The Recurrent Giant Cell TumourDr. A. Srinivasa RaoM.S.(Orth); Fellow Ortho. Path. (USA)Emeritus Professor, Gandhi Medical...
IncidenceIn USA 5% of Primary bone tumorsIn Asian Countries 20 – 30 %          More common in South India
W.H.OGCT is an Aggressive potentially Malignantlesion
Natural Course of DiseaseLytic lesion in boneDestructive expansion with periosteal new bone forming shellThin shell – “egg...
A small percentage of them are malignant
Surgery
Histology – frankly malignant
RecurrenceThe other disturbing, most challengingcomplication in the management of GCT
Terms used in Management of GCTCurettage (intra lesional)
Terms used for Management                                    ProceduresCurettage (intra lesional)                         ...
Terms used for ManagementCurettage (intra lesional)Aggressive Curettage(curettage + adjuvant)    Adjuvants – Procedures or...
Terms used for ManagementCurettage (intra lesional)Aggressive Curettage(curettage + adjuvant)    Adjuvants – Procedures or...
Extended Curettage - thoroughMr.PK., Ext.Curettage, Auto Fibula & Allocancellous grafting                                 ...
Mr.PK;   3 yr FU
Extended Curettage,Case 2   H2O2 adjuvant         Bone Grafting - Auto Fibula & Allo Cancellous
2 yr Post op
Clinical FU 3 yrs
Extended CurettageCase 3   H2O2 Adjuvant         Bone Graft – Auto Fibula & Allo Cancellous
Case 3 – 28 mths FU
RecurrenceCampannacchi 1987    51 local recurrences    90% appeared in 3 yrsIn a large series   Majority recurred by 2 yea...
Aim of Treatment of GCTTo reduce the incidence of local recurrencewhile preserving maximal joint function   - Curettage pr...
Recurrence                       Curettage25 %     Klenka et.al. Mayo Clinic; CORR 201134 %     McDonald JBJS 198642.9 %  ...
Recurrence                       Burr & Bone graft32.5 %   Malek et.al., Int. Orthop.,2006
Recurrence                  PMMA Cementation14 % Kirschen CORR 199622 % Becker et.al. JBJS 200822 % Knochentumoren JBJS 20...
Recurrence                           Phenol 9.1 % Durr et.al. Eur J Surg Onc 199915 % Becker et.al. JBJS 2008 No effect on...
Recurrence                      Liquid Nitrogen7.9 %   Malawar, CORR 1991
Recurrence                  Wide Resection7%   McDonald JBJS 19860%   Chanchairujira et al J Med Ass Thai 20115%   Klenka ...
Recurrent GCT              Campannacchi JBJS 1987Intralesional procedures 27 %Marginal Excision        8%Radical procedure...
Recurrence                   After Pathological fractureDoes not increase rate of Recurrence                       JBJS 1995
Recurrence                       Summary of StatisticsAdjuvants do reduce Recurrence rateRecurrence can occur after any ad...
Predictors of Recurrence / Prognosis ?       Best treatment of these tumours &       Risk factors for recurrence -        ...
Predictors of Recurrence / Prognosis ? Radiology Histology VEGF & MMP-9 expression
Radiology – Campanacchi Grading1               2                3
RadiologyDifference of opinionGrade 3 – increased rate of recurrencePosser et.al. CORR 2005Turcotte OCNA 2006Recurrence ra...
Campanacchi Grade 1
Campanacchi Grade 3
Campanacchi     Giant Cell Tumour, Bone & Soft tissue Tumours,; Springer Verlog 1990Unpredictable behaviour of GCT is not ...
HistologyBenign & Malignant can be differentiatedGrading is not validPrediction of clinical behaviour of GCT based onHisto...
VEGF & MMP-9                  Kumta et.al. Life Sciences 2003VEGF (Vascular Endothelial Growth Factor)MMP-9 (Matrix Metall...
Recurrence                 ManagementRecurettage & adjuvant usageCustomary to deal more radically –         Resection & Re...
Case 1.   SARITHA          23 yr F   9 mths           2 yrs
Saritha - 3 yrs FU
Saritha - 4 yrs FU
6 yrs FU – No Recurrence
Case 2. Sravan                                        25 yr M12/04        2/05        (2 mo)                 9/06         ...
5 yrs P.O.  Total 7 yr FUNo RecurrenceSatisfactory Function
Case 3.   Custom Mega Prosthesis
2 yrs FU; Benefit-Risk Ratio
Case. 4   Recurrent GCT          Distal Radius
Resection & ReconstructionSkin sloughed out - Amputation
Recurrent GCT    Case 5       after Enneking Resection ArthrodesisRecurrence &Path. Fr in 3 months
Enneking Resection Arthrodesis
Resection Arthrodesis – Enneking typeRecurrence proximal shaft – excision & graft
Resection Arthrodesis – Enneking type
MessageRecurrences may be managed with appropriatesurgeriesNo Amputation unless - the tumour is frankly malignant - is too...
SummaryGCT is an aggressive tumourCurettage & bone grafting preserves joint function;Recurrence is a problemAdjuvants mini...
Summary (contd)Radiology & Histology cannot predict RecurrenceVEGF & MMP-9 may predict aggressiveness of tumourRecurrences...
a s rao
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The recurrent giant cell tumour

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The recurrent giant cell tumour

  1. 1. The Recurrent Giant Cell TumourDr. A. Srinivasa RaoM.S.(Orth); Fellow Ortho. Path. (USA)Emeritus Professor, Gandhi Medical CollegeHyderabadHonorary Fellow, IOAConsultant, Orthopedic Oncology,KIMS, Secunderabad
  2. 2. IncidenceIn USA 5% of Primary bone tumorsIn Asian Countries 20 – 30 % More common in South India
  3. 3. W.H.OGCT is an Aggressive potentially Malignantlesion
  4. 4. Natural Course of DiseaseLytic lesion in boneDestructive expansion with periosteal new bone forming shellThin shell – “egg shell crackling”Shell broken – still has soft tissue cover – pseudo capsuleIf left alone – breaks into sub cut. tissue and later skin – fungates Aggressive Still Benign
  5. 5. A small percentage of them are malignant
  6. 6. Surgery
  7. 7. Histology – frankly malignant
  8. 8. RecurrenceThe other disturbing, most challengingcomplication in the management of GCT
  9. 9. Terms used in Management of GCTCurettage (intra lesional)
  10. 10. Terms used for Management ProceduresCurettage (intra lesional) - PhenolAggressive 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. 11. Terms used for ManagementCurettage (intra lesional)Aggressive Curettage(curettage + adjuvant) Adjuvants – Procedures or Packing materialsExtended CurettageMarginal excision
  12. 12. Terms used for ManagementCurettage (intra lesional)Aggressive Curettage(curettage + adjuvant) Adjuvants – Procedures or Packing materialsExtended CurettageMarginal excisionEn bloc excisionResectionWide resection
  13. 13. Extended Curettage - thoroughMr.PK., Ext.Curettage, Auto Fibula & Allocancellous grafting ACL seen Through cavity
  14. 14. Mr.PK; 3 yr FU
  15. 15. Extended Curettage,Case 2 H2O2 adjuvant Bone Grafting - Auto Fibula & Allo Cancellous
  16. 16. 2 yr Post op
  17. 17. Clinical FU 3 yrs
  18. 18. Extended CurettageCase 3 H2O2 Adjuvant Bone Graft – Auto Fibula & Allo Cancellous
  19. 19. Case 3 – 28 mths FU
  20. 20. RecurrenceCampannacchi 1987 51 local recurrences 90% appeared in 3 yrsIn a large series Majority recurred by 2 years Very few recurred by 3 yrs Single recurrence by 6 yrs
  21. 21. Aim of Treatment of GCTTo reduce the incidence of local recurrencewhile 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. 22. Recurrence Curettage25 % Klenka et.al. Mayo Clinic; CORR 201134 % McDonald JBJS 198642.9 % Durr et.al.; Eur. J Surg Onc. 199949 % Becker et.al JBJS 200849 % Knochentumoren JBJS 200858.8 % Balke et.al Cancer Res Clin Onc 2009
  23. 23. Recurrence Burr & Bone graft32.5 % Malek et.al., Int. Orthop.,2006
  24. 24. Recurrence PMMA Cementation14 % Kirschen CORR 199622 % Becker et.al. JBJS 200822 % Knochentumoren JBJS 200815 % Chanchairujira et al J Med Ass Thai 2011
  25. 25. Recurrence Phenol 9.1 % Durr et.al. Eur J Surg Onc 199915 % Becker et.al. JBJS 2008 No effect on Recurrence Klenka et.al CORR, 2011
  26. 26. Recurrence Liquid Nitrogen7.9 % Malawar, CORR 1991
  27. 27. Recurrence Wide Resection7% McDonald JBJS 19860% Chanchairujira et al J Med Ass Thai 20115% Klenka et.al. Mayo Clinic; CORR 2011
  28. 28. Recurrent GCT Campannacchi JBJS 1987Intralesional procedures 27 %Marginal Excision 8%Radical procedures 0%
  29. 29. Recurrence After Pathological fractureDoes not increase rate of Recurrence JBJS 1995
  30. 30. Recurrence Summary of StatisticsAdjuvants do reduce Recurrence rateRecurrence can occur after any adjuvant treatmentIncidences are not consistent & vary widelyType of adjuvant used / nature of filling material had noeffect on recurrence rate Turcotte et.al. CORR 2002It is likely that the adequacy of removal of tumourdetermines the outcome rather than the use of adjuvantmodalitiesExtended curettage ( marginal excision) has leastrecurrence rate
  31. 31. Predictors of Recurrence / Prognosis ? Best treatment of these tumours & Risk factors for recurrence - Controversial
  32. 32. Predictors of Recurrence / Prognosis ? Radiology Histology VEGF & MMP-9 expression
  33. 33. Radiology – Campanacchi Grading1 2 3
  34. 34. RadiologyDifference of opinionGrade 3 – increased rate of recurrencePosser et.al. CORR 2005Turcotte OCNA 2006Recurrence rates are independent of CampanacchigradingRamedios JBJS 1997No significant relation between radiology & recurrenceSishir Rastogi IJO 2007
  35. 35. Campanacchi Grade 1
  36. 36. Campanacchi Grade 3
  37. 37. Campanacchi Giant Cell Tumour, Bone & Soft tissue Tumours,; Springer Verlog 1990Unpredictable behaviour of GCT is not alwaysrelated to Radiographic & Histologicalappearances
  38. 38. HistologyBenign & Malignant can be differentiatedGrading is not validPrediction of clinical behaviour of GCT based onHistology is impossible Cancer 1980Rough guide – No. of Giant cells & No. of Nucleiin each Giant Cell
  39. 39. VEGF & MMP-9 Kumta et.al. Life Sciences 2003VEGF (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. 40. Recurrence ManagementRecurettage & adjuvant usageCustomary to deal more radically – Resection & ReconstructionCustom Mega ProsthesisAmputation
  41. 41. Case 1. SARITHA 23 yr F 9 mths 2 yrs
  42. 42. Saritha - 3 yrs FU
  43. 43. Saritha - 4 yrs FU
  44. 44. 6 yrs FU – No Recurrence
  45. 45. Case 2. Sravan 25 yr M12/04 2/05 (2 mo) 9/06 (1½ yrs) 4/07 (7 mths) 1/09 (27 mths)
  46. 46. 5 yrs P.O. Total 7 yr FUNo RecurrenceSatisfactory Function
  47. 47. Case 3. Custom Mega Prosthesis
  48. 48. 2 yrs FU; Benefit-Risk Ratio
  49. 49. Case. 4 Recurrent GCT Distal Radius
  50. 50. Resection & ReconstructionSkin sloughed out - Amputation
  51. 51. Recurrent GCT Case 5 after Enneking Resection ArthrodesisRecurrence &Path. Fr in 3 months
  52. 52. Enneking Resection Arthrodesis
  53. 53. Resection Arthrodesis – Enneking typeRecurrence proximal shaft – excision & graft
  54. 54. Resection Arthrodesis – Enneking type
  55. 55. MessageRecurrences may be managed with appropriatesurgeriesNo Amputation unless - the tumour is frankly malignant - is too big for conservative management - tumour recurred more than twice
  56. 56. SummaryGCT is an aggressive tumourCurettage & bone grafting preserves joint function;Recurrence is a problemAdjuvants minimise recurrence; Nothing to choosebetween different adjuvantsAdequacy of tumour removal determines outcome“Extended curettage”, H2O2 adjuvant & allo cancellousbone grafting is economical; has least recurrence rate
  57. 57. Summary (contd)Radiology & Histology cannot predict RecurrenceVEGF & MMP-9 may predict aggressiveness of tumourRecurrences can be recuretted; but excision &reconstruction preferredAmputation for malignant GCT or for tumours too largeto be conserved
  58. 58. a s rao

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