Surgical Management of GCT of Long Bones

Introduction: Giant cell tumor of bones is an unusual neoplasm that accounts for 4% of all primary tumors of bone, and it represent about (10%) of malignant primary bone tumors with it's different grades from borderline to high grade malignancy. Usually, the age of patients ranges from 20 to 55 years, and the peak age incidence is in the third decade of life, with slight female predominance (1.2:1). It is a locally aggressive tumor which involves the ends of long bones in skeletally mature individuals in more than 80% of cases, and 75% of them occur around the knee joint. Less frequently, giant cell tumors occur in the vertebrae (2-5%) and in the sacrum 10%. Material and Methods: This is a prospective study of twenty patients with giant cell tumor (GCT) of the bones treated at Dr. Pinnamaneni Siddartha Institute of medical sciences and research foundation, between 2015 and 2019. All patients were evaluated by clinical examination, plain X-ray, CT scan and MRI (in some cases). Biopsy was taken in all cases to confirm the diagnosis and to define the grade of the tumor. All patients underwent surgical treatment including curettage, curettage combined with cryosurgery and bone cement or bone graft, bone resection and amputation. Selection of the surgical technique was based on site and size of the lesion, soft tissue involvement (intra- or extra-compartmental), tumor grade and if recurrent or not. Patients were followed- up for a minimum of twelve months. Results: Out of 20 patients 8 patients were males and 12 patients were females, (male to female ratio was (1: 1.5). The age of our patients ranged from 20 to 65 years, with a mean age of 32.9 years. Based on Enneking's staging system, 15 patients (75%) were stage IA, 3 patients (15%) were stage IB and 2 were stage IIB. Histopathological examination of all cases revealed giant cell tumor of borderline malignancy. Curettage alone was done in 4 patients, curettage and bone cement in 3 patients, curettage, cryosurgery and bone graft in 8 patients, curettage, cryosurgery and bone cement in 2 patients, resection in 3 patients. There were no mortalities among our cases. Local recurrence was highest in cases treated with curettage only (50%), lowest in cases treated with curettage and cryosurgery with bone cement (16.6%). Conclusion: The main primary treatment of GCT is surgery; the type of which depends on preoperative evaluation, which includes clinical evaluation that involves the site and size of the tumor in relation to surrounding structures, together with plain X-ray, CT scan and/or MRI as indicated, and tissue biopsy to define tumor grade. Curettage alone results in high rate of local recurrence. On the other hand, curettage and adjuvant cryosurgery using bone cement or bone grafts give low rate of local recurrence. Resection is recommended for stages IB and IIB, extremely large lesions, and in cases where resection results in no significant morbidity as proximal fibula and flat bones. Amputation is preserved for massive recurrences and malignant transformation.