The surgical Treatment and Outcome of Pathological Fracture in Patients with Giant Cell Tumor of Bone

doi:10.4236/ss.2011.25051

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Surgical Science, 2011, 2, 228-231

doi:10.4236/ss.2011.25051 Published Online July 2011 (http://www.SciRP.org/journal/ss)

The surgical Treatment and Outcome of Pathological

Fracture in Patients with Giant Cell Tumor of Bone

Tomoaki Torigoe1, Atsuhiko Terakado1, Yoshiyuki Suehara1, Taketo Okubo1, Tatsuya Takagi1,

Kazuo Kaneko1, Yasuo Yazawa2

1Department of Orthopaedic Surgery, Juntendo University School of Medicine, Tokyo, Japan

2Department of Orthopaedic Oncology, Saitama International Medical Center, Saitama, Japan

E-mail: [email protected]

Received April 12, 2011; revised June 13, 2011; accepted June 24, 2011

Abstract

Between 1992 and 2008, we treated 35 patients with giant cell tumor (GCT) of bone, seven of the 35 pre-

sented with a pathological fracture. The fractures were located in the femur in five, and in the humerus and

radius in one patient each. The surgical treatments were curettage in six cases and wide resection in the distal

radius case. Two of the seven patients developed local recurrence, giving a local recurrence rate of 29%. The

local recurrence rate in GCT patients without a pathological fracture was 21%. There was a tendency for

there to be a higher recurrence rate associated with fractured GCT, but no statistically significant difference

was observed between the two groups. Therefore, it was considered that a pathological fracture was not a

risk factor for local recurrence in GCT.

Keywords: Giant Cell Tumor of Bone, Pathological Fracture

1. Introduction

There have been several reports that a pathological frac-

ture in subjects with a pr imary malignant bone tu mor is a

risk factor for local recurrence and survival [1]. Scully

reported that pathological fractu re was a statistically risk

factor for local recurrence in osteosarcoma [2 ]. Although

a giant cell tumor (GCT) of bone is considered to have

the potential for local recurrence [3], it is unclear

whether a pathological fracture is a risk factor for local

recurrence in GCT cases. We studied the relationship

between pathological fractures and local recurrence in

GCT cases.

2. Patients and Methods

We retrospectively reviewed 35 patients with GCT in the

extremities treated at Juntendo University Hospital and

Juntendo Orthopedic Oncology Collaboration (JOOC)

affiliated hospitals between 1992 and 2008. The clinical

and radiological records of all 35 patients were reviewed.

Clinical and radiological evidence of a fracture had been

seen either at diagnosis or during the course of preopera-

tive treatment. A histopathological diagnosis was ob-

tained in all of the cases. Statistical comparisons were

made using a Chi-squared analysis and the Fisher exact

test.

3. Results

In total, seven of 35 patients had a pathological fracture

before the initial surgery, four of whom were male, and 3

were female, and they had a median age of 25 years (18

to 36) (Table 1). The median follow-up was 35 months

(5 to 73). The tumor was located in the femur in five, and

in the humerus and radius in one patient each. In the fe-

mur fractures, four were distal, and one was proximal. In

the humerus, the fracture was in the proximal humerus,

and in the radius, the fracture was in the distal portion.

The fractures had been present at diagnosis in six pa-

tients, and developed after biopsy in one patient. Six

fractures occurred after trauma and one occurred sponta-

neously. According to the grading system of Campanacci,

two lesions were grade I, two were grade II, and three

were grade III. The surgical treatment was curettage of

the tumor with high speed burring in six, and wide resec-

tion with a vascularized fibula graft in one distal radius

ase. Chemical adjuvant treatment was indicated in five c

T. TORIGOE ET AL.

229

Table 1. Summary of seven patients with GCT with pathological fracture.

Case Age/SexLocation* Campanacci

grade Surgery Adjuvant Reconstruction Local Recurrence

1 22/M D Femur II 1st Curettage Alcohol 1st Bone graft + PMMA (+) 73

nd Wide resectionNone 2nd Prosthesis (+)

rd Wide resectionNone 3rd None (–)

2 21/F D Femur III 1st Curettage Alcohol 1st Bone graft + PMMA (+) 61

nd Curettage Alcohol 2nd Bone graft + PMMA (–)

3 19/F D Femur II Curettage

Alcohol +

Phenol Bone graft (–) 24

4 36/F D Femur I Curettage None Bone graft (–) 73

5 23/M P Femur I Curettage Alcohol Bone graft (–) 5

6 34/M D Radius III Wide resection None Vascularized fibula graft (–) 33

7 18/M P Humerus III Curettage Alcohol Bone graft + PMMA (–) 32

*D, Distal; P, Proximal; PMMA, Pol ymethylmethacrylate.

of six curettage cases. Local recurrence developed in two

distal femur cases at 11 and 21 months after surgery.

The Campanacci grades in the local recurrent cases

was grade II and III. The treatment of the local recur-

rence was repeat curettage in the patient with the grade

III tumor, and wide resection and reconstruction with an

endoprosthesis in the patient with the grade II tumor. The

patient treated with a wide resection developed a second

local recurrence in the soft tissue 62 months after the

second operation. This patient was treated with a wide

resection of the recurrent tumor in the soft tissue, and no

third recurrence has been observed as of the most recent

follow-up, which was 69 m onths after the third operati on.

A total of 28 of the 35 GCT cases without fractures

were studied as controls. The tumors without fractures

were located in the femur in nine, in the tibia in ten, in

the radius in five, and in the fibula in four. The Cam-

panacci grades of these tumors were evaluated as grade I

in 14 cases, II in four and III in ten cases. The surgical

treatment of tumors without a fracture was curettage with

or without chemical adjuvant in 23 cases, and wide re-

section in 5 cases. The median age of patients without a

fracture was 31 years old (19 to 57) and no statistically

significant difference was observed in the age between

the groups with and without fractures (p = 0.06). There

were also no significant differences in other factors,

anatomical location, Campanacci grade, surgery or fol-

low-up period between two groups. A local recurrence

was observed in six of the 28 cases without fractures.

The overall rate of local recurren ce in all 35 patients was

23%. The local recurrence rate in the group with frac-

tures was 29 % (2/7 ) and was 2 1% in the su bject s withou t

fractures (6/28). Although ther e was a tendency for there

to be a higher recurrence rate associated with a patho-

logical fracture, no statistically significant difference was

observed between the two groups (p = 0.69). The local

recurrence rate after the curettage operation was 33%

(2/6) in cases with a pathological fracture, and was 26%

(6/23) in cases without a fracture, which was also not

significantly different. Although no distant metastasis

was observed in cases with fractures, multiple lung and

soft tissue metastases were observed in one of the cases

without a fracture.

4. Discussion

Although a giant cell tu mor of bone is a benign tumor, it

is considered to be locally aggressive and has the poten-

tial to result in local recurrence, like malignant tumors.

The local recurrence rate of GCT varies in the literature,

and the prevalence of local recurrence ranges from 0 to

45% after burring and/or chemical adjuvant treatment

[4-8]. The reported risk factor for local recurrence of GCT

was tumor progression outside the bone. Campanacci re-

ported a radiographic grading system for GCT, and this

grading system designates tumors on a scale from grades

I to III [9]. Grade I tumors have a well-defined border

with a thin rim of mature bone, and the cortex is intact or

slightly thinned, but not deformed in plain X-ray. Grade

II tumors have relatively well-defined margins but no

radiopaque rim, and the combined cortex and rim of the

reactive bone is rather thin and moderately expanded, bu t

still present. Grade III tumors have fuzzy borders sug-

gesting a rapid and possible permeating growth, with the

tumor bulging into the soft tissue, but with the soft tissue

lesion not following the contour of the bone, and not

limited by an apparent shell of reactive bone. In some

studies, a correlation between the Campanacci grade and

T. TORIGOE ET AL.

230

recurrence rate was reported [10,11]. Prosser reported

that the overall local recurrence rate of GCT was 19%,

and the recurrence rate of the tumors with extraskeletal

extension (Campanacci Grade III) was 29% [12].

In osteosarcoma, a primary bone malignancy, Sculley

reported that a pathological raised concerns about tumor

dissemination by the hematoma, and should be consid-

ered to be a contraindication to limb salvage surgery [13].

Abudu reported that limb sparing surgery with adequate

margins of excision could be achieved in many patients

with pathological fractures due to primary osteosarcoma

without compromising survival, but the risk of local re-

currence was significant [14]. It is possible that a patho-

logical fracture in GCT may release tumor cells into the

surrounding soft tissues like in osteosarcoma, and Coo-

per reported that GCT tumor cells were observed in the

synovium of the ankle joint after a distal tibia p athologi-

cal fracture and in the soft tissues around a fracture site

in the distal femur [15]. Campanacci reported a possibil-

ity that a pathological fracture was the risk factor in GCT,

but the relationship was not clear in his report [9].

O’donnell reported that the overall local recurrence rate

of GCT was 25%, and that the local recurrence rate of

GCT in patients with a pathological fracture was 50%,

thus indicating that a pathological fracture was associ-

ated with an increased recurrence rate [16]. Conversely,

some reports have suggested that there is a lower local

recurrence rate in GCT patients with a fracture than in

those without a fracture, but the surgeons in this report

were more inclined to perform extensive surgery for le-

sions with pathological fractures, because they considered

there was a risk of tumor cell contamination into the sur-

rounding tissues [8, 17]. Dreinhöfer reported that four of

10 patients with fractured GCT at diagnosis had local

recurrence after the curettage surgery, and that the local

recurrence rate in patients with fractured GCT was similar

to that in patients with non-fractured GCT [18]. He sug-

gested that extensive surgery, such as an en-bloc resection

and reconstruction with tumor prosthesis, was not neces-

sary for GCT with pathological fracture as the first opera-

tion, and extensive treatment should be considered only

when a local recurrence occurs after a curettage surgery.

In our present study, no significant difference was ob-

served in the local recurrence rate between GCT patients

with and without fractures. We theref ore do not consider

a pathological fracture to be a definite risk factor for lo-

cal recurrence in GCT, and a curettage operation with

adjuvant treatment should therefore be advocated for

treating such tumors.

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