The multidisciplinary management of giant cell tumor of bone

Abstract

Giant cell tumor of bone is a locally aggressive lesion with a predilection for local recurrence, and in a small proportion of patients, metastatic disease can develop. Surgery is the mainstay of management for extremity-based lesions. For tumors located in challenging anatomical locations such as the sacrum and spine however, surgery may be associated with unacceptable functional morbidity. There are limited data regarding other treatment modalities such as radiation therapy, cytotoxic chemotherapy, interferon and bisphosphonates. Serial arterial embolization can be effective in some cases. Recent evidence has demonstrated denosumab to be a promising agent in the treatment of unresectable or metastatic disease.

Keywords::

• denosumab
• giant cell
• management
• multi modality
• osteoclast
• receptor activator of nuclear factor κ-B
• surgery

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Giant cell tumor of bone (GCTB) is a benign lesion but can be locally aggressive and has a propensity to recur.

• Approximately 5% of patients develop benign pulmonary deposits which are slow-growing, but can be symptomatic. Most instances of lung disease are associated with local recurrence (LR) of GCTB.

• Intralesional curettage alone is associated with a high LR rate. The completeness of tumor removal correlates with local control, and adjuvants such as high-speed burr, cement, cryotherapy and phenol can provide extended margins. It is the treatment of choice for extremity lesions.

• Wide resection is reserved for GCTB associated with refractory LR, expendable bones, extensive soft-tissue extension or unsalvageable articular surfaces.

• Radiation therapy is associated with malignant transformation after a short latency in a small but significant number of cases. Newer technology may reduce this risk. It is reserved for tumors unsuitable for surgical resection, denosumab or serial arterial embolization.

• Serial arterial embolization is effective in stabilizing disease for GCTB affecting the sacrum and other anatomically morbid locations.

• There is no high-level evidence supporting the use of interferon or bisphosphonates in routine management of GCTB. However, in advanced cases of GCTB, bisphosphonates may help stabilize disease and control pain. Their precise role in the management of GCT remains to be defined.

• Cytotoxic chemotherapy should be reserved for malignant GCTB.

• Denosumab is a promising new therapy, particularly for unresectable central lesions or extremity lesions in which surgery would entail significant functional morbidity. Unanswered questions remain regarding its durability of effect, and the potential for long-term complications.