|Year : 2020 | Volume
| Issue : 3 | Page : 95-101
Management of benign bone tumors in a tertiary hospital in North West Nigeria
MI Maitama, YZ Lawal, LI Dahiru, FS Ejagwulu, KE Amaefule
Department of Orthopedic and Trauma Surgery, Ahmadu Bello University, Zaria, Kaduna, Nigeria
|Date of Submission||23-Oct-2020|
|Date of Acceptance||23-Mar-2021|
|Date of Web Publication||07-Aug-2021|
Dr. M I Maitama
Reader/Consultant Orthopedic Surgeon, Department of Trauma and Orthopedic Surgery, Ahmadu Bello University, Samaru Campus, Community Market, 810211, Zaria, Kaduna State
Source of Support: None, Conflict of Interest: None
Background: Tumors originating from bone and cartilage are mostly benign with distinct feature of non-metastasis. Such tumors may occur in any bone of the skeleton, and are more frequent in the younger age group. Complete excision and curettage as the main modality of treatment is in most of the cases adequate with satisfactory outcomes. This study reviewed the histological types of primary benign bone tumors and results of various surgical options of treatment offered.
Patients and Methods: Thirty-nine patients with histologically confirmed benign bone tumors arising from upper and lower limbs were retrospectively selected over 13-year period from August 2007 to August 2020 and analyzed.
Results: Twenty-two patients were males while 17 were females. Age range is between 3 and 53 years, mean of 24.8 years with highest frequency in the third decade. Histological types were 18 giant cell tumors, 14 osteochondromas, 3 Ecchondromas, 2 Enchondromas and 2 Ossifying fibromas. Twenty five patients had excisional biopsy alone, 6 had excisional biopsy and bone grafting, 3 had limb amputation/dis articulation, 2 had excision with limb reconstruction using dynamic external devices, a patient underwent excision with bone cementing, one had excision and joint replacement (hip hemiarthroplasty), and another one had excision and joint arthrodesis.
Conclusion: Benign bone tumors remain largely asymptomatic accounting for the late presentation. Excisional biopsy alone remains the commonest modality of treatment with good result. Giant cell tumor remained the commonest benign tumor in our center. Population based study is needed to assess its true epidemiology.
Keywords: Benign bone tumors, Giant cell tumor, Bone tumor excision, Limb salvage
|How to cite this article:|
Maitama M I, Lawal Y Z, Dahiru L I, Ejagwulu F S, Amaefule K E. Management of benign bone tumors in a tertiary hospital in North West Nigeria. Arch Int Surg 2020;10:95-101
|How to cite this URL:|
Maitama M I, Lawal Y Z, Dahiru L I, Ejagwulu F S, Amaefule K E. Management of benign bone tumors in a tertiary hospital in North West Nigeria. Arch Int Surg [serial online] 2020 [cited 2021 Dec 3];10:95-101. Available from: https://www.archintsurg.org/text.asp?2020/10/3/95/323468
| Introduction|| |
Benign bone tumors are new growths from osseocartilaginous tissues that are often seen among the younger population. Majority are asymptomatic hence the likelihood of late presentation, often due to unrelated symptoms or discovered accidentally during routine physical examination. For that reason, the true incidence of benign bone tumors is therefore difficult to determine. Most benign tumors exhibit different biological behavior with some remaining quiescent for a very long period, others continue to grow with time, and a few of them may be locally aggressive and metastatic. Some may transform into malignant variety over time or recur after complete excision. Symptomatic benign bone tumors exhibit different patterns of clinical presentation including pain, swelling, joint stiffness, deformities, limb length inequality, and pathological fractures. Diagnosis is usually made by clinical and radiological evaluations subject to histological confirmation. Several treatment modalities have been described for benign bone tumors such as curettage alone, curettage and bone grafting, curettage and bone cementing, en bloc resection, prophylactic or definitive bone fixation for extensive bone erosion or pathological fracture and joint replacement often with basic or customized mega prostheses. Small lesions with minimal bone destruction may be treated by excision and curettage alone, while aggressive large-sized tumors are treated by segmental or en bloc resection and limb reconstruction. We hereby report our institution's experience with managing various histological types of benign bone tumors and the outcome of their treatment.
| Patients and Methods|| |
This is a retrospective study of histologically confirmed benign bone tumors arising from upper and lower limbs managed over 13 years from August 2007 to August 2020. Data were retrieved from the patient's case records, histology bench book, and contact telephone numbers where available. Information of patients as regards the histological type of the musculoskeletal tumor, age of the patient, sex and the site of involvement, disease chronology, type of surgery offered, and the patient clinical status at follow-up were all extracted and analyzed. Patients' with incomplete data were excluded from the study.
| Results|| |
Thirty-nine cases were analyzed over the study period. Giant cell tumor accounted for 18 cases representing 46.2%, followed by 14 (35.9%) cases of osteochondroma. There were two cases of ossifying fibromas and 2 enchondromas representing 5.1% each. Lastly, ecchondroma accounted for 3 cases (7.7%). The age range was between 3 and 53 years, the mean age was 24.8 years, with the highest frequency in the third decade. The youngest patient was a boy with osteochondroma of the right distal radius, while the oldest was a female with enchondroma of the right first metacarpal bone. The highest number of benign tumors was in the third decade which accounted for 17 cases (43.6%) followed by the second decade accounting for 11 cases (28.2%). There was an increasing frequency from the first decade of life to peak at the third decade then gradually declined as the age advanced with only one case in the age-group of 51–60 years. Twenty-two (56.4%) patients were males while 17 (43.6%) were females, with female to male ratio of 1:1.3. [Table 1] shows the anatomic location of the bone and cartilage tumors showing commonest involved sites of carpal bones, femur, and tibia, and least involved sites of the ulna and pelvic bones. [Table 2] shows that majority of patients underwent surgical excision often with curettage for intracavitary tumors, followed by excision, cortical, cancellous, or cortical cancellous bone grafting. A patient presented with giant cell tumor of the left distal femur that was completely excised and condylar defect filled with acrylic bone cement. Another patient presented with giant cell tumor of the right femoral neck with pathological fracture and avascular necrosis of the ipsilateral femoral head but with intact acetabulum. This patient underwent segmental resection and hemiarthroplasty with cemented 47 mm bipolar endoprosthesis. Two patients underwent segmental resection of the affected long bone and the bone gap was managed by a dynamic external device (linear rail system bone transport). Ankle joint arthrodesis was performed in a patient who had a previous left ankle excisional biopsy for osteochondroma and presented 9 years later with severe ankle arthritis and instability but with no evidence of tumor recurrence. Three patients presented late with a diagnosis of giant cell tumor and badly damaged extremities and therefore underwent amputation. This brings the ratio of limb salvage to sacrifice in our small series of 39 patients to 13:1.
| Discussion|| |
Thirty-nine patients were analyzed over the study period [Figure 1]. This included the histopathological types, age [Figure 2] and sex [Figure 3] distribution, anatomic location, various surgical options of treatment offered, and the outcome of such treatments. There are specific indications for surgical interventions in patients with benign bone tumors as not all cases are treated operatively. These include symptomatic tumor, aggressive biologic behavior, risk of physeal damage and subsequent growth arrest, pathological fracture, and joint destruction. Due to tumor aggression and late presentation, three of our patients (7.7%) with locally aggressive giant cell tumor had to undergo limb amputation. A similar option of treatment was offered by Eyesan et al. who reported six patients [31.6%] with non-malignant tumors to have had ablative surgery due to either late presentation or inaccurate preoperative diagnosis. Limb amputation is not commonly indicated for benign bone tumors as the emphasis is on limb salvage, which notwithstanding, several authors have reported limb amputation or disarticulation for benign bone tumors due to excessive local tissue damage or recurrence after primary excision.,, Giant cell tumor was found to be the commonest type of benign extremity tumor in our series contrary to most international publications that cited osteochondroma as the commonest.,, Even studies conducted locally in the country in 2007, 2009, 2010, and 2011 have all shown a higher incidence of osteochondroma over that of giant cell tumor. Change in trend was however noted as from 2014 when osteochondroma and giant cell tumor were reported in equal frequency, while in 2017, giant cell tumor was reported to have been commoner than osteochondroma. Are we witnessing a surge in frequency of giant cell tumor over osteochondroma in Nigeria? At present, we don't have the answer, but multi-center research in the country may be needed for further evaluation.
Excision of lytic bone tumor (giant cell tumor and enchondromas) in the form of curettage alone without using a bone void filler or complete excision of cortical overgrowth (exostoses and ecchondromas) was offered in 25 (64.1%) patients in our study. Most of these lytic lesions were small in terms of tumor volume, and complete excision does not significantly affect the mechanical strength and integrity of the bone. Kundu et al. have reported satisfactory outcome, of curettage alone, of benign bone tumors and tumor-like lesions without filling the cavity with bone grafts or bone graft substitutes in selected sizes and locations of the affected bone. Even with the assertion that curettage alone with adjuvant calcitonin treatment for lytic giant cell tumor may be useful, Nouri et al. have shown that the use of calcitonin as an adjuvant is not effective and that filling agents are not necessarily required after curettage of giant cell tumors as a means of preventing recurrence. Several authors,, have concluded that it is the effectiveness and completeness of curettage using a high-speed burr that should be more important than the type of filling material in preventing recurrence particularly of giant cell tumor, due to its aggressive nature, in selected size and location of the affected skeleton. Cure rates of 90%–95% have been reported using curettage alone as a mode of treatment in benign bony lesions.
Six of our patients (15.3%) underwent excision and bone grafting. These lesions were moderate to large in terms of tumor volume and complete excision may have significantly weakened the mechanical strength of the affected bone to have risked pathological fracture. Autograft was used, in all six patients, having both osteoinductive, osteoconductive properties and when mixed with the initial hematoma that forms in the cavity after curettage, gives excellent incorporative osteogenesis and defect filling capability. Main disadvantages are donor site morbidity and limited quantity of graft when dealing with larger cavity defect. One of the six patients who underwent excision and bone grafting presented with diaphyseal tibial ossifying fibroma and pathological fracture ab-initio, consequently she had tumor excision and plate fixation with non-vascularized fibula strut graft and casting. The graft was incorporated at 12 months follow-up without evidence of recurrence, although she subsequently died from unrelated illness. Pathological fracture may complicate diaphyseal benign lytic lesions, particularly in weight-bearing bones of the femur and tibia. Wai et al. have reported pathologic fractures of the proximal femur secondary to benign bone tumors and were successfully treated by extended curettage, bone grafting, and internal fixation with no single recurrence at 4-year follow-up. Grzegorzewski et al. also reported successful long-term results of surgical excision and cortical strut graft with non-vascularized, autologous fibula. However, vascularized fibular graft was shown to incorporate faster than non-vascularized in the treatment of bone defect due to aggressive benign bone tumors.
A patient presented with a giant cell tumor of the medial condyle of the right distal femur Campanacci's grade III. Tumor was completely excised and the large cavity filled with acrylic bone cement [Figure 4], [Figure 5], [Figure 6]. The use of acrylic bone cement as an adjunct to surgical excision of giant cell tumor may have helped to reduce the incidence of tumor recurrence in addition to providing immediate structural stability to the weakened part of the excised bone. This is possibly due to tissue hyperthermia from the heat of polymerization of the cement or direct cytotoxic effects of the methyl methacrylate monomer. Björn et al. have reported 2 of 14 giant cell tumor recurrences (14.3%) after curettage with cementation compared with 12 of 22 recurrences (54.5%) after curettage and bone grafting alone. Several authors have reported favorable results on the use of adjuvant methacrylate bone cement in the treatment of giant cell tumors,,,,,, even though when applied close to a joint, may be associated with the risk of periarticular cartilage damage and early onset of degenerative arthritis. The patient presented 2 years after surgery with tumor recurrence and loosening of acrylic cement was advised to undergo total knee replacement with tumor (mega) prosthesis but was lost to follow up. A similar pattern of recurrence was reported in Campanacci's Grade III giant cell tumor. The author recommended tumor resection rather than curettage for grade III tumor with extensive soft tissue involvement.
Two patients (5.1%) underwent segmental resection of the affected long bone and limb reconstructed using dynamic external device (linear rail system) [Figure 7] and [Figure 8]. For aggressive diaphyseal benign tumors that are associated with bone loss following wide segmental resection, the gap can be managed by either primary docking of the excision site followed by limb lengthening or by transporting a segment of bone proximally or distally by the same principle of distraction callotasis to bridge the gap. The latter technique has advantage of giving more chances of complete clearance with tumor-free bone margin thereby decreasing the likelihood of recurrence. Main disadvantages are the time taken to complete the process of distraction and the need for multiple operations for docking, adjustment and possible bone lengthening. For gaps that are not wide, primary docking can be undertaken combined with limb lengthening. Main advantage is the healing process simultaneously taking place at docking (gap) site and corticotomy site thereby shortening the long waiting period, however, the risk of residual tumor at the fracture edge following inadequate/conservative excision and tumor recurrence may also have to be taken into consideration despite its benign nature. Several authors have reported successful long-term results of distraction histogenesis for limb reconstruction after tumor resection.,,,,, Another patient, an 11-year-old male, underwent excisional biopsy for juxta articular distal tibial osteochondroma in 2007. However, he represented in 9 years later at the age of 20 years with severe arthritis and deformity of the ipsilateral ankle joint, presumably as a complication of distal tibial physeal injury either due to primary tumor damage or secondary to the surgical procedure carried out, necessitating ankle arthrodesis. Joint arthrodesis is an established surgical procedure in orthopedic oncology aimed at restoring joint stability and function.,
|Figure 7: Giant cell tumor of distal radius treated by excision and bone transport|
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Joint replacement in form of right hip hemiarthroplasty with cemented 47 mm bipolar endoprosthesis was offered in a 23-year-old male patient with a giant cell tumor of the femoral neck that extended down to involve the calcar femoral with associated pathological fracture. At 10-year follow-up, he was having excellent limb function without clinical and radiological evidence of recurrence, cement loosening or protrusion acetabula [Figure 9] and [Figure 10]. Similar option of treatment for Campanacci's stage-III Giant cell tumor of the proximal femur was reported by Khan et al. with good to excellent functional and oncological outcomes.
We found recurrence rate of giant cell tumor in our study to be 4 out of 18 cases within the first 2 years after surgery representing 22%. This is slightly lower than that reported by Lim of 31% within the first 2 years and some few,,,, but higher than that reported by many others,,,,, using single or combination of multiple adjuncts (high-speed burr, phenol, hydrogen peroxide, liquid nitrogen or argon beam coagulation) that may have shown to decrease its recurrence rate.
| Conclusion|| |
In the present study of 39 patients, excisional biopsy alone remains the commonest modality of treatment among the options of excision and grafting, bone cementing, joint replacement, and limb reconstructions with satisfactory functional and oncological outcomes. Giant cell tumor remained the commonest benign tumor in our center with the recurrence rate of 22% within the first 2 years after primary surgery.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2]