Intralesional nerve-sparing surgery versus non-surgical treatment for giant cell tumor of the sacrum

Shinji Tsukamoto,Yasuhito Tanaka,Andreas F Mavrogenis,Kanya Honoki,Paolo Spinnato,Nikolin Ali,Davide Maria Donati,Costantino Errani

doi:10.1186/s12891-021-04907-0

Abstract

BackgroundThere is no standard treatment for giant cell tumors of the sacrum. We compared the outcomes and complications in patients with sacral giant cell tumors who underwent intralesional nerve-sparing surgery with or without (neo-) adjuvant therapies versus those who underwent non-surgical treatment (denosumab therapy and/or embolization).MethodsWe retrospectively investigated 15 cases of sacral giant cell tumors treated at two institutions between 2005 and 2020. Nine patients underwent intralesional nerve-sparing surgery with or without (neo-) adjuvant therapies, and six patients received non-surgical treatment. The mean follow-up period was 85 months for the surgical group (range, 25–154 months) and 59 months (range, 17–94 months) for the non-surgical group.ResultsThe local recurrence rate was 44% in the surgical group, and the tumor progression rate was 0% in the non-surgical group. There were two surgery-related complications (infection and bladder laceration) and three denosumab-related complications (apical granuloma of the tooth, stress fracture of the sacroiliac joint, and osteonecrosis of the jaw). In the surgical group, the mean modified Biagini score (bowel, bladder, and motor function) was 0.9; in the non-surgical group, it was 0.5. None of the 11 female patients became pregnant or delivered a baby after developing a sacral giant cell tumor.ConclusionsThe cure rate of intralesional nerve-sparing surgery is over 50%. Non-surgical treatment has a similar risk of complications to intralesional nerve-sparing surgery and has better functional outcomes than intralesional nerve-sparing surgery, but patients must remain on therapy over time. Based on our results, the decision on the choice of treatment for sacral giant cell tumors could be discussed between the surgeon and the patient based on the tumor size and location.

Highlights

There is no standard treatment for giant cell tumors of the sacrum
We retrieved the following data from the patients’ medical records: age; sex; tumor size measured by computed tomography (CT) or magnetic resonance imaging (MRI); anatomical level of the tumor; Campanacci stage [2]; tumor involvement of the sacroiliac joint; involvement of the vascular or other organ systems; location; spinal instability; surgical approach; reconstruction; local recurrence or tumor progression; treatment for local recurrence; neurological status and pain before and after treatment; lung metastasis; oncological outcome; complications related to surgery, denosumab, zoledronic acid, or embolization; Karnofsky performance status; and evaluation of bowel, bladder, and motor function using modified Biagini score (Table 1) [17]
The local recurrence rate was 44% in the intralesional nerve-sparing surgery group, and tumor control was achieved in all patients in the non-surgical treatment group

Summary

Introduction

We compared the outcomes and complications in patients with sacral giant cell tumors who underwent intralesional nerve-sparing surgery with or without (neo-) adjuvant therapies versus those who underwent non-surgical treatment (denosumab therapy and/or embolization). Most sacral GCTBs occur at the S1–2 levels [6], and wide resection, including the nerve roots of S1-S3, can reduce the local recurrence rate. It can cause severe functional losses, such as motor deficits and bowel, bladder, or sexual dysfunction, as well as lumbopelvic discontinuity [7]. The recurrence rate is high, intralesional nerve-sparing surgery is recommended as a general surgical procedure for GCTBs [8,9,10]. Intralesional nerve-sparing surgery could be associated with complications such as postoperative infection and massive bleeding during surgery [8,9,10]

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Results

Discussion

Conclusion