Abstract
Background
Giant cell tumor (GCT) of bone has a rare potential for metastatic spread. This study aimed at evaluating the incidence of chest metastases in GCT and their oncological outcome and identifying possible risk factors.
Methods
Medical records of 466 (313 de novo and 153 recurrent) patients with primary GCT of bone were retrospectively reviewed. Fifteen (3.2%) patients developed chest metastasis. Time from diagnosis of the primary bone lesion to the diagnosis of metastasis, treatment modalities of metastasis, and the course of treatment were revised. The functional outcome was evaluated using the Musculoskeletal Tumor Society (MSTS) scoring system, and postoperative complications were recorded.
Results
This study included 7 males and 8 females with a mean age of 27.3 ± 7.9 years. The most common site of the primary tumor was the distal femur. All fifteen patients were recurrent cases. The mean follow-up period was 67.7 ± 33.2 months. Chest metastasis was diagnosed after a mean time of 28.1 ± 28.9 months from the initial diagnosis of the bone lesion. One patient died of disease (DOD) 18 months after the surgical intervention. The incidence of chest metastasis in recurrent cases was 9.8%, while de novo cases did not develop chest metastasis, P < 0.001. Previous curettage was associated with a higher incidence of chest metastasis (14.6%) compared to previous resection (4.2%), P = 0.03.
Conclusions
Chest metastasis following GCT of bone is rare. Risk factors include recurrent cases, especially following previous curettage. Patients have a good prognosis and a low mortality rate.
Level of evidence
Level IV, retrospective.
Keywords: Giant cell tumor, Chest metastasis, Curettage, Resection, Risk factors, Recurrence, Treatment
1. Introduction
Giant cell tumor (GCT) of bone is a benign locally aggressive lytic tumor that arises most commonly in the long bones, metaphysis and epiphysis, especially the distal femur and proximal tibia.1,2 These tumors account for nearly 20% of all benign tumors of bone and typically present in the age of 20–40 years.3,4
GCT of bone has an unpredictable clinical behavior with a rare potential for metastatic spread.2,5, 6, 7, 8, 9 Metastasis of GCTs of bone is extremely rare, and it can occur in the lymph nodes, muscles, bone, skin, and breast; however, pulmonary metastasis is the most common with a reported incidence of 1%–9%.5, 6, 7,9, 10, 11, 12 The mechanism of developing pulmonary metastasis is still controversial and may be due to tumor-directed vascular invasion, or iatrogenic.5,7,12
Invasive operations such as curettage have been suggested to dislodge and deposit the tumor into the blood vessel.5,11 Many patients have been reported to develop pulmonary metastasis after undergoing multiple curettages for the primary tumor.11,13
Pulmonary metastasis is usually characterized by having similar histological features as the benign primary tumor and slow growth.5,7,8,13, 14, 15 The course of pulmonary metastatic lesions can be characterized by spontaneous regression, growth cessation, continuous slow growth or rapid growth.7,10
Risk factors for chest metastasis of GCT have been previously reported in a few reports.5,10,11 Moreover, there have been reports that determine the options for the treatment of metastases which include; observation, surgical resection, chemotherapy, and other medical treatments.5,8,12,15,16
Due to the limited literature, the aim of this study was to evaluate the incidence of chest metastases in GCT as well as their oncological outcome and identifying any possible risk factors.
2. Methods
This was a retrospective study of retrieved data from medical records of 466 (313 de novo and 153 recurrent) patients who were treated for primary GCT of bone at our center or recurrent cases referred from other hospitals between 1998 and 2017. Patients with a minimum follow-up of two years were included in this study, except for one patient who died of the disease after 18 months of follow-up. The study was conducted after Institutional Review Board approval.
The collected data included the demographics, clinical evaluation of patients, including the site of the primary lesion, history of prior surgical interventions, history of local recurrence and metastasis, previous histopathologic examination, duration from primary treatment to recurrence, local surgical management and local recurrence after the patient was received to our center, time from diagnosis of the primary bone lesion to the diagnosis of metastasis, therapeutic and surgical management of the metastasis, the course of treatment, and follow-up events until the last hospital visit.
Radiographic images, including plain X-rays, computed tomography (CT), magnetic resonance imaging (MRI), were revised, in addition to chest X-rays and CT scans for evaluation of pulmonary metastasis, Fig. 1, Fig. 2. Follow-up chest CT scans were used to measure and evaluate the course of metastatic nodules with treatment, whether stationary, progressive, or regressive. Chest CT scans were done every 3 months in the first 2 years, then every 6 months in the following 2 years, then annually for 5 years. Moreover, the Campanacci grading system17 for radiographic classification was reviewed.
Fig. 1.
A female patient 24 years old (No. 8) with GCT of the distal ulna. A) Preoperative X-rays, anteroposterior and lateral views. B) Preoperative CT coronal cut. C) Immediate postoperative X-ray after tumor resection. D) Final follow-up X-rays anteroposterior and lateral views. E) Chest CT axial cuts showing multiple pulmonary metastases appeared after 39 months of diagnosis.
Fig. 2.
A female patient 20 years old (No. 10) with GCT of the distal femur and history of previous curettage. A) Preoperative X-ray. B) Preoperative MRI coronal view. C) Postoperative X-rays after wide resection of the tumor and knee fusion using vascularized fibula and fixation with broad DCP. D) and E) Chest CT axial cuts showing multiple pulmonary metastasis appeared after 24 months of primary tumor diagnosis.
The functional outcome was assessed by the Musculoskeletal Tumor Society (MSTS) scoring system.18 Also, postoperative complications were recorded.
2.1. Statistical analysis
IBM SPSS version 25.0 (SPSS Inc., Armonk, NY) was used for data analysis. Quantitative data were expressed as mean ± standard deviation, while qualitative data were expressed as frequency. The Chi-square test and Fisher's exact test were used to compare the categorical data whenever appropriate. P < 0.05 was considered statistically significant.
3. Results
3.1. Preoperative details
Out of the 466 patients diagnosed with GCT of bone in our database, 15 (3.2%) patients (7 males, 8 females), with a mean age of 27.3 ± 7.9 (range, 16–40) years, had chest metastasis.
The primary tumor site was the distal femur (n = 7), proximal tibia (n = 2), distal radius (n = 2), distal ulna (n = 1), proximal phalanx of ring finger (n = 1), ribs (n = 1), and soft tissue of distal thigh (n = 1).
All patients presented in this study were recurrent cases. Twelve patients had previous curettage and filling of the cavity with polymethyl methacrylate (PMMA); 7 patients had curettage once, 3 patients had curettage twice, and 2 patients had curettage 3 times. The remaining 3 patients had previous resection.
Four patients presented with a pathological fracture. Eight patients presented to our center with chest metastasis, while the other seven patients developed the metastasis during the follow-up period.
Campanacci grading was grade I in 1 patient, grade II in 5 patients, grade III in 7 patients, and malignant in 2 patients, Table 1.
Table 1.
Clinical data of the patients.
| No./gender/age | Location | Pathological fracture | Previous surgery | Campanacci grade | Operation | Margin | Resection | Local recurrence | Time from first surgery to local recurrence, mo | Complications | Time from initial diagnosis to Metastasis, mo | Treatment of metastasis | Metastasis treatment Outcome | Follow-up, mo | MSTS Score |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1/F/24 | Distal femur | No | CUR and PMMA | Malignant | WR + modular prosthesis | WM | Intraarticular | No | 2 | No | 20 | Chemotherapy, denosumab, metastatectomy | Stationary | 82 | 26 |
| 2/F/39 | Proximal tibia | No | CUR, PMMA and ORIF 3 times | II | WR + VF + broad DCP | WM (contaminated at superior TF joint) | Intraarticular | No | 60 | Foot drop | 10 | Observation | Stationary | 43 | 24 |
| 3/M/40 | Distal femur | Yes | Resection | III | WR + modular prosthesis | WM (intralesional contamination) | Intraarticular | Yes | 96 | Endoprosthetic breakage | 48 | Observation | Stationary | 105 | 30 |
| 4/M/19 | Thigh soft tissue | No | CUR and PMMA | II | WR | WM (MM in areas) | – | No | 6 | No | 0a | Chemotherapy, interferon | Stationary | 72 | 30 |
| 5/M/32 | Distal radius | No | CUR and PMMA then resection and reconstruction with proximal fibula | III | WR + Ulnar centralization + reconstruction plate | WM | Intraarticular | Yes | 48 | No | 48 | Chemotherapy | Complete resolution | 122 | 28 |
| 6/M/30 | Distal femur | No | CUR and PMMA 3 times | III | Excision + vein graft | MM (intralesional) | – | Yes | 36 | No | 54 | Chemotherapy, denosumab | Stationary | 59 | AKA |
| 7/F/40 | Distal femur | No | CUR and PMMA | II | WR + modular prosthesis | WM (MM intraarticular) | Intraarticular | No | 10 | No | 6 | Denosumab | Stationary | 33 | 28 |
| 8/F/24 | Distal ulna | Yes | Resection | I | MR | MM (contaminated) | Intraarticular | Yes | 32 | No | 39 | Chemotherapy, denosumab | Regression | 102 | 30 |
| 9/F/16 | Ribs | No | Resection | Malignant | WR + Prolene mesh | WM (contaminated) | Intercalary | Yes | 1 | No | 0a | Chemotherapy, interferon, metastatectomy | Complete resolution | 51 | – |
| 10/F/20 | Distal femur | No | CUR and PMMA twice | III | WR + VF + knee fusion + broad DCP | MM | Intraarticular | No | 36 | No | 24 | Chemotherapy | Regression | 30 | 24 |
| 11/M/30 | Distal radius | No | CUR and PMMA | III | WR + VF + 2 small DCP | WM | Intraarticular | No | 10 | Fracture of plate + DOD | 12 | Steroids | Progression | 18 | 26 |
| 12/M/29 | Distal femur | No | CUR and PMMA twice | III | WR + modular prosthesis | WM | Intraarticular | No | 24 | No | 18 | Observation | Complete resolution | 50 | 28 |
| 13/F/24 | Proximal tibia | Yes | CUR and PMMA | II | CUR + PMMA + Steinman pins | Intralesional | – | No | 6 | No | 111 | Observation | Stationary | 120 | 30 |
| 14/F/23 | Ring finger proximal phalanx | No | CUR and PMMA | II | CUR + PMMA | Intralesional | – | Yes | 5 | No | 8 | Denosumab | Complete resolution | 81 | 30 |
| 15/M/19 | Distal femur | Yes | CUR, PMMA and external fixator | III | AKA | WM | Radical | No | 12 | No | 24 | Chemotherapy | Stationary | 48 | AKA |
PMMA polymethyl methacrylate, CUR curettage, WR wide resection, VF vascularized fibula, MR marginal resection, DCP dynamic compression plate, AKA Above knee amputation, WM wide margin, MM marginal margin, TF tibiofibular, DOD died of disease, MSTS score Musculoskeletal Tumor Society score.
0 = chest metastasis presented at the time of diagnosis of the primary bone tumor.
3.2. Operative details
A core biopsy was done for all patients before the operative intervention to confirm the diagnosis.
Twelve patients underwent wide resection and reconstruction, 2 patients underwent extended curettage and filling the cavity with PMMA, and one patient (No. 15), who presented with recurrent massive distal femoral lesion not amenable for limb salvage, underwent above-knee amputation.
The method of reconstruction was variable according to the tumor location; modular prosthesis in 4 patients (distal femoral lesions), vascularized fibula in 3 patients (distal radial, distal femoral, and proximal tibial lesions), ulnar centralization in one patient (distal radial lesion), Prolene mesh in one patient, and soft tissue reconstruction only in 3 patients (GCT of soft tissue, a distal femoral lesion with soft tissue recurrence, and distal ulna lesions).
The track of any previous intervention was excised with the tumor mass. Dealing with the surrounding tissue followed rules similar to sarcoma resection to avoid soft tissue contamination. Also, the original filler and internal fixation materials were removed en-bloc for the resection cases.
Wide margin was achieved in 10 patients, marginal margin in 3 patients, and intralesional in 2 patients.
The resections were intraarticular in 9 patients, intercalary in 1 patient, and radical in 1 patient (the amputation case).
The mean resection length was 12.2 ± 3.6 (range, 6–16) cm. The mean operative time was 3.9 ± 2 (range, 1–8) hours. The mean blood loss was 2.6 ± 2.4 (range, 0–8) liters.
3.3. Postoperative and follow-up details
The mean follow-up period was 67.7 ± 33.2 (range, 18–122) months. Two patients had malignant GCT after histopathological examination of the resected specimen, whereas the rest had conventional GCT.
The 3 patients with de novo tumors developed local recurrence after treatment in our center. The recurrence was extensive in one patient (No. 6) and ended with above knee amputation. In all patients, the mean time from the primary surgery to the first recurrence was 25.6 ± 26.6 (range, 1–96) months.
Pulmonary metastasis was diagnosed after a mean time of 28.1 ± 28.9 (range, 0–111) months from the initial diagnosis of the bone lesion. Two patients presented with chest metastasis at the time of initial diagnosis of the bone lesion. All patients had multiple chest metastasis.
The protocol of treatment of chest metastasis was based on the patient presentation and the course of metastasis. Once chest metastasis was diagnosed, the patients were followed up by chest CT to evaluate the course of metastasis. If it regressed or had a stationary course, observation was done. If it progressed or became symptomatic, medical treatment by chemotherapy, denosumab, or interferon was added. If it continued to progress after medical treatment, surgical intervention with metastasectomy was performed.
Different treatment modalities for chest metastasis with different responses were observed. Three patients received chemotherapy, two patients received chemotherapy and denosumab, and two patients received denosumab. Moreover, one patient received chemotherapy, denosumab, and metastasectomy, one patient received chemotherapy, interferon, and metastasectomy, one patient received chemotherapy and interferon, and one patent received steroids. The treatment of metastasis for the remaining four patients was observation, and it showed a stationary course after the surgical intervention for the primary tumor.
The course of chest metastasis was stationary in 8 patients, and it showed complete resolution in 4 patients. Moreover, it regressed in 2 patients and progressed in 1 patient who died from the disease, Table 2.
Table 2.
Mode of treatment and outcome of chest metastasis.
| Mode of treatment | Complete resolution | Regression | Stationary | Progression | Total |
|---|---|---|---|---|---|
| Observation | 1 | 0 | 3 | 0 | 4 |
| Chemotherapy | 1 | 1 | 1 | 0 | 3 |
| Denosumab | 1 | 0 | 1 | 0 | 2 |
| Steroids | 0 | 0 | 0 | 1 | 1 |
| Chemotherapy, denosumab | 0 | 1 | 1 | 0 | 2 |
| Chemotherapy, interferon | 0 | 0 | 1 | 0 | 1 |
| Chemotherapy, denosumab, metastatectomy | 0 | 0 | 1 | 0 | 1 |
| Chemotherapy, interferon, metastatectomy | 1 | 0 | 0 | 0 | 1 |
| Total | 4 | 2 | 8 | 1 | 15 |
The two patients with malignant GCT developed metastasis after a mean of 10 ± 14.1 (range, 0–20) months. They were treated by chemotherapy and metastasectomy plus denosumab in one patient in whom the metastasis was stationary, and interferon in the other patient who had complete resolution of the metastasis.
The mean MSTS score was 27.8 ± 2.3 (range, 24–30) points.
One patient died of disease (DOD) 18 months after the surgical intervention due to the progression of chest metastasis.
Three patients developed postoperative complications. Two patients suffered from implant failure; one of them had endoprosthetic breakage without loosening and underwent revision of the prosthesis. The other patient developed fracture of the plate over a vascularized fibula, which was revised by another plate and iliac crest bone graft. One patient suffered from foot drop.
3.4. Risk factors for chest metastasis
Out of the 466 patients with GCT treated at our center, 153 patients were recurrent cases. The incidence of chest metastasis in recurrent cases was 9.8% (15 patients), while de novo cases (313 patients) did not develop chest metastasis. This was statistically highly significant, P < 0.001.
The incidence of chest metastasis in patients with recurrent tumors who had previous curettage was 14.6% (12 patients), while it was 4.2% (3 patients) in patients who had previous resection. This was statistically significant, P = 0.03, Table 3.
Table 3.
Correlation between different risk factors and the incidence of chest metastasis.
| Risk factors | Chest metastasis | No chest metastasis | P-value | |
|---|---|---|---|---|
| Recurrence | Recurrent (153) | 15 (9.8%) | 138 (90.2%) | < 0.001 |
| De novo (313) | 0 (0%) | 313 (100%) | ||
| Previous surgery | Curettage (82) | 12 (14.6%) | 70 (85.4%) | 0.03 |
| Resection (71) | 3 (4.2%) | 68 (95.8%) | ||
∗p < 0.05: is significant but p > 0.05: is not significant.
4. Discussion
GCT of bone is a benign locally aggressive tumor with a rare incidence of metastasis, especially to the lungs.9,11,12 The incidence of chest metastasis in patients with GCT of bone in the current series was 3.2%, which was comparable to that reported in previous literature, Table 4.5, 6, 7,9, 10, 11, 12, 13, 14,16,19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29
Table 4.
Incidence of lung metastasis in patients with giant cell tumor of bone as reported in the literature.
| Study | Patients (n) | Patients with lung metastases (n) | Males (n) | Females (n) | Mean age (years) |
|---|---|---|---|---|---|
| Bertoni 200319 | 327 | 6 | 5 | 1 | 25.3 |
| Chan 201520 | 167 | 11 | 5 | 6 | 25.3 |
| Chen 201610 | 168 | 7 | 4 | 3 | 39.1 |
| Cheng 199713 | 104 | 5 | 2 | 3 | 28.6 |
| Dominkus 200621 | 649 | 14 | 8 | 6 | 27.1 |
| Donthineni 200922 | 51 | 7 | 4 | 3 | 29.9 |
| Faisham 200623 | 20 | 6 | 5 | 1 | 33.7 |
| Gresen 197324 | 195 | 2 | 1 | 1 | 57.0 |
| Gupta 200814 | 470 | 24 | 15 | 9 | 29.1 |
| Kay 199416 | 66 | 6 | 4 | 2 | 28.2 |
| Kito 20176 | 141 | 12 | 9 | 3 | 27.0 |
| Osaka 199725 | 78 | 6 | 3 | 3 | 22.3 |
| Rock 198426 | 31 | 8 | 4 | 4 | 34.3 |
| Sanjay 199827 | 69 | 3′ | 1 | 2 | 22.7 |
| Tubbs 199228 | 475 | 13 | 6 | 7 | 30.0 |
| Viswanathan 201012 | 470 | 23 | 13 | 10 | 26.0 |
| Vult von Steyern 200629 | 137 | 1 | 1 | 0 | 21.0 |
Previously reported risk factors of metastasis include recurrence of tumor, surgical manipulation of initial bone tumor, aggressive tumors, and location of the tumor.10, 11, 12,15,16,21
In our study, the incidence of chest metastasis was significantly higher in recurrent cases (9.8%) compared to de novo cases in which no chest metastasis occurred.
In this series, the predominant primary site for metastatic GCTs was the distal femur followed by the proximal tibia and distal radius. Dominkus et al.21 found that the primary tumor was predominantly located around the knee joint (71%). Other studies have also revealed that most GCTs arise around the knee joint.10,12,30 Chen et al.10 found no association between metastasis and the site of the primary bone lesion.
Other risk factors that were previously reported for the development of metastasis are Campanacci grade III.23 In this study, nine patients had Enneking stage 3 lesions, including 2 patients diagnosed as malignant GCT after the final histopathological examination.
Earlier reports suggested that surgical manipulation during operative procedures promotes the risk of developing pulmonary metastasis.10,15 In this study, 12 out of 15 cases had previous curettage. The incidence of chest metastasis in patients with recurrent tumors who had previous curettage (14.6%) was significantly higher than in patients who had previous resection (4.2%).
The most common previously reported risk factor for pulmonary metastasis is local recurrence.13,15,16,20,21,26,28,31 In this study, all the patients developed metastasis after suffering from local recurrence. A recent study conducted by Wang et al.32 found 18 (5.8%) cases of pulmonary metastasis in 310 patients with GCT. Local recurrence was an independent risk factor for pulmonary metastasis; 16 (88.9%) patients had a history of local recurrence.32
Local recurrence can be avoided by adequate curettage of the tumor. When facing recurrent tumors, wide resection of the tumor instead of curettage would provide local tumor control. Some authors reported that resection surgery decreases the onset rate of pulmonary metastasis.6,10 However, one has to weigh the advantages of preserving the patient's own joint with the low risk of developing chest metastases that are mostly not lethal.
The mean time from initial surgery to the first recurrence was 25.6 months, which was higher than Kito et al.,6 who reported a mean time of 1.4 years (16.8 months).
In our study, one patient had progression of chest metastasis and eventually died of disease. Patients with pulmonary metastasis from GCT of bone should be monitored closely. Tsukamoto et al.33 evaluated 22 patients with pulmonary metastases from GCT of bone managed initially by observation, and metastasis progression was seen in 12 (54.5%) patients. Rock et al.26 recommended aggressive surgical treatment in the form of wedge resection or lobectomy for the treatment of pulmonary metastasis. Chan et al.20 proposed a resection for lesions that are increasing in size or lesions causing symptoms, while some authors recommended resection for feasible lesions.12,17 The rationale for less aggressive pulmonary metastasectomy in metastasizing GCT is that these metastases often exhibit no changes in volume and may show spontaneous regression.
In this study, metastasectomy was not immediately performed at the initial diagnosis of chest metastasis. Four patients did not receive treatment and showed no progression of the lesions, and one of them showed complete resolution of the lesion. Nine patients received medical treatment for the lesions. Two patients showed complete resolution, two patients showed a decrease in the size of the lesions, four patients showed a stationary course, and only one patient developed progression and died of disease. Two patients had metastasectomy for enlarging lesions together with medical treatment; one of them showed complete resolution, and the other showed a stationary course.
Kito et al.6 reported that residual metastatic lesions in patients with incomplete resection of pulmonary metastases showed no enlargement in size with spontaneous shrinkage after a median time of 6.2 years. Surgery was only performed when increases in the volume and number of metastatic lesions had been confirmed to consider its feasibility.6
Denosumab role in pulmonary metastasis is currently unknown.10 Denosumab, a monoclonal antibody, binds receptor activator of nuclear factor-κB ligand (RANKL) and inhibits the RANK-RANKL binding, thereby inhibiting the osteoclastic activity.34,35 Denosumab has been used as adjuvant therapy, and it can reduce surgical morbidity.35 Some authors used denosumab to treat metastatic lesions of GCTs of the bone and obtained good results.34,36 In the current study, denosumab was not used for the treatment of the primary lesions, but it was used alone or in conjunction with other treatment modalities in 5 patients for control of chest metastasis. All the cases in which denosumab was used either remained stationary, decreased in size, or showed complete resolution.
Kaiser et al.37 reported a case report of a patient with pulmonary metastasis of giant cell tumor of bone that was refractory to conventional chemotherapy, and showed a significant decrease in the lesion size after using interferon. In our study, interferon was used as a part of the treatment regimen for pulmonary metastasis in two patients, in addition to chemotherapy in one patient who had a stationary course, and in addition to chemotherapy and metastasectomy in one patient who showed complete resolution.
The mortality rate of reported metastatic cases varied widely from 0 to 23%.12,15, 16, 17,20,21,23,26,28 In our study, one patient DOD due to an increase in volume and number of metastatic pulmonary lesions. There is an agreement that patients with untreated pulmonary metastasis have a good prognosis and favorable survival rates.7,10,12, 13, 14, 15,21,38 The mortality rate in our study was 6.7%.
We believe that it is unnecessary to perform pulmonary metastasectomy immediately after the diagnosis of metastasis, and it is more appropriate to perform resection only when there is an increase in volume and number of metastases. Also, biopsy of metastatic lesions developed from GCT of bone is not essential. Close observation and serial radiological evaluation are adequate with resection of metastatic lesions that are increasing in size and those causing symptoms.
This study has some limitations. Due to its retrospective nature, the relatively small sample size since metastasizing GCT is a rare entity, interpretations of the results should be taken with caution. PET scan was not done to rule out metastasis in other parts of the body. Some potential risk factors could not be analyzed due to lack of data; for example, many pathology reports did not comment on the GCT grades.
As the incidence of pulmonary metastasis of GCT of bone is uncommon, a multi-center study to evaluate the risk factors would be ideal.
5. Conclusions
Chest metastasis following GCT of bone constitutes an uncommon entity. Risk factors for developing chest metastasis include recurrent cases, especially following previous curettage. Chest metastasis can be diagnosed at the same time of diagnosis of the recurrent bone lesion up to several years after diagnosis. Close observation of metastasis is essential until reaching a stationary course. Most of the progressive lesions may be controlled by medical treatment. Performing pulmonary metastasectomy immediately after the diagnosis of metastasis is unnecessary. Patients with chest metastasis of GCT of bone have a good prognosis and low mortality rate. As the incidence of pulmonary metastasis of GCT of bone is uncommon, a meta-analysis or a large multi-center study to evaluate the risk factors is required.
Declaration of competing Interest
None of the authors received financial support for this study.
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