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Observation is appropriate as this pathology has a low rate of metastasis
0%
1/361
En bloc resection of tumor with repair of lateral collateral ligament and biceps femoris tendon to the lateral tibia has the lowest recurrence rate and overall very low rate of knee instability
50%
182/361
En bloc resection of tumor with structural allograft of fibula with attached lateral collateral ligament and biceps femoris tendon is needed for stability
26%
95/361
Curettage, thermal or chemical cautery of the walls, with bone grafting is the appropriate treatment and will preserve knee stability with equivalent recurrence to en bloc resection
18%
64/361
Therapeutic dosing of Denosumab followed by maintenance dosing has an acceptably low recurrence rate when compared to surgical resection
4%
16/361
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This patient presents with a large destructive lesion with a biopsy-proven diagnosis of giant cell tumor and peroneal nerve compression. En-bloc resection of the tumor with repair of the lateral collateral ligament and biceps femoris to the tibia is the treatment of choice in giant cell tumors of the proximal fibula. Giant Cell Tumors are aggressive tumors found in the epiphysis of long bones, usually around the knee joint. This pathology typically presents in patients from the age of 30-50 years old and is reported to metastasize to the lungs in 2-4% of cases. Treatment depends on location, with typical treatment involving marginal resection via curettage and adjuvant thermal and/or chemical cautery with bone void grafting as necessary. However, in notably large tumors about the proximal fibula, lower recurrence rates and low rates of instability have been reported with wide resection and repair of the native lateral collateral ligament and biceps femoris tendon to the lateral tibia. Denosumab does induce the destruction of giant cells and is indicated for the treatment of inoperable or metastatic giant cell tumors, but has been associated with high local recurrence rates and has been suggested as a possible risk factor for increased local recurrence when used adjuvantly in the setting of curettage, as discussed below. Abdel et al. reported their institutional case series on proximal fibula bony tumors, including giant cell tumors. The authors reported on 120 patients with no functionally limiting knee instability with proper repair of the lateral collateral ligament and biceps femoris tendon. The local recurrence rate of giant cell tumors was 66% with marginal excision and 11% with wide excision. The authors conclude that giant cell tumors of the proximal fibula should be treated with en bloc resection and repair of lateral structures over standard curettage techniques.Errani et al. completed a retrospective review of 408 patients treated with giant cell tumors. The local recurrence rate was 60% (15 of 25) for patients treated with curettage and denosumab compared to 16% (36 of 222) for patients treated with curettage alone. Denosumab was the only independent risk factor for a poor prognosis, indicating that Denosumab may increase the risk of local recurrence in patients with giant-cell tumors of bone treated with curettage.Incorrect Answers:Answer 1: Observation is recommended for giant cell tumors that are inoperable or multiply recurrent.Answer 3: Structural allograft reconstruction with attached lateral collateral ligament and biceps femoris tendon is unnecessary for varus stability, as the appropriate repair is sufficient. Answer 4: En-bloc resection is recommended for proximal fibular giant cell tumors due to lower recurrence rates.Answer 5: Denosumab is not recommended for proximal fibular giant cell tumors due to the high recurrence rate.
3.5
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