associated with bone cementingIn 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. 13. Cementing & O.A.KneeFollow up of nine patients at a mean period of11 years (6 to 16) after curettage and cementingof a giant-cell tumour around the knee showedno evidence that the long-term presence ofcement close to the knee joint was associatedwith the development of degenerativeosteoarthritis. J Bone Joint Surg Br. 2007 Mar;89(3):361-5.Giant-cell tumour of the knee: the condition of the cartilage aftertreatment by curettage and cementing. von Steyern FV, Kristiansson I, Jonsson K, Mannfolk P, HeinegårdD, Rydholm A. Department of Orthopaedics, Centre for Medical Imaging and Physiology,Lund University Hospital, Lund, Sweden.
    14. 14. Comparison of the degenerative changesComparison of the degenerative changes in weight-bearingjoints following cementing or grafting techniques in giantcell tumour patients: medium-term results. - Szalay K, AntalI, Kiss J, Szendroi M. ; Orthopaedic Clinic of SemmelweisUniversity, Budapest, Hungary.Eighty patients were included in this follow-up study, 44 ofwhom underwent curettage followed by bone grafting, and 36who had curettage followed by cementation. At the 24-monthpost-operative examination, significantly less degenerativechange was found in patients with bone cement than in thosewith bone grafting. Int Orthop. 2006 Dec;30(6):505-9. Epub 2006 Sep
    15. 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 ofMedicine, Kurume, Japan, Arch Orthop Trauma Surg (1993) 112:51-55
    16. 16. Intralesional CurettageCurettage, high-speed burring with addedphenol/liquid nitrogen treatment and cementationis a useful and safe method in the treatment ofgiant cell tumors. The advantages include a lowrecurrence rate, as well as immediate stabilizationallowing early mobilization. Patients who haveCampanacci grade I tumors have the highestchance of being disease-free after the firstoperation. 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. 17. A 30yr, female with biopsy proved Giantcell tumour
    18. 18. Post-op X-ray
    19. 19. 1997
    20. 20. 1998 recurrence at bone graft site
    21. 21. 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.
    22. 22. 2006
    23. 23. Functional results 10 yrs. P.O. in 2006
    24. 24. Functional results 10 yrs. P.O. in 2006
    25. 25. Sept.2011
    26. 26. Functional result in Sept. 2011 – 14 yrs. P.O.
    27. 27. 2005
    28. 28. Six month Post -op
    29. 29. Curettage +Cementing is not contra indicated in fractures
    30. 30. GCTCuretting + bone graftingRecurrence
    31. 31. 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
    32. 32. Recurrence Feb 2011
    33. 33. March 2011
    34. 34. Curetted bone Bone graft posterior cortex Knee Shaft Graft ShaftKnee Exposed medial Curetted bone articular cartilage
    35. 35. March 2011Immediate Post Op
    36. 36. 2000
    37. 37. Curettage + cementingg
    38. 38. 2006
    39. 39. 2009
    40. 40. Functionalresult2009
    41. 41. Feb 2012
    42. 42. June 200935 / M
    43. 43. Confirmation of cement spill over
    44. 44. Feb 2012
    45. 45. Feb 2012
    46. 46. En block excision
    47. 47. 25 years Female 2006
    48. 48. Articular cartilage is clearly visible
    49. 49. Post op Six month later
    50. 50. 40 Yrs/ M/ 2006
    51. 51. Curettage + Bone graft
    52. 52. Recurrence after bone graft
    53. 53. 2008
    54. 54. 2009
    55. 55. Talus
    56. 56. Curettage + cement
    57. 57. 1991, 35/ M, Pathological fracture THR + cement
    58. 58. Recurrence1993 1 year post radiationRe-curettage+ Radiation
    59. 59. 2003 – 12 years post surgery
    60. 60. Pathological Fracture neck femur - 2006
    61. 61. Six month post operativefunctional status
    62. 62. 21 years old Female gradual deterioration since July 2009Leading to pathological fracture neck femur
    63. 63. Lesser Trochanter Calcer femoris
    64. 64. Eaten away head of femur
    65. 65. Post Operative
    66. 66. 24 / F / GCT / 2003
    67. 67. Post op X-ray One year later
    68. 68. 25 years Male, Feb - 2011
    69. 69. 3 months P.O.
    70. 70. Six months post op
    71. 71. At 3 monthsAt 6 months
    72. 72. At 3 months At 6 months
    73. 73. 30 / female / swelling shoulder 1 year
    74. 74. Wide Window
    75. 75. Function After 3 years -Dec 2012
    76. 76. 1987 – a case of GCT upper end humerusRx by curettage + bone graft.Follow up at 2006
    77. 77. 18 years old female
    78. 78. Curettage + Bone graft + G bone
    79. 79. Curettage + G bone
    80. 80. Developed recurrence in thetransplanted graft suggestedand adjacent metacarpal.Patient refused furtherreconstruction /limitedamputation of fingers.Metacarpals and phalangeshave 100% recurrence in our
    81. 81. 35 / F/ 2003 GCT lower end radius
    82. 82. Bone grafting
    83. 83. Recurrence
    84. 84. Aug 2002 Nov 2002
    85. 85. Recurrence after 5 years in a transplanted Fibula
    86. 86. Lost from Follow up
    87. 87. 35 / F/ 2000 June
    88. 88. Curettage + Bone grafting
    89. 89. Recurrence
    90. 90. 2008
    91. 91. Reconstruction was donein Nov 2000.2006 – six years later
    92. 92. Developed GCT of TendonAug 2010 – 10 years later
    93. 93. 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.
    94. 94. 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.
    95. 95. Prevention of recurrence – literatureThe most important factor for local recurrence appearedto be inadequate curettage with similar recurrence ratesregardless of the type of bone graft used. A carefulapproach to the surgical margin including use of a dentalburr and local adjuvant treatment with phenol, the rate oflocal 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 OrthopedicSurgery, Chang Gung Medical College, Taoyuan, Taiwan, R.O.C.
    96. 96. 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
    97. 97. Recommendation - literatureThis study demonstrates that either curettage andpacking with cement or wide resection areeffective in treatment of giant cell tumor of bone.There is, however, a better functional result aftercurettage and packing with cement than followingwide resection. We recommend curettage andcement packing for giant cell tumor of bonewhenever 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 wideresection.Liu HS, Wang JW.
    98. 98. DISCLAIMERInformation contained and transmitted by this presentation isbased on personal experience and collection of cases atChoithram Hospital & Research centre, Indore, India, duringlast 25 years. It is intended for use only by the students oforthopaedic surgery. Views and opinion expressed in thispresentation are personal opinion. Depending upon the x-rays and clinical presentations viewers can make their ownopinion. For any confusion please contact the sole author forclarification. Every body is allowed to copy or download anduse the material best suited to him. I am not responsible forany controversies arise out of this presentation. For anycorrection or suggestion please contact naneria@yahoo.com

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