Chen et al present a novel way of treating bone tumours without causing excess damage to the muscle (tendon) insertion, and thus ensuring reduced recurrence and better recovery
Abstract
Background
The purpose of this study was to investigate the clinical efficacy of extended resection with osteotomy, fenestration and conservation of muscle (tendon) insertion in the treatment of bone tumours.
Methods
A total of 15 patients with locally aggressive bone tumours (Enneking stage II) in the adjacent muscle (tendon) insertion of the proximal extremity were enrolled in the present study (mean age of 29 years). Extended curettage of lesions with osteotomy, fenestration or conservation of muscle (tendon) insertion and internal fixation with a bone graft or bone cement were performed at stage I. Postsurgical brace protection was used for four to 12 weeks and the patients were periodically followed-up by x-ray and functional assessment. Recurrence, postsurgical Enneking score and outcome rating were assessed.
Results
Treated cases included 15 patients aged 29 ± 7.75 years (range 18 to 42) with a male to female ratio of 8:7. Six had a femoral tumour and nine had a humeral tumour. These tumours comprised three chondroblastomas, five giant-cell tumours and seven aneurysmal bone cysts. Follow-up for 48 ± 12.95 months (range 25 to 72) revealed that 13 of 15 (87%) patients exhibited no recurrence. Local recurrence was observed in a patient with an aneurysmal bone cyst (nine months) and one with a giant-cell tumour (12 months). Mean Enneking scores were 27 ± 4.07 (range 18 to 29). Except for the patient with the recurrent giant-cell tumour, all patients reported good (13%, two out of 15) or very good (80%, 12 out of 15) outcomes. Very good outcomes were reported in 92% of patients (12 out of 13) without recurrence.
Conclusions
The procedures used in this study achieved high clinical efficacy, complete lesion removal, reduced recurrence and good restoration of joint function in patients with primary locally aggressive Enneking stage II bone tumours of the proximal extremities
Locally aggressive bone tumours are a group of commonly recurrent and metastatic bone tumours that predominantly occur in the epiphysis of the long bone of the adjacent joints, including giant-cell tumour (GCT) of bone, aneurysmal bone cyst (ABC), chondroblastoma (CBT) and osteoblastoma.1 According to Enneking surgical staging, progression of these tumours can be understood in terms of their stage.2 Using this scale, stage I represents the latent phase. At stage II, tumours become active, exhibiting expansive growth and thinning of the bone cortex within the compartment. Stage III is the most aggressive, with lesions piercing through the bone cortex and involving soft tissues surrounding the compartment. Routine treatment includes surgical therapy with extended curettage (IC) of lesions, local adjuvant treatment, graft implantation and effective internal fixation.1
Because most lesions are adjacent to the joint and muscle (tendon) insertion, IC of lesions may cause damage to the surrounding area, exerting detrimental effects on postsurgical limb function. If protection is limited to the muscle (tendon) insertion, a sufficient operative field is difficult to obtain, preventing effective curettage. Therefore, improved methods for treatment selection are required for more effective and successful treatment of locally aggressive musculoskeletal tumours. The current status of treatment and recurrence of these tumours, as discussed in the present study, are briefly reviewed.
Treatment of aneurysmal bone cysts
ABCs are relatively rare in primary bone tumours, constituting only 1-2%. These tumours exhibit rapid growth and high invasiveness, and are often destructive to surrounding tissues.3 Ubiquitin-specific protease 6 has been implicated in the development of ABCs,3,4 and treatment with curettage and bone grafting or bone cementation has been reported to achieve 70% to 90% success with 10-30% recurrence rates.3,5 IC, or aggressive curettage, applies drills, local adjuvant therapies (such as cauterisation), phenolic therapies or cryotherapies to reduce the rate of local recurrence.3,5,6 ABCs of specific sites, such as the vertebral body and pelvis, can be treated with sclerosing therapies using percutaneous injections of Ethibloc, ethanol and methylprednisolone. In addition, selective arterial embolisation has been recommended as an alternative therapy.7
Treatment of chondroblastomas
A CBT is a rare cartilage-derived bone tumour that constitutes 1% of all benign bone tumours. It predominantly affects young men and often exhibits invasiveness or malignant behavior.8,9 Following recommended surgical treatments, the two- to three-year recurrence rate is as high as 10-20%, which may partially be due to wide application of inappropriate surgical methods.9,10 IC, however, has been demonstrated to reduce local recurrence rates.9-11 IC has been employed for the treatment of bone CBT, producing a recurrence rate of only 11% (two out of 18) in one study.11 In another study of 25 patients with a CBT, IC produced a recurrence rate of only 4.2% (one out of 24) over an eight-year follow-up period.8
Treatment of giant-cell tumours of bone
GCTs of bone constitute 4-8% of all primary bone tumours and predominantly occur in 20- to 40-year-old (middle-aged) individuals.12 Recently, biotherapy with receptor activator