The proximal fibular free flap - an ideal material for reconstructing distal radius defect after Giant tumor cell resection. A case report

Giant cell tumors (GCT) of the distal end of radius are relatively common tumors, representing approximately 5% of all primary bone tumors. It is the third most common location for GCT following distal femur and proximal tibia. In general, treatment includes thorough tumor excision, reconstruction of the defect, and wrist joint rehabilitation. The proximal fibular free flap is an ideal material for distal radius reconstruction after giant cell tumor excision. We present a case of a 57-year-old female, admitted to the hospital due to painful and limited proper wrist movement. Based on X-ray and Magnetic resonance imaging (MRI) images and histopathology findings, the patient was diagnosed with a stage 3 giant cell tumor of the distal radius. The patient underwent a one-step surgery of tumor excision and distal radius reconstruction by a vascularized proximal fibular free flap. 2 years follow-up post-surgery showed that the patient had no pain of the wrist, improved wrist joint function, no sign of recurrence, and good flap vitality and the knee joint remains normal. In conclusion, the surgery was successful with no further prolonged pain, improvement of the wrist joint function and overall improvement of the patient quality of life.

En-bloc excision of Giant Cell Tumors of the distal radius and arthrodesis of the translocated ipsilateral ulna: A report of two cases

The distal radius is the third most common site of giant cell tumor of bone (GCTB). The local aggressive invasion of this rare neoplasm requires reconstructive solutions after wide excision. The authors present two cases of patients diagnosed with Campanacci grade III GCTB of the distal radius successfully treated with en-bloc excision and translocation of the ipsilateral ulna. Pre-operative application of denosumab was given for one year to both patients. At one year of follow-up, both patients are disease-free and reported satisfactory results on Quick - Disabilities of the Arm, Shoulder and Hand (Quick-DASH) questionnaire and modified Musculoskeletal Tumor Society (MSTS) score. Although a challenge, the reported procedure offers good oncological and functional outcomes. Keywords: Giant cell tumor of bone; distal radius; en-bloc excision; translocation; ipsilateral ulna; wrist arthrodesis

The role of denosumab in the complex treatment of giant cell tumor of the spine: reducing of local recurrence rate, surgery time and blood loss

Objective. To assess the effect of the combined treatment method including preoperative denosumab therapy on the results of treatment of patients with giant cell tumors of the spine.Material and Methods. A single-center retrospective-prospective study of a series of clinical cases included 15 patients with giant cell tumors of vertebrae. The average follow-up period was 56 months. A total of 11 patients received denosumab therapy according to the following scheme: 120 mg subcutaneously on the 1st, 8th, 15th and 28th days of the first month and then once every 28 days. Surgical options included marginal resection, segmental resection, or en-bloc resection with or without spinal reconstruction/stabilization. In the case of locally advanced and inoperable disease, long-term therapy with denosumab was carried out until the disease progressed or serious adverse events appeared.Results. Thoracic vertebrae were involved in 7 (46.6 %) of 15 cases, lumbar in 4 (26.7 %) and cervical in 4 (26.7 %). Local recurrence rate after surgery alone was 40 % (2/5), average time to recurrence onset was 4.5 months. No relapses were observed after combined treatment performed in four patients. Disease progression during long-term denosumab therapy for inoperable disease recurrence was not recorded (0/7). The average number of denosumab injections before surgery and during long-term therapy was 15 and 24 injections, respectively. Denosumab therapy allows reducing the duration of surgery and the volume of blood loss.Conclusion. Combined therapy of giant cell vertebral tumor allows to reduce the risk of recurrence of the disease, as well as to reduce surgery duration and blood loss. Long-term continuous therapy for inoperable cases allows achieving long-term stabilization of the effect. Due to the rarity of giant cell tumors of the spine, a further prospective recruitment of patients is required to study the efficacy and safety of combined therapies.

Discovery of Lijianmin-Chengkun Complexes and Their Oncological Application in Osseous and Intraarticular Lesions Around the Knee

Objective: This research aims to refresh the limited understanding about the canal and vascular structures within the epiphysis and metaphysis of the tibia and femur and their oncological significance.Methods: This study was started with characterization of a novel structure using radiographs and anatomic dissections, followed by a descriptive clinical study with 55 participants to investigate the effects of tumors on this novel discovery and a retrospective cohort study with 82 participants to investigate whether the structure would be a risk factor for tumor recurrence after the curettage of giant cell tumor of bone.Results: A new anatomical knee structure, the Lijianmin-Chengkun (LC) complex, was discovered in healthy adults, and its clinical implications were examined in this study. This new-found anatomical structure is composed of an epiphyseal and metaphyseal canal which surrounds a blood vessel, foramen, and foramen-covered synovium. All LC complexes showed similar radiographical, anatomical, and histological characteristics and were located within specific tibial and femoral intercondylar regions. These LC complexes seem to facilitate tumor residue and extension and may be a risk factor for tumor recurrence after curettage of femoral and tibial giant cell tumors (P = 0.031).Conclusion: The LC complexes are related to local tumor recurrence and bidirectional tumor dissemination between intraosseous and intraarticular regions. These findings have opened up a new perspective and may provide new targets for intervention in malignant and aggressive tumors around the knee joint.

Intralesional nerve-sparing surgery versus non-surgical treatment for giant cell tumor of the sacrum

Background There is no standard treatment for giant cell tumors of the sacrum. We compared the outcomes and complications in patients with sacral giant cell tumors who underwent intralesional nerve-sparing surgery with or without (neo-) adjuvant therapies versus those who underwent non-surgical treatment (denosumab therapy and/or embolization). Methods We retrospectively investigated 15 cases of sacral giant cell tumors treated at two institutions between 2005 and 2020. Nine patients underwent intralesional nerve-sparing surgery with or without (neo-) adjuvant therapies, and six patients received non-surgical treatment. The mean follow-up period was 85 months for the surgical group (range, 25–154 months) and 59 months (range, 17–94 months) for the non-surgical group. Results The local recurrence rate was 44% in the surgical group, and the tumor progression rate was 0% in the non-surgical group. There were two surgery-related complications (infection and bladder laceration) and three denosumab-related complications (apical granuloma of the tooth, stress fracture of the sacroiliac joint, and osteonecrosis of the jaw). In the surgical group, the mean modified Biagini score (bowel, bladder, and motor function) was 0.9; in the non-surgical group, it was 0.5. None of the 11 female patients became pregnant or delivered a baby after developing a sacral giant cell tumor. Conclusions The cure rate of intralesional nerve-sparing surgery is over 50%. Non-surgical treatment has a similar risk of complications to intralesional nerve-sparing surgery and has better functional outcomes than intralesional nerve-sparing surgery, but patients must remain on therapy over time. Based on our results, the decision on the choice of treatment for sacral giant cell tumors could be discussed between the surgeon and the patient based on the tumor size and location.

Case series study: the diagnosis and treatment of fifty tumors and pseudotumors at the proximal femur

Introduction: Tumor and pseudotumor (TP) at the proximal femur (PF) can seriously affect mortality, extremity function, and body integrity. However, reports often focused on a specific tumor, not regional lesions. This study focuses on clinical findings, imaging, micro-pathology, and the treatment of all TP at the site. Methods: The study involved all patients who had a confirmed tumor or pseudotumor diagnosis at the PF. The clinical findings, X-ray, and biopsy were recorded and analyzed. Treatment was optional depending on the patient's situation and available condition of the hospital. The functional outcome, bone healing were defined at the last examination or two years of follow-up. Results: Fifty patients were involved in the study. Twenty-four patients had apparent tumors. TP at the PF, neck-trochanter, trochanters, and neck were 21 (42%), 16 (32%), 9 (18%), and 4 (8%) cases, respectively. There were 29 (58%) pathologic fractures. Biopsy was made for all patients. Twenty-three cases (46%) were malignant, and 8 (16%) cases were giant cell tumors. Thirtythree patients suffered from an operation. Ennerking's functional score was excellent, good, fair, and poor in 24 (48%), 5 (10%), 1 (2%), and 20 (40%) patients, respectively. For the last outcomes of 33 operated patients, 17 healed, three unchanged, one worse, and two dead. Conclusions: For the PF TP, the rate of malignant and pathological fracture was high. The giant cell tumor was not rare. The resection of the TP combined with grafts using ordinary fixation devices was satisfactory.

Results of neoadjuvant denosumab in giant cell tumor of the bone depending of the tumor location and the surgical grade

Background. The standard treatment for giant-cell tumors of the bone includes radical surgery. However, specific anatomical location of the tumor and/or its spread may hinder its complete excision or result in poor functional outcomes. Currently, combination treatment that includes preoperative denosumab and surgery is preferable. It saves patients’ lives and improves their quality of life. Reduction of local recurrence rate by combination therapy for giant-cell tumors of the bone is being actively studied now.Objective – to analyze treatment outcomes of patients with giant-cell tumors of the bone, including those who received combination treatment that included preoperative therapy with denosumab followed by surgery.Materials and methods. This study included 277 patients with giant-cell tumors treated in N.N. Blokhin National Cancer Research Center between 2005 and 2020. The mean duration of follow-up was 56 months. Study participants were divided into two groups. Group 1 included patients who received surgical treatment alone (n = 212), whereas Group 2 comprised patients who received combination treatment (n = 65). Neoadjuvant therapy included subcutaneous denosumab 120 mg on days 1, 8, 15, and 28, then every 4 weeks until stable effect. There were two variants of surgical treatment: radical (removal by a single block or segmental resection with defect replacement, with or without fixation) and non-radical (excochleation or marginal resection with defect replacement, with or without fixation).Results. During treatment, patients in Group 2 had a significantly milder pain syndrome (assessed both using the visual analog scale for pain and Watkins scale) compared to Group 1. In case of radical surgery, the incidence of local recurrence was 12 % and 0 % in Groups 1 and 2, respectively; the difference was significant (р <0.05). Tumor location and volume of surgery played an important role in disease recurrence (р <0.05). The incidence of complications after radical surgery was 36.9 % and 12.5 % in Groups 1 and 2, respectively; the difference was significant (р <0.05). In addition to that, neoadjuvant therapy with denosumab substantially reduced the duration of surgery and blood loss in patients with challenging anatomical location of the tumor (р <0.05).Conclusion. Combination treatment for giant-cell tumors that includes neoadjuvant therapy with denosumab reduces the risk of recurrence, duration of surgery, blood loss, and the risk of postoperative complications. However, it is important to consider tumor location and the volume of surgery. Since the disease is quite rare, further study of long-term efficacy and safety of combination treatment for giant-cell tumors, including rare ones and those with challenging anatomical location, is necessary.