The recurrent giant cell tumor is an aggressive bone tumor with a high rate of local recurrence after treatment. Curettage and bone grafting is commonly used to treat giant cell tumors but has a 25-50% recurrence rate. More extensive procedures like extended curettage, adjuvants like phenol or liquid nitrogen, and bone grafts may reduce the recurrence rate to around 10-30%. Radiology and histology cannot reliably predict recurrence. Higher levels of VEGF and MMP-9 expression in tumor tissue may indicate a higher risk of recurrence. Recurrences are generally treated with repeat curettage or more aggressive procedures like resection and reconstruction. Amputation is reserved for tumors that are frankly malignant or too large to be adequately treated

1. The Recurrent Giant Cell Tumour
Dr. A. Srinivasa Rao
M.S.(Orth); Fellow Ortho. Path. (USA)
Emeritus Professor, Gandhi Medical College
Hyderabad
Honorary Fellow, IOA
Consultant, Orthopedic Oncology,
KIMS, Secunderabad

2. Incidence
In USA 5% of Primary bone tumors
In Asian Countries 20 – 30 %
More common in South India

3. W.H.O
GCT is an Aggressive potentially Malignant
lesion

4. Natural Course of Disease
Lytic lesion in bone
Destructive expansion with periosteal new bone forming shell
Thin shell – “egg shell crackling”
Shell broken – still has soft tissue cover – pseudo capsule
If left alone – breaks into sub cut. tissue and
later skin – fungates
Aggressive Still Benign

5. A small percentage of them are malignant

6. Surgery

7. Histology – frankly malignant

8. Recurrence
The other disturbing, most challenging
complication in the management of GCT

9. Terms used in Management of GCT
Curettage (intra lesional)

10. Terms used for Management
Procedures
Curettage (intra lesional)
- Phenol
Aggressive Curettage - H2O2 Lavage
(curettage + adjuvant) - Cryosurgery (Liquid Nitrogen)
Adjuvants – Procedures or
Packing materials
Packing Materials
- Bone Graft (auto / allo)
- Bone Cement
High speed Burr

11. Terms used for Management
Curettage (intra lesional)
Aggressive Curettage
(curettage + adjuvant)
Adjuvants – Procedures or
Packing materials
Extended Curettage
Marginal excision

12. Terms used for Management
Curettage (intra lesional)
Aggressive Curettage
(curettage + adjuvant)
Adjuvants – Procedures or
Packing materials
Extended Curettage
Marginal excision
En bloc excision
Resection
Wide resection

13. Extended Curettage - thorough
Mr.PK., Ext.Curettage, Auto Fibula & Allocancellous grafting
ACL seen
Through
cavity

14. Mr.PK; 3 yr FU

15. Extended Curettage,
Case 2 H2O2 adjuvant
Bone Grafting - Auto Fibula & Allo Cancellous

16. 2 yr Post op

17. Clinical FU 3 yrs

18. Extended Curettage
Case 3 H2O2 Adjuvant
Bone Graft – Auto Fibula & Allo Cancellous

19. Case 3 – 28 mths FU

20. Recurrence
Campannacchi 1987
51 local recurrences
90% appeared in 3 yrs
In a large series
Majority recurred by 2 years
Very few recurred by 3 yrs
Single recurrence by 6 yrs

21. Aim of Treatment of GCT
To reduce the incidence of local recurrence
while preserving maximal joint function
- Curettage preserves joint function; but risk of recurrence
- Resection and Reconstruction minimises recurrence;
but joint function jeopardised
- Custom Mega Prosthesis preserves joint function &
minimises recurrence; but risk of failure in long run
Benefit –Risk Ratio to be assessed

22. Recurrence
Curettage
25 % Klenka et.al. Mayo Clinic; CORR 2011
34 % McDonald JBJS 1986
42.9 % Durr et.al.; Eur. J Surg Onc. 1999
49 % Becker et.al JBJS 2008
49 % Knochentumoren JBJS 2008
58.8 % Balke et.al Cancer Res Clin Onc 2009

23. Recurrence
Burr & Bone graft
32.5 % Malek et.al., Int. Orthop.,2006

24. Recurrence
PMMA Cementation
14 % Kirschen CORR 1996
22 % Becker et.al. JBJS 2008
22 % Knochentumoren JBJS 2008
15 % Chanchairujira et al J Med Ass Thai 2011

25. Recurrence
Phenol
9.1 % Durr et.al. Eur J Surg Onc 1999
15 % Becker et.al. JBJS 2008
No effect on Recurrence Klenka et.al CORR, 2011

26. Recurrence
Liquid Nitrogen
7.9 % Malawar, CORR 1991

27. Recurrence
Wide Resection
7% McDonald JBJS 1986
0% Chanchairujira et al J Med Ass Thai 2011
5% Klenka et.al. Mayo Clinic; CORR 2011

28. Recurrent GCT
Campannacchi JBJS 1987
Intralesional procedures 27 %
Marginal Excision 8%
Radical procedures 0%

29. Recurrence
After Pathological fracture
Does not increase rate of Recurrence
JBJS 1995

30. Recurrence
Summary of Statistics
Adjuvants do reduce Recurrence rate
Recurrence can occur after any adjuvant treatment
Incidences are not consistent & vary widely
Type of adjuvant used / nature of filling material had no
effect on recurrence rate Turcotte et.al. CORR 2002
It is likely that the adequacy of removal of tumour
determines the outcome rather than the use of adjuvant
modalities
Extended curettage ( marginal excision) has least
recurrence rate

31. Predictors of Recurrence / Prognosis ?
Best treatment of these tumours &
Risk factors for recurrence -
Controversial

32. Predictors of Recurrence / Prognosis ?
Radiology
Histology
VEGF & MMP-9 expression

33. Radiology – Campanacchi Grading
1 2 3

34. Radiology
Difference of opinion
Grade 3 – increased rate of recurrence
Posser et.al. CORR 2005
Turcotte OCNA 2006
Recurrence rates are independent of Campanacchi
grading
Ramedios JBJS 1997
No significant relation between radiology & recurrence
Sishir Rastogi IJO 2007

35. Campanacchi Grade 1

36. Campanacchi Grade 3

37. Campanacchi
Giant Cell Tumour, Bone & Soft tissue Tumours,; Springer Verlog 1990
Unpredictable behaviour of GCT is not always
related to Radiographic & Histological
appearances

38. Histology
Benign & Malignant can be differentiated
Grading is not valid
Prediction of clinical behaviour of GCT based on
Histology is impossible Cancer 1980
Rough guide – No. of Giant cells & No. of Nuclei
in each Giant Cell

39. VEGF & MMP-9 Kumta et.al. Life Sciences 2003
VEGF (Vascular Endothelial Growth Factor)
MMP-9 (Matrix Metalloprotease)
Their expressions were more in Recurrent GCTs
This could be a prognostic factor
Kumta et.al. Life Sciences; Aug 2003

40. Recurrence
Management
Recurettage & adjuvant usage
Customary to deal more radically –
Resection & Reconstruction
Custom Mega Prosthesis
Amputation

41. Case 1. SARITHA
23 yr F
9 mths 2 yrs

42. Saritha - 3 yrs FU

43. Saritha - 4 yrs FU

44. 6 yrs FU – No Recurrence

45. Case 2. Sravan
25 yr M
12/04
2/05
(2 mo)
9/06
(1½ yrs)
4/07 (7 mths) 1/09 (27 mths)

46. 5 yrs P.O.
Total 7 yr FU
No Recurrence
Satisfactory Function

47. Case 3. Custom Mega Prosthesis

48. 2 yrs FU; Benefit-Risk Ratio

49. Case. 4 Recurrent GCT
Distal Radius

50. Resection & Reconstruction
Skin sloughed out - Amputation

51. Recurrent GCT
Case 5 after Enneking Resection Arthrodesis
Recurrence &
Path. Fr in 3 months

52. Enneking Resection Arthrodesis

53. Resection Arthrodesis – Enneking type
Recurrence proximal shaft – excision & graft

54. Resection Arthrodesis – Enneking type

55. Message
Recurrences may be managed with appropriate
surgeries
No Amputation unless
- the tumour is frankly malignant
- is too big for conservative management
- tumour recurred more than twice

56. Summary
GCT is an aggressive tumour
Curettage & bone grafting preserves joint function;
Recurrence is a problem
Adjuvants minimise recurrence; Nothing to choose
between different adjuvants
Adequacy of tumour removal determines outcome
“Extended curettage”, H2O2 adjuvant & allo cancellous
bone grafting is economical; has least recurrence rate

57. Summary (contd)
Radiology & Histology cannot predict Recurrence
VEGF & MMP-9 may predict aggressiveness of tumour
Recurrences can be recuretted; but excision &
reconstruction preferred
Amputation for malignant GCT or for tumours too large
to be conserved

58. a s rao