Extended Curettage for Giant Cell Tumors of Bone: A Surgeon's View.

The key to intralesional surgical treatment of giant cell tumor of bone (GCTB) is extended curettage. As GCTB is locally aggressive with a high propensity for local recurrence, a primary factor of surgical treatment is the ability to achieve local tumor clearance. GCTB commonly affects the epimetaphyseal region of the bone, which may compromise the integrity of the articular surface. With the exception of expendable bone that may be considered for resection without the challenge of reconstruction (e.g., the proximal aspect of the fibula or the distal aspect of the ulna), a large majority of cases of GCTB can be treated with joint-preserving techniques. In the present article, we share a video demonstration including the surgeon view of intralesional surgery for GCTB, with emphasis on the 360° visualization of the tumor cavity, dilemmas regarding use of adjuvants for extended curettage, and options in cavity reconstruction. DESCRIPTION: The surgical procedure involves 4 essential components.(1) Surgical exposure and isolation of the soft tissues. The technique begins with a complete exposure that allows visualization of the entire tumor cavity. The initial part of the exposure involves getting to the bone and to the soft-tissue mass outside the bone, when present. The muscles are separated from the bone and retracted away from the soft-tissue component of the tumor. Soft tissue is adequately retracted to allow complete visualization of the tumor cavity. The tissues around the cavity are protected by placing hydrogen peroxide-soaked mops around the tumor cavity. The aim is to isolate the bone opening and avoid any contamination of soft tissue by the tumor, as hydrogen peroxide kills GCTB cells on contact ALTERNATIVES: GCTB requires tumor clearance for local control. One alternative to intralesional surgical treatment performed around the knee is resection of the tumor-affected segment of bone and reconstruction with an endoprosthesis. This is a joint-sacrificing alternative and, in our experience, should be reserved for patients with joint involvement, multiply recurrent disease, or insufficient remaining wall to curet. RATIONALE: When adequate tumor clearance is possible, joint-salvaging intralesional surgical treatment remains the superior option to achieve physiological joint function EXPECTED OUTCOMES: The rate of local recurrence following intralesional surgical treatment ranges from 16% to 25% IMPORTANT TIPS: Illumination and magnification within the tumor cavity provide better visualization.Isolation of the soft tissue around the tumor with use of hydrogen peroxide-soaked mops can prevent seeding and contamination.Meticulous tumor clearance is more important to minimize recurrence than the use of adjuvants.Use of a C-arm helps to better guide extension of the curettage and avoid inadvertent joint penetration.Maintaining joint congruity is essential.