Giant Cell Tumors on the Spine: Risks, Treatments, and Surgical Options

Giant cell tumor located on the lumbar vertebrae?

After undergoing an MRI and biopsy, I was diagnosed with a giant cell tumor at the lumbar spine L3.
Currently, my symptoms include occasional weakness in my legs, along with soreness in my lower back, thighs, and near the anal area.
These symptoms are not constant; they vary, often being more painful at night, but they are manageable enough that I can still sleep, walk, and have normal bowel and bladder function.

I consulted a spine specialist at a medical center in Taipei, who explained that if surgery is necessary, they would first make an incision on the side to remove the tumor, followed by spinal reconstruction, and then a second incision at the back to insert screws.
The surgery is expected to take approximately 12 to 16 hours.
When I asked the doctor about the success rate of the surgery, he estimated it to be around 50%.
He warned that post-surgery, there is a risk of bowel and bladder incontinence or even paralysis, and there could be significant blood loss during the procedure, posing a risk to life.
He also mentioned that giant cell tumors have a high recurrence rate, and if the tumor is not completely removed, there is a high chance of recurrence, which would make any subsequent surgeries much more difficult.
He indicated that this is one of the surgeries they least want to face.
I would like to ask what defines a successful surgery? Is it simply not damaging the nerves and blood vessels? Does failure equate to paralysis or disability? I am uncertain whether the doctor truly assesses the success rate as only 50%, if that is his own level of confidence, or if he is just presenting the worst-case scenario.
Additionally, would it be better for a neurosurgeon to perform this surgery? What are the differences between orthopedic spine specialists and neurosurgeons? Would the risk of nerve damage be lower if a neurosurgeon performs the surgery?
I found some information online suggesting that for giant cell tumors located on the spine, the ideal approach is to perform a "total vertebrectomy" to minimize the recurrence rate.
However, the risks associated with total vertebrectomy are very high, so there must be a balance between tumor removal and nerve preservation.

What are the pros and cons of using treatments such as radiation therapy, denosumab, bisphosphonates, or embolization before or after surgery? My doctor has not mentioned these options, and I am feeling quite lost about what to do next.
If there is a 50% chance of paralysis if the surgery fails, I am concerned.
I have seen another doctor who suggested that if I decide on a surgeon, I should receive denosumab injections 2 to 3 weeks before the surgery, as this could reduce blood loss and improve surgical outcomes.
However, denosumab is quite expensive and not covered by insurance.
If it would indeed help, I would certainly consider it essential to proceed with the injections.

mi, 20~29 year old female. Ask Date: 2021/01/02

Dr. Chen Bochen reply Orthopedics

First, an incision will be made on the side to remove the tumor and perform spinal reconstruction, followed by another incision in the back to insert screws.
This is the standard procedure.
The surgeons who operate on the spine and those who specialize in bone tumors are usually from different fields, so treating spinal bone tumors requires interdisciplinary collaboration.
Therefore, it is recommended to go to a medical center.

Performing selective spinal segmental embolization 1-2 days prior to surgery can reduce the risk of significant bleeding during the operation, typically carried out by a radiologist.
If the medical center where the surgery is performed has the technical capability, it is advisable to proceed with this.

Radiation therapy is recommended to be administered after the surgical wound has slightly healed, with low-dose irradiation, as preoperative radiation can lead to adhesions and wound healing complications.

Giant cell tumors generally respond better to denosumab, which is not inexpensive, but the cost should be relatively minor compared to the expenses associated with spinal surgery.

Your MRI already shows signs of nerve compression, indicating a significant likelihood that surgery will be necessary.

Taipei Veterans General Hospital and Linkou Chang Gung Memorial Hospital have more comprehensive teams for bone tumors and spinal conditions.
It is advisable to consult with an orthopedic oncologist at either of these institutions, who can coordinate the medical team for your treatment.

I am not familiar with other hospitals and cannot provide recommendations.
Wishing you a smooth medical journey and a speedy recovery.

Reply Date: 2021/01/02

More Info

Giant cell tumors (GCTs) of the bone, particularly when located in the spine, present a complex clinical challenge. These tumors are generally considered to be benign but can exhibit aggressive behavior, especially when they occur in critical areas such as the vertebrae. Your situation, with a giant cell tumor at the L3 vertebra, is concerning due to the potential for neurological compromise and the risk of recurrence.

Surgical Considerations and Success Rates
The surgical approach to giant cell tumors in the spine typically involves a combination of tumor resection and spinal reconstruction. The procedure you described, which includes making incisions for tumor removal and spinal stabilization, is standard. The estimated surgery duration of 12-16 hours reflects the complexity of the operation, especially given the proximity of the tumor to critical structures such as nerves and blood vessels.

When discussing surgical success, it is essential to define what that means in this context. Success can be defined as the complete removal of the tumor without damaging surrounding nerves or blood vessels, leading to symptom relief and a return to normal function. However, the risk of complications, including paralysis or bowel/bladder dysfunction, is significant, particularly in surgeries involving the spine. The 50% success rate mentioned by your surgeon likely reflects the inherent risks associated with the procedure, including the possibility of incomplete tumor removal, which can lead to recurrence.

Risks and Complications
The risks associated with surgery for giant cell tumors include:
1. Neurological Damage: There is a risk of nerve injury, which can lead to weakness, numbness, or paralysis.

2. Infection: As with any surgical procedure, there is a risk of postoperative infection.

3. Blood Loss: Significant blood loss can occur during surgery, especially in vascular areas.

4. Recurrence: GCTs have a high recurrence rate, particularly if not completely excised.

Treatment Options
In addition to surgery, there are several adjunctive treatments that can be considered:
1. Denosumab: This medication is a monoclonal antibody that inhibits RANKL, a protein involved in the formation and function of osteoclasts (the cells that break down bone). Denosumab has shown effectiveness in reducing the size of giant cell tumors and may be used preoperatively to shrink the tumor, potentially making surgical resection easier and safer. However, it is not covered by insurance, which can be a significant financial burden.

2. Radiation Therapy: This is typically reserved for cases where surgery is not feasible or as an adjunct to surgery to reduce the risk of recurrence. However, radiation can lead to complications such as delayed wound healing if administered too close to the time of surgery.

3. Bisphosphonates: These medications can also be used to manage bone lesions but are generally less effective than denosumab for giant cell tumors.

4. Embolization: This procedure can be performed prior to surgery to reduce blood flow to the tumor, thereby minimizing blood loss during the operation.

Choosing the Right Surgeon
Regarding whether a neurosurgeon or an orthopedic spine surgeon is more appropriate for this procedure, both specialties have their strengths. Neurosurgeons are trained to handle complex spinal cases and have extensive experience with the nervous system, which may reduce the risk of nerve injury. Orthopedic surgeons specializing in spine surgery also have the expertise needed for spinal reconstruction. Ideally, a multidisciplinary team approach, involving both specialties, may provide the best outcomes.

Conclusion
Navigating the treatment of a giant cell tumor in the spine requires careful consideration of the risks and benefits of surgery, as well as the potential for adjunctive therapies. It is crucial to have open discussions with your healthcare team about your concerns, the potential outcomes, and the best course of action tailored to your specific situation. Seeking a second opinion, especially from a center with a specialized bone tumor team, may provide additional insights and options for your treatment plan.

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