Giant cell tumor: Curettage and bone grafting

Background: Curettage and wide resection are accepted methods of treatment of giant cell tumor (GCT) of bone. The success rate with curettage in different reports varies widely. There is a paucity in the literature regarding selection of cases for curettage. Present study is an analysis of outcome of 34 cases treated by curettage and bone grafting. Materials and Methods: Thirty-four cases of GCT of bone, 28 fresh and six with recurrence were treated by curettage and bone grafting. All cases of Campanancci grade 1, 2 and grade 3 which on computerized tomography scan showed break in the cortex confined to one surface and cortical break less than one third of circumference were treated by curettage and bone grafting. Results: 4 (14%) of these lesions treated primarily by us showed recurrence after one and half year. Conclusion: Curettage and bone grafting is a reliable method in the treatment of GCT, provided guidelines regarding selection of cases and principles of tumor surgery are strictly adhered to.

G iant cell tumor (GCT) of bone is a benign but work by inducing an additional circumferential area of locally aggressive tumor that usually involves the necrosis to ''extend'' the curettage. 1 ends of long bones. It occurs most frequently in the third decade of life, i.e. after physeal plate closure.
We present the outcome of GCT of the bone treated by The lesion consists of multinucleated giant cells mixed curettage and bone grafting since 1989 to highlight the with mononuclear stromal cells. They represent 20% of usefulness of CT scan in selecting cases for curettage and all benign bone tumors and 5% of all bone tumors. 1 High grafting and the choice of the surgical approach. incidence is seen in China and India, where they represent up to 20% of all bone tumors. 2,3

MATERIALS AND METHODS
GCT of the bone has an unpredictable behavior, not always Fifty-two patients treated by us during 1989-2004 constituted related to radiographic or histological appearance. 4 This the clinical material. Thirty-two of our cases were around makes the treatment of the disease a subject of constant the knee joint. Most of our patients (35 cases) were in the debate. The best treatment should ensure local control of third decade. There were 21 males and 31 females. Apart disease and maintain function. Curettage has been the from routine investigations such as Hb%, TLC, DLC, ESR, preferred treatment for most cases of GCT. Many earlier S. Calcium, S. Alkaline phosphatase, X-ray of the lesion studies had shown very high (25-50%) local recurrence and X-ray chest, all patients were subjected to CT scan. rates after curettage and bone grafting. 3-5 The use of modern Diagnosis was established by CT-guided core biopsy. imaging techniques and extended curettage through the use of power burrs and local adjuvants have improved outcome with reduced recurrence rates (10-20%). Phenol, liquid nitrogen, bone cement, hydrogen peroxide, zinc chloride and more recently, argon beam cauterization have been employed as local adjuvants. Chemical or physical agents Cases were classified according to Campanacci's grading system. 2,4 Procedure to be selected was decided based on CT scan findings. All cases which on CT scan showed break in the cortex confined to one surface [ Figure 1] and cortical break less than one-third of its circumference, were treated by curettage and grafting. All cases belonging to Campanacci's Grade 1 and 2 as well as cases belonging to Grade 3 which fulfilled the above criteria were treated by curettage and grafting. Twenty-eight primary lesions and six cases of recurrences were treated by curettage.
Bone graft was used to fill up the resultant cavity in all except four cases where bone cement was used. Present analysis is about these 34 cases underwent curettage and bone grafting.

RESULTS
Maximum follow-up was 17 years and minimum two years with a mean follow-up of six years. In patients treated by curettage and grafting, functional evaluation was done after four months according to Enneking's method that takes into consideration range of movement of the joint, pain, stability, deformity, muscle strength, functional activity and subjective opinion. It was found that all cases showed good function. 6 Of the 28 primary cases treated by curettage and bone grafting, cortical break. In a lesion of lower femur and upper tibia, if four had recurrence. Of these none of them recurred before the break in the cortex was in the posterior aspect [ Figure  one and a half years. One case of recurrence occurred after 1], posterior approach, isolating popliteal vessels and tibial six years. Two cases belonged to Stage 2 of Campanacci's nerve was preferred. In our series we went through posterior grading system and two cases belonged to Stage 3. One such approach in four cases of lower femur and six cases of recurrent case in the lower femur was treated by a custom upper tibia. In the rest of the cases of lower femur and prosthesis. One case of upper tibia underwent resection upper tibia, the approach was anteromedial or anterolateral arthrodesis. Another case of upper tibia did not come to us depending upon the cortical break in the CT scan. In a case for further treatment. Fourth one was in lower radius; it was of GCT calcaneum, the cortical break was on its superior treated by Enbloc resection and reconstruction with non nonarticular surface. We detached the insertion of tendo vascularized proximal fibula. 7,8 Out of six recurrent cases calcaneus for proper curettage and later repaired by using (all had their first surgery in other hospitals) treated by us by pullout sutures. Thus a wider area of tumor removal at the second curettage, four recurred. Both the first and second site of cortical break was achieved, where there was tumor recurrence occurred before one year which is much earlier extension to extraosseous tissues. All six cases of recurrence than the cases of recurrence we had in our primary cases. were initially treated elsewhere. Out of these four cases Two cases of upper end tibia out of the four opted for above underwent treatment initially with out CT scan and in knee amputation. One case of lower end femur opted for remaining two cases though CT scan was taken, approach radiation therapy and one was treated by custom prosthesis. was not through the area of cortical defect.
In three cases, recurrences occurred during pregnancy. This happened after one and a half years, three years and four After exposure, the site of the cortical break was identified years respectively. No case in the curettage group had lung by palpation and a circumferential area of 1 cm × 1 cm metastasis. 9 A 21-year-old lady, who presented with a second beyond the margin of the cortical break is marked using a recurrence in the lower radius, was treated by wide excision. cautery. With a small osteotome, the cortex is broken and She presented to us with deviation of tongue to one side, one with scissors, the area where there is soft tissue extension year after the third surgery. Investigation showed secondary is removed as a lid, taking care not to spill the tumor. The deposit in the base of skull (clivus) producing compression of cavity after thorough curettage, is washed several times with hypoglossal nerve [ Figure 2]. Biopsy confirmed the diagnosis hydrogen peroxide and saline. The cavity was cauterized of secondary deposit from GCT. with phenol and then tightly filled with bone graft. The cases were followed up at six-week intervals until six months and then at three-month intervals till one year and then at six-month intervals.

DISCUSSION
Curettage and wide resection have been the accepted methods of treatment for GCT of bone. [1][2][3][4] Turcotte considers that many Stage 3 tumors, multiple local recurrences and pathologic fracture when joint anatomy cannot be restored are better treated with wide resections. 1 The definite criteria that guide the orthopedic surgeon to decide whether a particular case is to be treated by curettage have not been defined adequately. In this study we are suggesting some in the cortex is posteromedial, the lesion is approached from there is a contamination of the soft tissue during surgery on 9. Huvos AG. Bone tumors: Diagnosis, treatment and prognosis.
the lateral side. This may be the reason for a higher rate of 2 nd ed. WB Saunders Co: Philadelphia; 1991.
second recurrence in the cases which presented to us with first recurrence. Recurrence rate in the 28 cases which had curettage as the primary procedure was 14%, almost similar to the recurrence rate which is reported in the literature. ed. Churchill-