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Local Recurrence of Giant Cell Tumor of Bone After Intralesional Treatment with and without Adjuvant Therapy

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
This manuscript was prepared by the orthopaedic surgeons of the Arbeitsgemeinschaft Knochentumoren, c/o Institut für Patholgie der Universität Basel, Schoenbeinstrasse 40, CH-4031 Basel, Switzerland. Principal investigator: Wolfgang T. Becker, MD (Orthopädische Klinik Volmarstein, Universität Witten/Herdecke, Hartmannstrasse 24, D-58300 Wetter, Germany, w.becker@gmx.com). Lead investigators (site): Wolfgang T. Becker, Jörn Dohle (Orthopädische Gemeinschaftspraxis, Alter Markt 9-13, D-42275, Wuppertal, Germany, dohle@gmx.net), Ludger Bernd (Orthopädische Klinik, Städtische Kliniken Bielefeld, Teutoburger Strasse 50, D-33604 Bielefeld, Germany [cases of Orthopädische Universitätsklinik Heidelberg]), Arnim Braun (Vulpius Klinik GmbH, Vulpius Strasse 29, D-74906 Bad Rappenau, Germany), Miklos Cserhati (Orthopädische Praxis Hohlstrasse 192, CH-8004 Zürich, Switzerland), Alfred Enderle (Schlagenweg 3, D-37077 Göttingen, Germany [cases of Universitätsklinikum Göttingen, Abteilung für Orthopädie]), Louis Hovy (Orthopädische Klinik Frankfurt-Höchst, Gotenstrasse 6-8, D-60929 Frankfurt am Main, Germany [cases of Orthopädische Universitätsklinik Friedrichsheim, Frankfurt am Main]), Zdenek Matejovsky (Orthopedic Clinic, 1st Medical School, Charles University, Institute for Postgraduate Studies, Teaching Hospital Bulovka, CS-18081 Prague, Czech Republic), Miklos Szendroi (Department of Orthopedics, Semmelweis University, Karolina út, H-1113 Budapest, Hungary), Klemens Trieb (Abteilung für Orthopädie und Orthopädische Chirurgie, Klinikum Kreuzschwestern, Grieskirchnerstrasse 42, A-4600 Wels, Austria [cases of Orthopädische Universitätsklinik, Wien]), and Per-Ulf Tunn (Klinik für Chirurgie und Chirurgische Onkologie, Charité Campus Buch, Robert-Rössle-Klinik im HELIOS Klinikum Berlin, Lindenberger Weg 80, D-13125 Berlin, Germany). Study design and manuscript preparation: Wolfgang T. Becker, Jörn Dohle, and Louis Hovy. Data assessment and analysis and radiographic and clinical staging: Wolfgang T. Becker, Jörn Dohle, Ludger Bernd, Arnim Braun, Miklos Cserhati, Alfred Enderle, Louis Hovy, Zdenek Matejovsky, Miklos Szendroi, Klemens Trieb, and Per-Ulf Tunn.
Investigation performed at Orthopädische Klinik Volmarstein, Universität Witten/Herdecke, Wetter, Germany

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 May 01;90(5):1060-1067. doi: 10.2106/JBJS.D.02771
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Background: The use of adjuvants after curettage has been well established for the treatment of giant cell tumor of bone. The purpose of this study was to analyze the rates of recurrence following different types of treatment as well as the influence of various factors of tumor presentation on those rates.

Methods: The data regarding benign giant cell tumors of the appendicular skeleton from ten bone tumor centers were evaluated. Axial and malignant tumors were excluded. The recurrence rates associated with the different treatment modalities were analyzed, and hazard ratios for a recurrence were calculated for multiple factors of tumor presentation.

Results: The study included 384 surgical procedures, involving 256 primary and 128 recurrent tumors. The mean duration of follow-up was 64.2 months. Wide excision was performed in seventy-eight cases (20.3%), and an intralesional procedure was done in 306 (79.7%). Of the intralesional procedures, 103 (33.7%) were performed without the use of adjuvants, 102 (33.3%) included filling with polymethylmethacrylate, seventy-four (24.2%) included polymethylmethacrylate filling after phenolization, and twenty-seven (8.8%) included use of local toxins. The overall recurrence rate after the intralesional procedures was 49% when no adjuvants had been used, 22% when polymethylmethacrylate only had been used as an adjuvant, 27% when polymethylmethacrylate had been used after phenolization, and 15% when phenol or other local toxins had been used (without polymethylmethacrylate). The highest rate of recurrence (36%) after curettage with adjuvants was associated with extracompartmental tumors. Recurrent tumors were not at increased risk for another recurrence, even when they were extracompartmental. The recurrence rate following curettage of a primary tumor without the use of adjuvants (55%) was higher than that following the same treatment of a recurrent tumor (39%) (p = 0.033).

Conclusions: Use of polymethylmethacrylate as an adjuvant significantly reduces the recurrence rate following intralesional treatment of benign giant cell tumors, and it appears to be the therapy of choice for primary as well as recurrent giant cell tumors of bone. The significantly better results following treatment of recurrent tumors without adjuvants compared with the results of the same treatment of primary tumors were probably related to increased surgical thoroughness brought about by the surgeon's awareness of dealing with a riskier tumor.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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