Surgical Treatment And Prognostic Factors Of The Spinal Giant Cell Tumors

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Surgical Treatment and the Risk Factors for Recurrence of the Primary Mobile Spinal Giant Cell TumorsObjective:Spinal giant cell tumor(SGCT)has high rate of postoperative recurrence.En bloc resection of giant cell tumor of the mobile spine has been widely accepted for its low recurrence rate,but during our clinical practice,we found intralesional excision with some adjuvant treatments can also achieve satisfactory prognosis.The purpose of this study is to investigate the factors that affect the recurrence free survival(RFS)after initial surgery in patients with primary mobile spinal giant cell tumors,and to evaluate the safety and therapeutic effects of intralesional excision for primary mobile spinal giant cell tumors.Methods:A retrospective analysis of mobile SGCTs between August 2003 and August 2015 was performed.A total of 31 patients comprising 14 males and 17 females with a mean age of 31.4 years(range 17 to 59)were included.These 31 patients were diagnosed as SGCT first time.All complete clinical data,radiographs,computed tomography(CT),magnetic resonance imaging(MRI)scans and pathological data were reviewed.A univariate analysis was performed comparing the patient demographics,perioperative characteristics,resection mode,adjuvant treatments,medical treatment and clinical outcomes between patients who were recurrent and not.The Kaplan-Meier method was used to identify independent prognostic factors,and the log rank test was used for comparison.Cox regression model was used to calculate the hazard ratio(HR).One-way analysis of variance(One-Way ANOVA,Bonferroni test)was used to compare intraoperative blood loss between different surgical groups,and a P value of less than 0.05 was deemed significant.Results:Three patients received en bloc total spondylectomy,28 patients received intralesional excision,among them,9 patients received curettage,11 patients received extended curettage,8 patients received piecemeal resection.Among them,6 cases were located in cervical vertebrae,16 cases located in thoracic vertebrae,1 case located in thoracolumbar vertebrae,and 8 cases in lumbar vertebrae.All patients were alive at last follow-up,with a mean follow-up length of 65.5 months(range 24.6 to 137.3).The total local recurrence rate in our cohort was 19.4%(6/31 patients).There was a 44.4%(4/9 patients)local recurrence rate for intralesional curettage,9.1%(1/11 patients)for extended curettage,12.5%(1/8 patients)for piecemeal resection,and 0%for en bloc total spondylectomy,the total local recurrence rate apart from intralesional curettage was 9.1%(2/22 patients).The recurrence rate of the intralesional curettage group was significate higher than other groups(p=0.002).The local recurrence rate was lower with inactivation of the lesion(p=0.007).The local recurrence rate was lower by the usage of bisphosphonates(p=0.047).The local recurrence rate was not influenced by the gender(p=0.153),the usage of radiation therapy(p=0.194),selective arterial embolization(p=0.406)and denosumab(p=0.285).No statistically significant difference was noted between the staged surgery or not(p=0.446).No statistically significant difference was noted between the age<24 or>24(p=0.157).Cox regression analysis suggested that intralesional curettage was a risk factor for local recurrence,as the relative risk was 20.5(95%CI,1.9~217.9).Conclusions:The removal of the entire lesions by en bloc or piecemeal method in combination with inactivation of the lesions is able to achieve satisfactory local control and clinical outcomes of primary mobile SGCTs.It is relatively an easy,safe and effective way to remove the lesions by intralesional excision combined with the inactivation of the lesion.The combined treatment such as the usage of bisphosphonate could reduce postoperative recurrence rate.Part ? Surgical Management in Cervical Spinal Giant Cell TumorObjective:To investigate the safety and efficacy of curettage and excision for giant cell tumor of the cervical spine.Methods:The complete clinical data,imaging data,diagnosis,treatment and prognosis of 6 patients with diagnosis of cervical spinal giant cell tumor in our center from April 2006 to July 2015 were analyzed retrospectively.Two males and 4 females with average age of 31.3±11.1 years old(range from 18 to 42 years).Among them,4 cases were located in the 2nd cervical vertebra,1 cases located in the 3 rd cervical vertebra,1 cases in the 4th cervical spinous process and vertebral lamina.In this cohort,all the 6 patients underwent intralesional surgery,three patients were Enneking grade 2,one cases underwent curettage,two cases underwent extended curettage among them;three cases were Enneking grade 3,one cases underwent extended curettage,and two cases underwent subtotal spondylectomy among them.Three patients received local inactivation of the lesion while the other 3 were not.One patient received local radiotherapy after her first posterior occipital-cervical fixation,and underwent posterior and anterior tumor resection,bone grafting and internal fixation 3 months later.One patient was treated with denosumab preoperatively,3 patients were treated with bisphosphonates postoperatively.The neurological status was evaluated by Frankel classification pre-and postoperatively,the pain scale was evaluated by Visual Analogue Scale(VAS)pre-and postoperatively.Imaging examination was used to assess the location and the extent of the tumor preoperatively,as well as the tumor recurrence postoperatively.Results:The mean follow-up period was 61.1±43.6 months(range,25-134months),without patient lost to follow up.One case underwent posterior surgery,while other 5 cases underwent anterior and posterior surgeries;3 patients underwent one-stage surgery,3 patients underwent staged surgeries,the mean intraoperative bleeding was 2142±3430ml(range from 300 to 9100 ml).The mean preoperative VAS score was 3(range from 2 to 5),the neck pain of the patients were all relieved postoperatively,and the mean VAS score was 0.The preoperative Frankel grade was E in all 6 patients,and the postoperative Frankel grades were E.One intracranial epidural hematoma occurred on the second day postoperatively,emergency evacuation of hematoma was then performed and the postoperative recovery was good.At the latest follow-up,no internal fixation loosening or failure was occurred in all patients,and no tumor recurrence was observed in all patients.Conclusion:Intralesional curettage and excision of the cervical spinal giant cell tumor is a safe and effective surgical method which can achieve satisfactory local control and prognosis.The comprehensive treatment of giant cell tumor of the cervical spine can effectively reduce the local recurrence of the tumor.Part ? Recurrence of Giant Cell Tumor of the Spine after ResectionObjectives:Spinal giant cell tumor(SGCT)is a benign,locally aggressive tumor which is rare but has a high recurrence rate postoperatively.Complete resection of these lesions remains a challenging surgical problem.Furthermore,the management of local recurrence can be more challenging.Therefore,we retrospectively reviewed the clinical details and further treatments of the recurrent SGCTs,hopefully to analysis the risk factors of recurrence and shed new light on the treatment options and prognosis of recurrent SGCTs.Methods:A retrospective analysis of recurrent SGCTs between April 2003 and August 2015 was performed.A total of 12 patients comprising 5 males and 7 females with a mean age of 29.2 years(range 18 to 43)were included.All complete clinical data,radiographs,computed tomography(CT),magnetic resonance imaging(MRI)scans and pathological data were reviewed.The Kaplan-Meier survival analysis was used to assess the disease-free survival of the patients,the log rank test was used for comparison,and a P value of less than 0.05 was deemed significant.Results:The mean follow-up was 89.0 months(range 49.7 to 188.1).Among them,7 cases were located in the thoracic vertebra,4 cases located in the lumbar vertebra,1 cases in the sacrum.All patients had Enneking stage 3 tumors,11(91.7%)of them had different extent of spinal canal involving at primary time.All patients received intralesional resection during the first time of surgery,and only one case received local adjuvant treatments,one case received adjuvant radiotherapy postoperatively,and another case with the usage of bisphosphonate.No case received selective arterial embolization or usage of denosumab at that time.After the recurrence,one patient was cured by the denosumab,and four with disease controlled by the use of medical treatments or adjuvant treatments.A total of 3 times of repeated recurrence were happened and 7 times of repeated surgical procedures were performed in 5 patients,there were 6 intralesional excision and one decompression surgery.The mean relapse free time after first surgery was 36.0 months(range 10.5 to 65.1).The overall mean relapse free time was 41.8 months(range 10.5 to 157).No distant metastasis was found in our series.At the last time of follow up,4 patients were diseases free,5 were diseases under control,2 with diseases aggravation,while one was died of disease progress 133.9 months after first surgery.Conclusions:Intralesional excision for the recurrent spinal giant cell tumors(SGCTs)is an effective option which may have satisfactory prognosis.However the curettage and the inactivation of the lesion should be carefully and thoroughly without missing in every corner.Early diagnosis of recurrence may be associated with better prognosis.Adjuvant treatments perioperatively and systemic medical treatments can decrease the recurrence rate meanwhile they also have therapeutic effect in the recurrent SGCTs.