Background: The RANK ligand inhibitor denosumab is being investigated for treatment of giant cell tumor of\nbone, but the available data in the literature remains sparse and controversial. This study analyzes the results of\ncombining denosumab with surgical treatment and highlights possible changes for the oncologic surgeon in daily\npractice.\nMethods: A total of 91 patients were treated surgically for giant cell tumor of bone between 2010 and 2014 in an\ninstitution, whereas 25 patients of the total additionally received denosumab and were part of this study. The\naverage age of the patients was 35 years. Eleven patients received denosumab pre- and postoperatively, whereas\nwith 14 patients, the denosumab treatment was applied either before (7 patients) or after (7 patients) the surgery.\nThe average preoperative therapy duration was 3.9 months and the postoperative therapy 6 months by default.\nResults: Sixteen patients presented a large tumor extension necessitating a resection of the involved bone or joint.\nIn 10 of these patients, the indication for a resection procedure was abandoned due to the preoperative denosumab\ntreatment and a curettage was performed. In the remaining six cases, the surgical indication was not changed despite\nthe denosumab treatment, and two of them needed a joint replacement after the tumor resection. Also with patients\ntreated with curettage, denosumab seems to facilitate the procedure as a new peripheral bone rim around the tumor\nwas built, though a histologic analysis reveals viable tumor cells persisting in the denosumab-induced bone formation.\nAfter an average follow-up of 23 months, one histologically proven local recurrence occurred, necessitating a second\ncurettage. A second patient showed a lesion in the postoperative imaging highly suspicious for local relapse which\nremained stable under further denosumab treatment. No adverse effect of the denosumab medication was observed\nin this study.\nConclusions: Denosumab can be a help to the oncologic surgeon by reconstituting a peripheral rim and switching\nthe stage from aggressive to active or latent disease. But as tumor cells remain in the new-formed bone, the surgical\ntechnique of curettage has to be changed from gentle to more aggressive to avoid higher local recurrence rates.
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