Long bones giant cells tumors: treatment by curretage and cavity filling cementation

Objective: Giant cell tumors (GCT) of bone are benign tumors with local aggressiveness that most of the time occur around the metaphyseal area of long bones, often in contact with the articular cartilage. Their treatment remains controversial because of their high recurrence rate. The authors report a retrospective series of 30 cases treated using curettage followed by cementation. They suggest demonstrating the mechanical and functional benefit of this technique, its benefit controlling the risk of recurrence, and of osteoarthritis potential.

Material and methods: Between 1992 and 2005, 30 patients with GCT were treated using curettage and cementation. Twenty-six of these tumors were present around the knee: 14 at the distal femur and 12 at the proximal tibia. Preoperative radiological evaluation with standard X-rays showed that the tumor measured a mean 71x45mm, for a mean volume of 78cm(3). Seventy-three percent of these GCT were in direct contact with the articular cartilage and 40% extended to the soft tissues as seen on the CAT scan and/or MRI. All patients were treated with curettage and cementation, 16 additional internal fixation procedures were performed. The mean follow-up of this series was 6 years and 4 months. All patients continue to be monitored, with none lost to follow-up.

Results: In all our cases, nine recurrences (30%) were observed during the first 2 years. Six patients were treated with a new curettage and cementation procedure and three underwent a total knee arthroplasty. None of these lesions had recurred at the last follow-up. The MSTS score, reflecting the function of the operated limb was a mean 93.33% (28 + or - 2/30). Standard radiological assessment showed a thin scalable border on four patients and was normal for the all-total arthroplasty cases. Two cases of minor osteoarthritis progression were noted (one less than 50% and a simple densification of subchondral bone), requiring no specific treatment. Three complications were noted: one leg deep venous thrombosis, one hematoma, and one deep infection without impacting the initial treatment outcome over the long term.

Discussion: The curettage and cementation technique is usual practice in GCT treatment. Simple and reproducible, this technique has a lower rate of complication than other treatment options such as cryotherapy. It produces a lower rate of recurrence with the dual benefit of excellent mechanical and functional qualities. Diagnosis of recurrence can be made earlier because of the thin scalable border at the bone-cement interface. This technique does not generally cause osteoarthritis, which was found in only two cases with no evidence of the cement having a direct effect. The 30% recurrence rate observed in this series shows that the benefit provided by the cement as an adjuvant preservative remains modest.

Conclusion: The cement mechanical and cytotoxic properties as well as its innocuity and its ease of handling make curettage and cementation one of the top-ranking GCT treatment options. An even lower rate of recurrence may be obtained through development of additional adjuvant treatments such as calcitonin and bisphosphonates.

Level of evidence: Level IV; Therapeutic study.