Responsabilidades penales derivadas de los delitos de blanqueo de capitales

surgical treatment

of localized-type

tenosynovial giant

cell tumours of

large joints

chapter se

ven

a multicentre-pooled database of

31 international sarcoma centres

M.J.L. Mastboom

_{, E.L. Staals}

_{, F.G.M. Verspoor}

_{, A.J. Rueten-}

Budde

_{, S. Stacchiotti}

_{, E. Palmerini}

_{, G.R. Schaap}

_{, P.C. Jutte}

_,

W. Aston

_{, A. Leithner}

_{, D. Dammerer}

_{, A. Takeuchi}

_{, Q. Thio}

_,

X. Niu

_{, J.S. Wunder}

_{, TGCT study-group*, M.A.J. van de Sande}

1 _{Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands}

2 _{Orthopaedic Surgery, Musculoskeletal Oncology Department, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy} 3 _{Orthopaedic Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands}

4 _{Mathematical institute, Leiden University, Leiden, The Netherlands}

5 _{Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy}

6 _{Medical Oncology, Musculoskeletal Oncology Department, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy} 7 _{Orthopaedic Surgery, Academic Medical Center, Amsterdam, The Netherlands}

8 _{Department of Orthopaedics, University Medical Center, University of Groningen, Groningen, The Netherlands} 9 _{Orthopedic surgery, Royal National Orthopedic Hospital, London, the United Kingdom}

10 _{Department of Orthopaedic Surgery, Medical University Graz, Graz, Austria} 11 _{Orthopedic surgery, Medical University of Innsbruck, Innsbruck, Austria}

12 _{Orthopaedic surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan} 13 _{Orthopedic surgery, Massachusetts General Hospital Harvard, Boston, United States of America} 14 _{Department of Orthopedic Oncology, Beijing Jishuitan Hospital, Beijing, 100035, China} 15 _{University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada}

*TGCT study-group:

M. Fiocco, H. Gelderblom, P.D.S. Dijkstra, R.J.P. van der Wal, P.A. Daolio, P. Picci, A. Gronchi, S. Ferrari, H. Özger, R.G. Maki, H.W.B. Schreuder, I.C.M. van der Geest, J.A.M. Bramer, M. Boffano, E. Goldenitsch, D. Campanacci, P. Cuomo, P.C. Ferguson, A.M. Griffin, Y. Sun, T. Schubert, K. Patel, M.S.J. Aranguren, A. Blancheton, F. Gouin, H.R. Dürr, C.F. Capellen, J. Schwab, S. Iwata, O. Vyrva, W. Weschenfelder, E.H.M. Wang, M. Wook Joo, Y.K. Kang, Y.G. Chung, W. Ebeid, J. Bruns, T. Ueda

Localized-type tenosynovial giant cell tumours

139

7

abstract

Background

Localized-type Tenosynovial Giant Cell Tumour (TGCT) is a rare, neoplastic disease with only limited data supporting treatment protocols. A multicentre-pooled collection of individual patient data resulted in the largest global retrospective cohort of localized-TGCT patients to date. We describe treatment protocols and evaluate their oncological outcome, complications and functional results. A secondary study aim was to identify risk factors for local recurrence after surgical treatment.

Methods

Patients with histologically proven localized-TGCT of large joints were included if treated between 1990-2017 in one of 31 tertiary sarcoma centres. In 941 patients with localized-TGCT, 62% were female, median age at initial treatment was 39 years with a median follow-up of 37 months. 67% affected the knee and the primary treatment at a tertiary centre was one-staged open resection in 73%. Proposed risk factors were tested in a univariate analysis and significant factors subsequently included for multivariate analysis, with an endpoint of first local recurrence after treatment in a tertiary centre.

Results

Recurrent disease developed in 12% of all cases, with local recurrence free survival rates at 3, 5 and 10 years of 88%, 83% and 79%, respectively. The strongest risk factor for recurrent disease was prior recurrence (p<0.001). Complications were noted in 4% after surgical treatment of localized- TGCT. Initial symptoms of pain and swelling improved after surgical treatment(s) in 71% and 85%, respectively. For therapy naïve cases, univariate and multivariate analyses yielded positive associations with local recurrence for tumour size ≥5 cm vs <5 cm (HR 2.50; 95%CI 1.32-4.74; p=0.005) and initial treatment with arthroscopy vs open resection (HR 2.18; 95%CI0.98-4.84; p=0.056).

Conclusions

Risk factors for recurrent disease after resection of localized-type TGCT were larger tumour size and initial treatment with arthroscopy. Relatively low complication rates and good functional outcome warrant an open approach with complete resection when possible, to reduce recurrence rates in high risk patients.

140

Chapter seven

introduction

In 2013 the WHO defined Tenosynovial Giant Cell Tumours (TGCT), after unification of Giant Cell Tumour of the Tendon Sheath and Pigmented Villonodular Synovitis (PVNS), as a benign mono-articular disease, arising from the synovial lining of joints, bursae or tendon sheaths in predominantly young adults1, 2_.

Clinically and radiographically, TGCT is subdivided into a lobulated often well-bordered lesion (localized-type) that does not involve the surrounding (teno-)synovial lining and a more aggressive lesion, involving a large part or all of the synovial lining (diffuse-type)1-3_{. Despite}

sharing the same histopathology and genetics, the natural course of disease in localized- and diffuse-TGCT is incomparable and necessitate a separate assessment of treatment protocol and surgical outcome. Based on anatomical site of the localized-type tumour, differentiation is made between disease affecting digits and disease occurring in and about larger joints4-6_{. The present}

study focuses on localized-TGCT of large joints (figure 1), most commonly affecting the knee or other weight bearing joints1, 2, 6, 7_.

The macroscopic appearance of localized-TGCT is typically a well-circumscribed lobulated lesion, with white to grey, yellow and brown mottled areas. According to the WHO, localized-TGCT is a small lesion, with a size range of 0.5 to 4 cm1, 2_{. However, according to the authors’ experience, the}

largest size can frequently exceed 4 cm, especially when compressed in relatively tight joints (e.g. foot and ankle) or situated in the anterior or posterior aspect of the knee.

The main patients complaints related to localized-TGCT include pain, joint effusion, stiffness, locking and limited range of motion8, 9_{. The predominant standard of care for localized-TGCT is}

surgical resection of the tumour, in order to: (1) reduce debilitating symptoms and prevent joint destruction caused by local compression of cartilage; (2) improve limb function; and (3) minimize the risk of local recurrence. Clinical and oncological outcomes following surgery depend on multiple factors including the localization and extent of disease and possibly the technical experience of the surgeons3, 7, 10-12_.

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7