Preoperative Radiological Parameters May Predict Recurrence in Giant Cell Tumor of Bone

Preoperative Radiological Parameters May Predict Recurrence in Giant Cell Tumor of Bone | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Preoperative Radiological Parameters May Predict Recurrence in Giant Cell Tumor of Bone Mehmet Fatih Uzun¹, Ibrahim Halil Kafadar, Burak Cakar¹, Fatih Golgelioglu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7108464/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Giant cell tumor of bone (GCTB) is a benign but locally aggressive bone neoplasm with a high risk of local recurrence. Identifying reliable radiological predictors of recurrence can improve surgical planning and patient outcomes. Methods In this retrospective study, 27 patients with histopathologically confirmed GCTB who underwent intralesional curettage, thermal cauterization, and PMMA were evaluated. Preoperative imaging parameters, including tumor volume, tumor-to-bone ratio, cortical thickness, subchondral distance, and MRI features such as paintbrush border and peritumoral edema, were analyzed for their association with recurrence, MSTS scores, and complications. Results The local recurrence rate was 11.1%. Paintbrush border appearance and increased tumor volume were significantly associated with recurrence (p = 0.01 and p = 0.009, respectively). Tumor volume showed a negative correlation with both pre- and postoperative MSTS scores. Thinner cortex in tumor-affected areas correlated with lower MSTS scores and higher soft tissue involvement. Tumor-to-bone ratio on AP radiographs also correlated significantly with recurrence, while subchondral distance did not. Conclusion Preoperative radiological findings such as tumor volume, cortical destruction, and paintbrush border may predict recurrence and functional outcomes in GCTB. Incorporating these parameters into treatment planning may reduce recurrence and improve functional recovery. Bone tumor cortical thickness curettage giant cell tumor paintbrush border recurrence Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Giant cell tumor of bone (GCTB) is a benign tumor that typically arises in the epiphyseal and metaphyseal regions of long bones. It most commonly affects adults between the ages of 20 and 45 and accounts for approximately 5–6% of all primary bone tumors [ 1 , 2 ]. Despite its benign histology, GCTB demonstrates locally aggressive behavior and is associated with a high risk of recurrence following surgical treatment, which can negatively impact long-term functional outcomes [ 3 , 4 ]. The most commonly preferred treatment method is intralesional curettage followed by cavity filling with polymethylmethacrylate (PMMA). The thermal and cytotoxic effects of PMMA are intended to destroy residual tumor cells and help reduce recurrence rates. Although this approach has been associated with favorable outcomes in many cases, recurrence can still occur in a subset of patients [ 5 ]. In recent years, preoperative imaging findings have gained attention not only for diagnostic purposes but also for their potential role in predicting local recurrence. The presence of a paintbrush border on magnetic resonance imaging reflects irregular intramedullary extensions of the tumor, which may complicate complete surgical removal. Similarly, large tumor volume may result in insufficient surgical margins and increase the risk of recurrence [ 6 , 7 ]. Although some studies have suggested a correlation between these imaging features and recurrence, the findings are not consistent [ 8 ]. Therefore, it is important to clarify the prognostic value of preoperative radiological parameters in assessing the risk of recurrence, particularly to guide surgical planning. The aim of this study was to evaluate the relationship between preoperative imaging features, particularly the presence of a paintbrush border and tumor volume, and the development of local recurrence in patients with GCTB treated with intralesional curettage and PMMA. Materials and Methods This retrospective study included patients who underwent surgical treatment for giant cell tumor of bone at the Department of Orthopedics and Traumatology, Erciyes University Medical Faculty, between January 2013 and June 2022. The study was approved by the Institutional Review Board of Erciyes University (Approval Date: 09.11.2022; Approval No: 2022/755). Imaging and Radiological Assessments All patients underwent anteroposterior (AP) and lateral radiographs of the affected extremity, contrast-enhanced MRI, and non-contrast CT scans. In cases of suspected metastasis, chest CT and posteroanterior (PA) chest radiographs were reviewed. The radiological parameters evaluated in this study are illustrated in Figs. 1 to 5 . Tumor-to-Bone Ratio and Tumor Volume On AP and lateral radiographs, the largest tumor diameter was divided by the corresponding bone diameter at the same level to calculate the tumor-to-bone ratio (Fig. 1 A–B). Tumor volume was measured on axial CT images using the PACS-integrated volume calculation tool (Sectra UniView, v20.2.9.3362) (Fig. 1 C). [ Figure 1 about here] Joint Surface Distance The shortest distance between the tumor margin and the articular surface was measured in coronal and sagittal CT slices and recorded as the subchondral distance (Fig. 2 ). This measurement was used to assess the extent of articular invasion. [ Figure 2 about here] Thinnest Cortex Thickness In axial CT sections, the thickness of the most thinned cortical area affected by the tumor was measured (Fig. 3 ). A value of 0 mm indicated complete cortical destruction. [ Figure 3 about here] Unaffected Cortical Thickness Cortical thickness was also measured in regions not affected by the tumor. These measurements were taken from contralateral or distant unaffected areas on axial CT slices (Fig. 4 ). [ Figure 4 about here] MRI Findings Peritumoral edema and the paintbrush border sign were evaluated on T1- and T2-weighted MRI sequences. The paintbrush border was defined as irregular signal extensions projecting into the bone. Edema was identified as high signal intensity on T2-weighted images (Fig. 5 ). [ Figure 5 about here] Surgical Technique All surgeries were performed by the same orthopedic oncology surgeon using a standardized technique consisting of intralesional curettage, thermal cauterization, and PMMA filling. A cortical window was created over the lesion, and the tumor tissue was thoroughly curetted. High-speed burrs were used to extend curettage down to healthy bone margins. Thermal cauterization was then applied in spray mode to the endosteal surface of the cavity. The defect was filled with antibiotic-loaded PMMA. In cases with significant cortical thinning, internal fixation was applied using plates and screws or Kirschner wires (Figs. 7–8). Postoperative Follow-up All patients were followed retrospectively based on scheduled postoperative visits at 3 weeks, 3 months, 6 months, 12 months, and annually thereafter. Magnetic resonance imaging (MRI) was routinely performed every 6 months during the first two years to monitor for local recurrence. Clinical assessments were obtained from medical records and outpatient follow-up notes. Local recurrence was defined as the development of a new lesion at the same anatomical site as the primary tumor, confirmed by radiological findings. Statistical Analysis The collected data were analyzed using SPSS software version 22.0 (IBM Corp., Armonk, NY, USA). The normality of the distribution of quantitative variables was assessed using the Kolmogorov–Smirnov test. Variables with normal distribution were expressed as mean ± standard deviation (mean ± SD). Comparisons between two independent groups were performed using the Student's t-test, while comparisons among more than two groups were conducted using one-way analysis of variance (ANOVA). For post hoc comparisons, the Scheffé test was applied. Paired samples t-test was used for comparisons of preoperative and postoperative data within the same group. The relationships between continuous variables were evaluated using Pearson’s correlation coefficient (r). Categorical variables were expressed as frequencies and percentages, and comparisons between groups were made using the Chi-square test. A p-value of < 0.05 was considered statistically significant. Results A total of 27 patients (13 males and 14 females; mean age: 35.19 ± 14.7 years) were included in the study. The mean follow-up duration was 33.19 ± 29.24 months. Lesions were most frequently located in the proximal tibia (40.7%) and distal femur (25.9%). The most common presenting symptoms were pain (40.7%) and limping (25.9%). Pathological fractures were observed in 11.1% of cases, and incidental findings in 14.8%. According to Campanacci staging, 59.3% of patients were classified as stage 2, 22.2% as stage 1, and 18.5% as stage 3. Soft tissue extension was observed in 18.5% of patients, and pulmonary metastasis in 3.1%. The local recurrence rate was 11.1% (n = 3), and the overall complication rate was 22.2% (n = 6) (Table 1 ). Table 1 Demographic characteristics of patients. Demographics Total (n = 27) Age (year) (mean ± SD) 35.19 ± 14.7 Mean follow-up time (months) (mean ± SD) 33.19 ± 29.24 Sex (n/%) Female Male 14 (51.9) 13 (48.1) Localization of lesions (n/%) Femur distal Tibia proximal Tibia distal Fibula proximal First metatarsal (proximal) Os cuboid Talus Radius distal 7 (25.9) 11 (40.7) 1 (3.7) 1 (3.7) 1 (3.7) 1 (3.7) 1 (3.7) 4 (14.8) Presenting complaints (n/%) Pain Swelling Limp Pathological fracture Incidental finding 11 (40.7) 2 (7.4) 7 (25.9) 3 (11.1) 4 (14.8) Campanacci grade (n/%) Grade 1 Grade 2 Grade 3 6 (22.2) 16 (59.3) 5 (%18.5) Soft tissue involvement (n/%) (+) (-) 5 (18.5) 22 (81.5) Lung metastasis (n/%) (+) (-) 1 (3.1) 26 (96.3) Recurrence (+) (-) 3 (11.1) 24 (88.9) Complication (+) (-) 6 (22.2) 21 (77.8) Data are presented as mean ± standard deviation or number (%). A significant negative correlation was found between preoperative MSTS scores and tumor volume (r = − 0.565, p = 0.002), as well as the tumor-to-bone ratio on AP (r = − 0.502, p = 0.008) and lateral radiographs (r = − 0.568, p = 0.002). Conversely, a positive correlation was observed between MSTS scores and the thinnest residual cortical thickness (r = 0.426, p = 0.02). Postoperative MSTS scores also showed a negative correlation with tumor volume (r = − 0.527, p = 0.005) and the tumor-to-bone ratio on lateral view (r = − 0.419, p = 0.03), and a positive correlation with residual cortical thickness (r = 0.450, p = 0.01). No significant correlation was found between AP ratio and postoperative MSTS scores (Table 2 ). Table 2 Correlation between preoperative and postoperative MSTS scores and radiological parameters. Tumor volume (cm³) Ratio of the largest tumor diameter to the largest bone diameter at the same level in AP X-ray (mm) Ratio of the largest tumor diameter to the largest bone diameter at the same level in lateral X-ray (mm) Thickness of the thinnest cortical layer affected by the tumor (mm) Preoperative MSTS score r − .565** − .502** − .568** .426* p 0.002 0.008 0.002 0.02 n 27 27 27 27 Postopoerative MSTS score r − .527** − .264 − .419* .450* p 0.005 0.18 0.03 0.01 n 27 27 27 27 p < 0.05 was considered statistically significant. r indicates the Pearson correlation coefficient, and n denotes the number of patients. MSTS stands for Musculoskeletal Tumor Society. A single asterisk () indicates that the correlation is significant at the 0.05 level (two-tailed), while a double asterisk (**) indicates significance at the 0.01 level (two-tailed).* When stratified by Campanacci stage, tumor volume (p = 0.02), AP ratio (p = 0.001), and lateral ratio (p = 0.002) were significantly higher in stage 3 tumors (Table 3 ). Table 3 Examination of the differences between the radiological features of the lesions and Campanacci grades. Grade n mean ± SD p Tumor volume (cm3) Grade 1 Grade 2 Grade 3 Total 6 16 5 27 18.62 ± 9.03 *a 47.32 ± 27.75 82.76 ± 65.15 *c 47.50 ± 39.30 0.02 Ratio of the largest tumor diameter to the largest bone diameter at the same level in AP X-ray (mm) Grade 1 Grade 2 Grade 3 Total 6 16 5 27 0.57 ± 0.10 *c 0.57 ± 0.14 *c 0.88 ± 0.08 *ab 0.63 ± 0.17 0.001 Ratio of the largest tumor diameter to the largest bone diameter at the same level in lateral radiograph (mm) Grade 1 Grade 2 Grade 3 Total 6 16 5 27 0.62 ± 0.18 *c 0.72 ± 0.11 *c 0.93 ± 0.07 *ab 0.74 ± 0.16 0.002 p < 0.05 was considered statistically significant. One-way ANOVA with post hoc Scheffé test was used to compare the groups. n: number of patients. Superscripts indicate significant differences between groups: a indicates a significant difference from Stage 1, b from Stage 2, and c from Stage 3. Comparing patients with and without recurrence revealed significantly higher tumor volumes (101.46 ± 79.17 cm³ vs. 40.76 ± 27.81 cm³, p = 0.009) and AP ratios (0.83 ± 0.13 vs. 0.60 ± 0.16, p = 0.03) in the recurrence group. Additionally, the presence of a paintbrush border was detected in 100% of recurrent cases, which was statistically significant (p = 0.01). No other radiological parameter was significantly associated with recurrence (Table 4 ). Table 4 Examination of the differences between the radiological parameters of the patients and the recurrence groups. Recurrence n Mean ± SD p Tumor volume (cm3) (+) (-) 3 24 101.46 ± 79.17 40.76 ± 27.81 0.009 Ratio of the largest tumor diameter to the largest bone diameter at the same level in AP X-ray (mm) (+) (-) 3 24 0.83 ± 0.13 0.60 ± 0.16 0.03 Ratio of the largest tumor diameter to the largest bone diameter at the same level in lateral radiograph (mm) (+) (-) 3 24 0.82 ± 0.17 0.73 ± 0.16 0.39 Distance from tumor edge to articular surface (mm) (+) (-) 3 24 0.53 ± 0.46 1.64 ± 2.56 0.47 Thickness of the thinnest cortical layer affected by the tumor (mm) (+) (-) 3 24 0.43 ± 0.75 0.62 ± 0.55 0.58 Thickness of unaffected cortical bone around the tumor (mm) (+) (-) 3 24 2.60 ± 0.63 2.67 ± 0.88 0.88 Paintbrush borders sign (+) (-) 3 24 1.00 ± 0.00 1.42 ± 0.50 0.01 Presence of peritumoral edema (+) (-) 3 24 1.00 ± 0.00 1.42 ± 0.50 0.17 p < 0.05 was considered statistically significant. Student’s t-test was used for continuous variables. Paintbrush border sign and peritumoral edema were scored as binary variables (1: present, 0: absent). n: number of patients. Patients with complications had significantly larger tumor volumes than those without complications (90.55 ± 55.12 cm³ vs. 35.20 ± 23.10 cm³, p = 0.001). No other radiological parameters were significantly associated with complication development (Table 5 ). Table 5 The relationship between radiological parameters and complications. Complications n Mean ± SD p Tumor volume(cm3) (+) (-) 6 21 90.55 ± 55.12 35.20 ± 23.10 0.001 Ratio of the largest tumor diameter to the largest bone diameter at the same level in AP X-ray (mm) (+) (-) 6 21 0.69 ± 0.22 0.61 ± 0.15 0.34 Ratio of the largest tumor diameter to the largest bone diameter at the same level on lateral radiograph (mm) (+) (-) 6 21 0.83 ± 0.15 0.71 ± 0.15 0.11 Distance from tumor edge to articular surface (mm) (+) (-) 6 21 0.80 ± 0.87 1.72 ± 2.71 0.42 Thickness of the thinnest cortical layer affected by the tumor (mm) (+) (-) 6 21 0.28 ± 0.44 0.69 ± 0.57 0.11 Thickness of unaffected cortical bone around the tumor (mm) (+) (-) 6 21 2.60 ± 0.71 2.68 ± 0.89 0.82 p < 0.05 was considered statistically significant. Statistical comparisons were performed using Student’s t-test. MSTS: Musculoskeletal Tumor Society Representative radiological findings are illustrated in Figs. 1 – 5 . Figure 1 shows tumor-to-bone ratios and tumor volumes; Fig. 2 depicts tumor–joint distance; Fig. 3 illustrates affected and unaffected cortical thicknesses; Fig. 4 demonstrates the paintbrush border sign; and Fig. 5 shows examples of peritumoral edema. Discussion GCTB is a locally aggressive but rarely metastasizing tumor that most commonly affects young adults[ 9 ]. The demographic and clinical characteristics in our study are largely consistent with those reported in the literature [ 4 ]. Most lesions were located around the knee, particularly in the proximal tibia and distal femur, with pain and limping being the most common presenting symptoms. A slight female predominance was observed, consistent with previous reports [ 10 ]. Intralesional curettage is the most commonly used surgical treatment for GCTB. PMMA is frequently used due to its thermal effect generated by free radicals during polymerization, which can cause up to 3 mm of necrosis in cancellous bone [ 11 ]. Previous studies have reported local recurrence rates ranging from 20–34.4% following curettage and PMMA application [ 12 , 13 ]. In our series, the recurrence rate was lower (11.1%), which may be attributed to the use of extended curettage, high-speed burring of the surrounding bone, and additional thermal cauterization. A significant negative correlation was found between tumor volume and both preoperative and postoperative MSTS scores. This suggests that larger tumors may compromise joint integrity and surrounding soft tissue structures, resulting in poorer functional outcomes. Conversely, cortical thickness at the thinnest point of tumor invasion was positively correlated with MSTS scores, indicating that preservation of cortical bone is associated with better postoperative function. In a study by Ankalkoti et al., the authors emphasized that larger tumor sizes posed greater challenges in preserving limb function following surgical intervention for GCTB [ 14 ]. Although MSTS scores were not specifically reported, the difficulty in achieving satisfactory functional outcomes in patients with extensive lesions was clearly highlighted. The study suggested that large tumor volume may necessitate more aggressive surgical strategies, potentially compromising joint integrity and surrounding soft tissues. In our study, larger tumor volume was significantly associated with increased complication rates. This finding is consistent with the results of Wang et al., who reported that cysts or tumors larger than 60 cm³ exhibited a much higher incidence of complications such as pathologic fracture and late osteoarthritis [ 15 ]. This may be due to more complex surgical procedures, longer operative times, and delayed postoperative recovery. Furthermore, higher Campanacci grades were associated with greater tumor volumes in our cohort, indicating a potential link between tumor size and biological aggressiveness. While some authors have argued that tumor volume correlates with poor prognosis, others have reported no such association with recurrence [ 16 – 18 ]. Zhou et al. [ 19 ] investigated 211 GCTB cases and reported that proximity to the joint surface and decreased cortical thickness were significantly associated with recurrence. In their study, the mean subchondral distance was 1.3 mm in the recurrence group and 3.3 mm in the non-recurrence group. Additionally, the thinnest cortical thickness was 0.48 mm in the recurrence group versus 0.87 mm in the control group (p < 0.001). These findings align with our results, suggesting that cortical destruction, soft tissue involvement, and inadequate surgical margins are key predictors of local recurrence. In our study, 66% of patients with recurrence had soft tissue extension, further emphasizing its role as a risk factor. Microscopic tumor remnants in adjacent soft tissues may also contribute to recurrence. Other studies have similarly reported that multifocal lesions and extensive soft tissue involvement are associated with higher recurrence risk [ 20 , 21 ]. Although peritumoral edema may reflect tumor aggressiveness, our findings did not reveal a significant association with recurrence. This suggests that edema is more likely to be a nonspecific inflammatory response rather than an independent prognostic indicator [ 8 ]. While the tumor-to-bone ratio has been previously assessed on plain radiographs and found unrelated to recurrence, our study found a significant association between this ratio and recurrence on AP views, but not on lateral views [ 22 ]. This discrepancy may be due to overlapping structures that obscure tumor margins in lateral projections. Chen et al. [ 23 ] suggested that when cortical thickness is less than 3 mm, there is a higher likelihood of subchondral invasion. Prosser et al. [ 18 ] found no significant correlation between joint distance and recurrence, which aligns with our findings. The paintbrush border appearance, characterized by irregular finger-like projections into surrounding bone on MRI, has been reported to be a strong predictor of recurrence [ 6 ]. Yifeng et al.[ 24 ] demonstrated its high predictive value for recurrence. In our study, all patients with positive paintbrush border signs experienced recurrence, and this association was statistically significant. This radiological feature is believed to represent microscopic bone infiltration and may indicate inadequate margin clearance during curettage. Therefore, careful surgical planning and consideration of adjuvant treatments are warranted in such cases. In conclusion, our study comprehensively evaluated radiological parameters potentially associated with recurrence and functional outcomes in patients with GCTB. Our findings suggest that tumor volume, cortical destruction, and paintbrush border appearance are significant predictors of recurrence. Their association with functional recovery also highlights the importance of detailed preoperative imaging not only for oncologic outcomes but also for preserving limb function. Easily identifiable findings such as the paintbrush border can play a critical role in surgical planning. Further multicenter, prospective studies with larger sample sizes are necessary to validate these observations and integrate them into clinical practice. Conclusion This study demonstrated that preoperative radiological parameters such as tumor volume, paintbrush border appearance, and cortical thickness are significantly associated with local recurrence and functional outcomes in patients with giant cell tumor of bone. Integrating these parameters into surgical planning may contribute to reducing recurrence rates and improving postoperative function. Abbreviations AP Anteroposterior CT Computed Tomography GCTB Giant Cell Tumor of Bone MRI Magnetic Resonance Imaging MSTS Musculoskeletal Tumor Society PA Posteroanterior PMMA Polymethylmethacrylate SD Standard Deviation Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. It was approved by the Erciyes University Clinical Research Ethics Committee (approval number: 2022/755, date: November 9, 2022). The requirement for informed consent was waived due to the retrospective nature of the study. Consent for publication Not applicable. Availability of data and materials All data generated or analyzed during this study are included in this published article and its supplementary information files. Competing interests The authors declare that they have no competing interests. Funding The authors received no specific funding for this work. Clinical trial number Not applicable Authors’ contributions MFU conceptualized the study, collected the data, and drafted the manuscript. IHK supervised the study design and revised the manuscript critically. BC contributed to data analysis and visualization. FG provided clinical insight and manuscript editing. AA helped with statistical analysis and final revisions. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Palmerini E, Picci P, Reichardt P, Downey G. Malignancy in Giant Cell Tumor of Bone: A Review of the Literature. Technol Cancer Res Treat. 2019;18:1533033819840000. Lin X, Liu J, Xu M. The prognosis of giant cell tumor of bone and the vital risk factors that affect its postoperative recurrence: a meta-analysis. Translational Cancer Res. 2021;10(4):1712. Abbasi AN, Qamar J, Habib A, Ali SME, Ahmed S, Khan MW. Unraveling the mystery: A comprehensive review of multidisciplinary strategies for managing giant cell tumor of the bone. 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He Y, Wang J, Zhang J, Du L, Lu Y, Xu J, et al. Magnetic resonance feature of paintbrush borders sign as a novel way to predict recurrence of giant cell tumor of bone after curettage: a pilot study. J Int Med Res. 2018;46(2):710–22. Additional Declarations No competing interests reported. Supplementary Files graphicalabstract.png EthicsApprovalFatih.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7108464","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":489240428,"identity":"5d519938-f1eb-4513-b513-c5847cb729d6","order_by":0,"name":"Mehmet Fatih Uzun¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYDCCAwwMzAw2DAxsEsxAJoOEDJFa0hgk2CTYEkBaeIjXAlRsAOIT1sJ3+3Ti44IEuzo+6Z7Pr27UWPAwsB8+ugGfFslzuZuNZyQkS7DJnN1mnXMM6DCetLQb+LQYnOHdJs37gxnol9xtxjlsQC0SPGaEtGz/zZNQD9SS88w45x9xWrYx8yQcBmlhfpzbRoQWyTO8m6V5Eo5LtkmkmTHn9knwsBHyC98Z3o2feRKq+eVnJD/+nPOtTo6f/fAxvFqQAZsEmCRWOQgwfyBF9SgYBaNgFIwcAAB7dUFTWLEU0AAAAABJRU5ErkJggg==","orcid":"","institution":"Erciyes University","correspondingAuthor":true,"prefix":"","firstName":"Mehmet","middleName":"Fatih","lastName":"Uzun¹","suffix":""},{"id":489240429,"identity":"926581f9-8e1f-4179-a522-0f6e18287b38","order_by":1,"name":"Ibrahim Halil Kafadar","email":"","orcid":"","institution":"Erciyes University","correspondingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"Halil","lastName":"Kafadar","suffix":""},{"id":489240430,"identity":"eafdbec5-051d-498c-83ba-30a3b3609127","order_by":2,"name":"Burak Cakar¹","email":"","orcid":"","institution":"Erciyes University","correspondingAuthor":false,"prefix":"","firstName":"Burak","middleName":"","lastName":"Cakar¹","suffix":""},{"id":489240431,"identity":"9b6279bf-77e7-4a4b-8b79-4e7401bed4f9","order_by":3,"name":"Fatih Golgelioglu","email":"","orcid":"","institution":"Bozok University","correspondingAuthor":false,"prefix":"","firstName":"Fatih","middleName":"","lastName":"Golgelioglu","suffix":""},{"id":489240432,"identity":"4541b0e8-74d9-4655-9722-f8de916bf6cb","order_by":4,"name":"Anil Aydin","email":"","orcid":"","institution":"Erciyes University","correspondingAuthor":false,"prefix":"","firstName":"Anil","middleName":"","lastName":"Aydin","suffix":""}],"badges":[],"createdAt":"2025-07-12 13:38:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7108464/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7108464/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87702387,"identity":"6a02060c-34f5-4a66-8bc7-41a15d3314e6","added_by":"auto","created_at":"2025-07-28 07:34:14","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":46691,"visible":true,"origin":"","legend":"\u003cp\u003eAxial imaging and radiographic demonstration of the tumor-to-bone diameter ratio in the anteroposterior (AP) view and tumor volume measurement. Tumor margins are delineated for volumetric calculation using MRI, and the widest tumor and bone diameters are measured on AP radiograph.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7108464/v1/3aa228770c6df512d18b3986.jpg"},{"id":87703440,"identity":"f00d4863-1f70-4006-af0a-df05bf82d1d9","added_by":"auto","created_at":"2025-07-28 07:42:10","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":57857,"visible":true,"origin":"","legend":"\u003cp\u003eMeasurement of the tumor-to-bone diameter ratio in the lateral radiographic projection. The largest tumor diameter and corresponding bone diameter at the same level are demonstrated.\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7108464/v1/3d45c0c22bf2a882b2ff8958.jpg"},{"id":87701783,"identity":"8fc779d9-d063-401f-8d41-f8033c35b27b","added_by":"auto","created_at":"2025-07-28 07:26:10","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":46108,"visible":true,"origin":"","legend":"\u003cp\u003eEvaluation of the thinnest cortical bone layer affected by the tumor. The thinnest point of cortical destruction adjacent to the lesion is shown on MRI.\u003c/p\u003e","description":"","filename":"figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7108464/v1/37db1ac82a7071ebd291a991.jpg"},{"id":87701780,"identity":"2f13f49e-d57c-47ba-97c9-c1d780af641a","added_by":"auto","created_at":"2025-07-28 07:26:10","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":50791,"visible":true,"origin":"","legend":"\u003cp\u003eMeasurement of the thickness of unaffected cortical bone around the tumor. Intact cortical areas adjacent to the lesion are used to assess baseline bone structure.\u003c/p\u003e","description":"","filename":"figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7108464/v1/d0b5088d8e36c65288b01fe2.jpg"},{"id":87700528,"identity":"065a3905-bc40-49e3-9ee0-73bd64e91c02","added_by":"auto","created_at":"2025-07-28 07:18:10","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":21987,"visible":true,"origin":"","legend":"\u003cp\u003eRadiological appearance of the paintbrush border sign and presence of peritumoral edema. Irregular, finger-like extensions of the tumor into surrounding bone are illustrated, along with hyperintense peritumoral edema visible on T2-weighted MRI sequences.\u003c/p\u003e","description":"","filename":"figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7108464/v1/6cb447d0c0acc7c018653668.jpg"},{"id":88751102,"identity":"91110b2e-a0be-4553-98d6-14db57424a1f","added_by":"auto","created_at":"2025-08-11 06:08:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1642148,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7108464/v1/4cb2c2bf-0d08-40a4-9a78-46787a1d0277.pdf"},{"id":87700520,"identity":"9b2d38e7-f491-4b74-88bb-6f4cb6557f8a","added_by":"auto","created_at":"2025-07-28 07:18:10","extension":"png","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":2260417,"visible":true,"origin":"","legend":"","description":"","filename":"graphicalabstract.png","url":"https://assets-eu.researchsquare.com/files/rs-7108464/v1/f3805707626b6de2eb4b4715.png"},{"id":87700519,"identity":"bd4d3014-814a-4c1c-9eba-b2d286357277","added_by":"auto","created_at":"2025-07-28 07:18:10","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":801673,"visible":true,"origin":"","legend":"","description":"","filename":"EthicsApprovalFatih.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7108464/v1/18d55417cbb66490aa5895e2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Preoperative Radiological Parameters May Predict Recurrence in Giant Cell Tumor of Bone","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGiant cell tumor of bone (GCTB) is a benign tumor that typically arises in the epiphyseal and metaphyseal regions of long bones. It most commonly affects adults between the ages of 20 and 45 and accounts for approximately 5\u0026ndash;6% of all primary bone tumors [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite its benign histology, GCTB demonstrates locally aggressive behavior and is associated with a high risk of recurrence following surgical treatment, which can negatively impact long-term functional outcomes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe most commonly preferred treatment method is intralesional curettage followed by cavity filling with polymethylmethacrylate (PMMA). The thermal and cytotoxic effects of PMMA are intended to destroy residual tumor cells and help reduce recurrence rates. Although this approach has been associated with favorable outcomes in many cases, recurrence can still occur in a subset of patients [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn recent years, preoperative imaging findings have gained attention not only for diagnostic purposes but also for their potential role in predicting local recurrence. The presence of a paintbrush border on magnetic resonance imaging reflects irregular intramedullary extensions of the tumor, which may complicate complete surgical removal. Similarly, large tumor volume may result in insufficient surgical margins and increase the risk of recurrence [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough some studies have suggested a correlation between these imaging features and recurrence, the findings are not consistent [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, it is important to clarify the prognostic value of preoperative radiological parameters in assessing the risk of recurrence, particularly to guide surgical planning.\u003c/p\u003e\u003cp\u003eThe aim of this study was to evaluate the relationship between preoperative imaging features, particularly the presence of a paintbrush border and tumor volume, and the development of local recurrence in patients with GCTB treated with intralesional curettage and PMMA.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis retrospective study included patients who underwent surgical treatment for giant cell tumor of bone at the Department of Orthopedics and Traumatology, Erciyes University Medical Faculty, between January 2013 and June 2022. The study was approved by the Institutional Review Board of Erciyes University (Approval Date: 09.11.2022; Approval No: 2022/755).\u003c/p\u003e\u003cp\u003e\u003cb\u003eImaging and Radiological Assessments\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll patients underwent anteroposterior (AP) and lateral radiographs of the affected extremity, contrast-enhanced MRI, and non-contrast CT scans. In cases of suspected metastasis, chest CT and posteroanterior (PA) chest radiographs were reviewed. The radiological parameters evaluated in this study are illustrated in Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e to \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTumor-to-Bone Ratio and Tumor Volume\u003c/strong\u003e\u003cp\u003eOn AP and lateral radiographs, the largest tumor diameter was divided by the corresponding bone diameter at the same level to calculate the tumor-to-bone ratio (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA\u0026ndash;B). Tumor volume was measured on axial CT images using the PACS-integrated volume calculation tool (Sectra UniView, v20.2.9.3362) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e[\u003c/b\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003eabout here]\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eJoint Surface Distance\u003c/strong\u003e\u003cp\u003eThe shortest distance between the tumor margin and the articular surface was measured in coronal and sagittal CT slices and recorded as the subchondral distance (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This measurement was used to assess the extent of articular invasion.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e[\u003c/b\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003eabout here]\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eThinnest Cortex Thickness\u003c/strong\u003e\u003cp\u003eIn axial CT sections, the thickness of the most thinned cortical area affected by the tumor was measured (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A value of 0 mm indicated complete cortical destruction.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e[\u003c/b\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cb\u003eabout here]\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eUnaffected Cortical Thickness\u003c/strong\u003e\u003cp\u003eCortical thickness was also measured in regions not affected by the tumor. These measurements were taken from contralateral or distant unaffected areas on axial CT slices (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e[\u003c/b\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e \u003cb\u003eabout here]\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMRI Findings\u003c/strong\u003e\u003cp\u003ePeritumoral edema and the paintbrush border sign were evaluated on T1- and T2-weighted MRI sequences. The paintbrush border was defined as irregular signal extensions projecting into the bone. Edema was identified as high signal intensity on T2-weighted images (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e[\u003c/b\u003eFigure \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e \u003cb\u003eabout here]\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSurgical Technique\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll surgeries were performed by the same orthopedic oncology surgeon using a standardized technique consisting of intralesional curettage, thermal cauterization, and PMMA filling. A cortical window was created over the lesion, and the tumor tissue was thoroughly curetted. High-speed burrs were used to extend curettage down to healthy bone margins. Thermal cauterization was then applied in spray mode to the endosteal surface of the cavity. The defect was filled with antibiotic-loaded PMMA. In cases with significant cortical thinning, internal fixation was applied using plates and screws or Kirschner wires (Figs.\u0026nbsp;7\u0026ndash;8).\u003c/p\u003e\u003cp\u003e\u003cb\u003ePostoperative Follow-up\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll patients were followed retrospectively based on scheduled postoperative visits at 3 weeks, 3 months, 6 months, 12 months, and annually thereafter. Magnetic resonance imaging (MRI) was routinely performed every 6 months during the first two years to monitor for local recurrence. Clinical assessments were obtained from medical records and outpatient follow-up notes. Local recurrence was defined as the development of a new lesion at the same anatomical site as the primary tumor, confirmed by radiological findings.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eThe collected data were analyzed using SPSS software version 22.0 (IBM Corp., Armonk, NY, USA). The normality of the distribution of quantitative variables was assessed using the Kolmogorov\u0026ndash;Smirnov test. Variables with normal distribution were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD). Comparisons between two independent groups were performed using the Student's t-test, while comparisons among more than two groups were conducted using one-way analysis of variance (ANOVA). For post hoc comparisons, the Scheff\u0026eacute; test was applied. Paired samples t-test was used for comparisons of preoperative and postoperative data within the same group. The relationships between continuous variables were evaluated using Pearson\u0026rsquo;s correlation coefficient (r). Categorical variables were expressed as frequencies and percentages, and comparisons between groups were made using the Chi-square test. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 27 patients (13 males and 14 females; mean age: 35.19\u0026thinsp;\u0026plusmn;\u0026thinsp;14.7 years) were included in the study. The mean follow-up duration was 33.19\u0026thinsp;\u0026plusmn;\u0026thinsp;29.24 months. Lesions were most frequently located in the proximal tibia (40.7%) and distal femur (25.9%). The most common presenting symptoms were pain (40.7%) and limping (25.9%). Pathological fractures were observed in 11.1% of cases, and incidental findings in 14.8%. According to Campanacci staging, 59.3% of patients were classified as stage 2, 22.2% as stage 1, and 18.5% as stage 3. Soft tissue extension was observed in 18.5% of patients, and pulmonary metastasis in 3.1%. The local recurrence rate was 11.1% (n\u0026thinsp;=\u0026thinsp;3), and the overall complication rate was 22.2% (n\u0026thinsp;=\u0026thinsp;6) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics of patients.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eDemographics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e (year) (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35.19\u0026thinsp;\u0026plusmn;\u0026thinsp;14.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMean follow-up time\u003c/b\u003e (months) (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.19\u0026thinsp;\u0026plusmn;\u0026thinsp;29.24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e (n/%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (51.9)\u003c/p\u003e\u003cp\u003e13 (48.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLocalization of lesions\u003c/b\u003e (n/%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemur distal\u003c/p\u003e\u003cp\u003eTibia proximal\u003c/p\u003e\u003cp\u003eTibia distal\u003c/p\u003e\u003cp\u003eFibula proximal\u003c/p\u003e\u003cp\u003eFirst metatarsal (proximal)\u003c/p\u003e\u003cp\u003eOs cuboid\u003c/p\u003e\u003cp\u003eTalus\u003c/p\u003e\u003cp\u003eRadius distal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (25.9)\u003c/p\u003e\u003cp\u003e11 (40.7)\u003c/p\u003e\u003cp\u003e1 (3.7)\u003c/p\u003e\u003cp\u003e1 (3.7)\u003c/p\u003e\u003cp\u003e1 (3.7)\u003c/p\u003e\u003cp\u003e1 (3.7)\u003c/p\u003e\u003cp\u003e1 (3.7)\u003c/p\u003e\u003cp\u003e4 (14.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePresenting complaints\u003c/b\u003e (n/%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePain\u003c/p\u003e\u003cp\u003eSwelling\u003c/p\u003e\u003cp\u003eLimp\u003c/p\u003e\u003cp\u003ePathological fracture\u003c/p\u003e\u003cp\u003eIncidental finding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (40.7)\u003c/p\u003e\u003cp\u003e2 (7.4)\u003c/p\u003e\u003cp\u003e7 (25.9)\u003c/p\u003e\u003cp\u003e3 (11.1)\u003c/p\u003e\u003cp\u003e4 (14.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCampanacci grade\u003c/b\u003e (n/%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrade 1\u003c/p\u003e\u003cp\u003eGrade 2\u003c/p\u003e\u003cp\u003eGrade 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (22.2)\u003c/p\u003e\u003cp\u003e16 (59.3)\u003c/p\u003e\u003cp\u003e5 (%18.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSoft tissue involvement\u003c/b\u003e (n/%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (18.5)\u003c/p\u003e\u003cp\u003e22 (81.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLung metastasis\u003c/b\u003e (n/%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (3.1)\u003c/p\u003e\u003cp\u003e26 (96.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRecurrence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (11.1)\u003c/p\u003e\u003cp\u003e24 (88.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eComplication\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (22.2)\u003c/p\u003e\u003cp\u003e21 (77.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eData are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or number (%).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA significant negative correlation was found between preoperative MSTS scores and tumor volume (r = \u0026minus;\u0026thinsp;0.565, p\u0026thinsp;=\u0026thinsp;0.002), as well as the tumor-to-bone ratio on AP (r = \u0026minus;\u0026thinsp;0.502, p\u0026thinsp;=\u0026thinsp;0.008) and lateral radiographs (r = \u0026minus;\u0026thinsp;0.568, p\u0026thinsp;=\u0026thinsp;0.002). Conversely, a positive correlation was observed between MSTS scores and the thinnest residual cortical thickness (r\u0026thinsp;=\u0026thinsp;0.426, p\u0026thinsp;=\u0026thinsp;0.02). Postoperative MSTS scores also showed a negative correlation with tumor volume (r = \u0026minus;\u0026thinsp;0.527, p\u0026thinsp;=\u0026thinsp;0.005) and the tumor-to-bone ratio on lateral view (r = \u0026minus;\u0026thinsp;0.419, p\u0026thinsp;=\u0026thinsp;0.03), and a positive correlation with residual cortical thickness (r\u0026thinsp;=\u0026thinsp;0.450, p\u0026thinsp;=\u0026thinsp;0.01). No significant correlation was found between AP ratio and postoperative MSTS scores (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation between preoperative and postoperative MSTS scores and radiological parameters.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTumor volume (cm\u0026sup3;)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRatio of the largest tumor diameter to the largest bone diameter at the same level in AP X-ray (mm)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRatio of the largest tumor diameter to the largest bone diameter at the same level in lateral X-ray (mm)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eThickness of the thinnest cortical layer affected by the tumor (mm)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003ePreoperative MSTS score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.565**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.502**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.568**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.426*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003ePostopoerative MSTS score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.527**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.264\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.419*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.450*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. r indicates the Pearson correlation coefficient, and n denotes the number of patients. MSTS stands for Musculoskeletal Tumor Society. A single asterisk () indicates that the correlation is significant at the 0.05 level (two-tailed), while a double asterisk (**) indicates significance at the 0.01 level (two-tailed).*\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhen stratified by Campanacci stage, tumor volume (p\u0026thinsp;=\u0026thinsp;0.02), AP ratio (p\u0026thinsp;=\u0026thinsp;0.001), and lateral ratio (p\u0026thinsp;=\u0026thinsp;0.002) were significantly higher in stage 3 tumors (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eExamination of the differences between the radiological features of the lesions and Campanacci grades.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrade\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003emean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTumor volume (cm3)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrade 1\u003c/p\u003e\u003cp\u003eGrade 2\u003c/p\u003e\u003cp\u003eGrade 3\u003c/p\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003cp\u003e16\u003c/p\u003e\u003cp\u003e5\u003c/p\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18.62\u0026thinsp;\u0026plusmn;\u0026thinsp;9.03\u003csup\u003e*a\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e47.32\u0026thinsp;\u0026plusmn;\u0026thinsp;27.75\u003c/p\u003e\u003cp\u003e82.76\u0026thinsp;\u0026plusmn;\u0026thinsp;65.15\u003csup\u003e*c\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e47.50\u0026thinsp;\u0026plusmn;\u0026thinsp;39.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRatio of the largest tumor diameter to the largest bone diameter at the same level in AP X-ray (mm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrade 1\u003c/p\u003e\u003cp\u003eGrade 2\u003c/p\u003e\u003cp\u003eGrade 3\u003c/p\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003cp\u003e16\u003c/p\u003e\u003cp\u003e5\u003c/p\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10\u003csup\u003e*c\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e0.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003csup\u003e*c\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e0.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08\u003csup\u003e*ab\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e0.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRatio of the largest tumor diameter to the largest bone diameter at the same level in lateral radiograph (mm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrade 1\u003c/p\u003e\u003cp\u003eGrade 2\u003c/p\u003e\u003cp\u003eGrade 3\u003c/p\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003cp\u003e16\u003c/p\u003e\u003cp\u003e5\u003c/p\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18\u003csup\u003e*c\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e0.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.11\u003csup\u003e*c\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e0.93\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07\u003csup\u003e*ab\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e0.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. One-way ANOVA with post hoc Scheff\u0026eacute; test was used to compare the groups. n: number of patients. Superscripts indicate significant differences between groups: a indicates a significant difference from Stage 1, b from Stage 2, and c from Stage 3.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eComparing patients with and without recurrence revealed significantly higher tumor volumes (101.46\u0026thinsp;\u0026plusmn;\u0026thinsp;79.17 cm\u0026sup3; vs. 40.76\u0026thinsp;\u0026plusmn;\u0026thinsp;27.81 cm\u0026sup3;, p\u0026thinsp;=\u0026thinsp;0.009) and AP ratios (0.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13 vs. 0.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16, p\u0026thinsp;=\u0026thinsp;0.03) in the recurrence group. Additionally, the presence of a paintbrush border was detected in 100% of recurrent cases, which was statistically significant (p\u0026thinsp;=\u0026thinsp;0.01). No other radiological parameter was significantly associated with recurrence (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eExamination of the differences between the radiological parameters of the patients and the recurrence groups.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRecurrence\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTumor volume (cm3)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e101.46\u0026thinsp;\u0026plusmn;\u0026thinsp;79.17\u003c/p\u003e\u003cp\u003e40.76\u0026thinsp;\u0026plusmn;\u0026thinsp;27.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRatio of the largest tumor diameter to the largest bone diameter at the same level in AP X-ray (mm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e\u003cp\u003e0.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRatio of the largest tumor diameter to the largest bone diameter at the same level in lateral radiograph (mm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.17\u003c/p\u003e\u003cp\u003e0.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.39\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDistance from tumor edge to articular surface (mm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e\u003cp\u003e1.64\u0026thinsp;\u0026plusmn;\u0026thinsp;2.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThickness of the thinnest cortical layer affected by the tumor (mm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e\u003cp\u003e0.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.58\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThickness of unaffected cortical bone around the tumor (mm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63\u003c/p\u003e\u003cp\u003e2.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.88\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePaintbrush borders sign\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e\u003cp\u003e1.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePresence of peritumoral edema\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e\u003cp\u003e1.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Student\u0026rsquo;s t-test was used for continuous variables. Paintbrush border sign and peritumoral edema were scored as binary variables (1: present, 0: absent). n: number of patients.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePatients with complications had significantly larger tumor volumes than those without complications (90.55\u0026thinsp;\u0026plusmn;\u0026thinsp;55.12 cm\u0026sup3; vs. 35.20\u0026thinsp;\u0026plusmn;\u0026thinsp;23.10 cm\u0026sup3;, p\u0026thinsp;=\u0026thinsp;0.001). No other radiological parameters were significantly associated with complication development (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe relationship between radiological parameters and complications.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComplications\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTumor volume(cm3)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e90.55\u0026thinsp;\u0026plusmn;\u0026thinsp;55.12\u003c/p\u003e\u003cp\u003e35.20\u0026thinsp;\u0026plusmn;\u0026thinsp;23.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRatio of the largest tumor diameter to the largest bone diameter at the same level in AP X-ray (mm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.22\u003c/p\u003e\u003cp\u003e0.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRatio of the largest tumor diameter to the largest bone diameter at the same level on lateral radiograph (mm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e\u003cp\u003e0.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDistance from tumor edge to articular surface (mm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.80\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87\u003c/p\u003e\u003cp\u003e1.72\u0026thinsp;\u0026plusmn;\u0026thinsp;2.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThickness of the thinnest cortical layer affected by the tumor (mm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.28\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e\u003cp\u003e0.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThickness of unaffected cortical bone around the tumor (mm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e\u003cp\u003e2.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Statistical comparisons were performed using Student\u0026rsquo;s t-test. MSTS: Musculoskeletal Tumor Society\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRepresentative radiological findings are illustrated in Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows tumor-to-bone ratios and tumor volumes; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e depicts tumor\u0026ndash;joint distance; Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e illustrates affected and unaffected cortical thicknesses; Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e demonstrates the paintbrush border sign; and Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows examples of peritumoral edema.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eGCTB is a locally aggressive but rarely metastasizing tumor that most commonly affects young adults[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The demographic and clinical characteristics in our study are largely consistent with those reported in the literature [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Most lesions were located around the knee, particularly in the proximal tibia and distal femur, with pain and limping being the most common presenting symptoms. A slight female predominance was observed, consistent with previous reports [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIntralesional curettage is the most commonly used surgical treatment for GCTB. PMMA is frequently used due to its thermal effect generated by free radicals during polymerization, which can cause up to 3 mm of necrosis in cancellous bone [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Previous studies have reported local recurrence rates ranging from 20\u0026ndash;34.4% following curettage and PMMA application [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In our series, the recurrence rate was lower (11.1%), which may be attributed to the use of extended curettage, high-speed burring of the surrounding bone, and additional thermal cauterization.\u003c/p\u003e\u003cp\u003eA significant negative correlation was found between tumor volume and both preoperative and postoperative MSTS scores. This suggests that larger tumors may compromise joint integrity and surrounding soft tissue structures, resulting in poorer functional outcomes. Conversely, cortical thickness at the thinnest point of tumor invasion was positively correlated with MSTS scores, indicating that preservation of cortical bone is associated with better postoperative function. In a study by Ankalkoti et al., the authors emphasized that larger tumor sizes posed greater challenges in preserving limb function following surgical intervention for GCTB [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Although MSTS scores were not specifically reported, the difficulty in achieving satisfactory functional outcomes in patients with extensive lesions was clearly highlighted. The study suggested that large tumor volume may necessitate more aggressive surgical strategies, potentially compromising joint integrity and surrounding soft tissues.\u003c/p\u003e\u003cp\u003eIn our study, larger tumor volume was significantly associated with increased complication rates. This finding is consistent with the results of Wang et al., who reported that cysts or tumors larger than 60 cm\u0026sup3; exhibited a much higher incidence of complications such as pathologic fracture and late osteoarthritis [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This may be due to more complex surgical procedures, longer operative times, and delayed postoperative recovery. Furthermore, higher Campanacci grades were associated with greater tumor volumes in our cohort, indicating a potential link between tumor size and biological aggressiveness. While some authors have argued that tumor volume correlates with poor prognosis, others have reported no such association with recurrence [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eZhou et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] investigated 211 GCTB cases and reported that proximity to the joint surface and decreased cortical thickness were significantly associated with recurrence. In their study, the mean subchondral distance was 1.3 mm in the recurrence group and 3.3 mm in the non-recurrence group. Additionally, the thinnest cortical thickness was 0.48 mm in the recurrence group versus 0.87 mm in the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These findings align with our results, suggesting that cortical destruction, soft tissue involvement, and inadequate surgical margins are key predictors of local recurrence. In our study, 66% of patients with recurrence had soft tissue extension, further emphasizing its role as a risk factor. Microscopic tumor remnants in adjacent soft tissues may also contribute to recurrence. Other studies have similarly reported that multifocal lesions and extensive soft tissue involvement are associated with higher recurrence risk [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough peritumoral edema may reflect tumor aggressiveness, our findings did not reveal a significant association with recurrence. This suggests that edema is more likely to be a nonspecific inflammatory response rather than an independent prognostic indicator [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile the tumor-to-bone ratio has been previously assessed on plain radiographs and found unrelated to recurrence, our study found a significant association between this ratio and recurrence on AP views, but not on lateral views [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This discrepancy may be due to overlapping structures that obscure tumor margins in lateral projections.\u003c/p\u003e\u003cp\u003eChen et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] suggested that when cortical thickness is less than 3 mm, there is a higher likelihood of subchondral invasion. Prosser et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] found no significant correlation between joint distance and recurrence, which aligns with our findings.\u003c/p\u003e\u003cp\u003eThe paintbrush border appearance, characterized by irregular finger-like projections into surrounding bone on MRI, has been reported to be a strong predictor of recurrence [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Yifeng et al.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] demonstrated its high predictive value for recurrence. In our study, all patients with positive paintbrush border signs experienced recurrence, and this association was statistically significant. This radiological feature is believed to represent microscopic bone infiltration and may indicate inadequate margin clearance during curettage. Therefore, careful surgical planning and consideration of adjuvant treatments are warranted in such cases.\u003c/p\u003e\u003cp\u003eIn conclusion, our study comprehensively evaluated radiological parameters potentially associated with recurrence and functional outcomes in patients with GCTB. Our findings suggest that tumor volume, cortical destruction, and paintbrush border appearance are significant predictors of recurrence. Their association with functional recovery also highlights the importance of detailed preoperative imaging not only for oncologic outcomes but also for preserving limb function. Easily identifiable findings such as the paintbrush border can play a critical role in surgical planning. Further multicenter, prospective studies with larger sample sizes are necessary to validate these observations and integrate them into clinical practice.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrated that preoperative radiological parameters such as tumor volume, paintbrush border appearance, and cortical thickness are significantly associated with local recurrence and functional outcomes in patients with giant cell tumor of bone. Integrating these parameters into surgical planning may contribute to reducing recurrence rates and improving postoperative function.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnteroposterior\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputed Tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGCTB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGiant Cell Tumor of Bone\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMSTS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMusculoskeletal Tumor Society\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePosteroanterior\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePMMA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePolymethylmethacrylate\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandard Deviation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki. It was approved by the Erciyes University Clinical Research Ethics Committee (approval number: 2022/755, date: November 9, 2022). The requirement for informed consent was waived due to the retrospective nature of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article and its supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMFU conceptualized the study, collected the data, and drafted the manuscript. IHK supervised the study design and revised the manuscript critically. BC contributed to data analysis and visualization. FG provided clinical insight and manuscript editing. AA helped with statistical analysis and final revisions. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePalmerini E, Picci P, Reichardt P, Downey G. Malignancy in Giant Cell Tumor of Bone: A Review of the Literature. Technol Cancer Res Treat. 2019;18:1533033819840000.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLin X, Liu J, Xu M. The prognosis of giant cell tumor of bone and the vital risk factors that affect its postoperative recurrence: a meta-analysis. Translational Cancer Res. 2021;10(4):1712.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbbasi AN, Qamar J, Habib A, Ali SME, Ahmed S, Khan MW. Unraveling the mystery: A comprehensive review of multidisciplinary strategies for managing giant cell tumor of the bone. J Orthop Rep. 2025;4(1):100384.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJha Y, Chaudhary K. Giant cell tumour of bone: a comprehensive review of pathogenesis, diagnosis, and treatment. Cureus. 2023;15(10):e46945.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTsukamoto S, Mavrogenis AF, Akahane M, Honoki K, Kido A, Tanaka Y, et al. Risk factors of fracture following curettage for bone giant cell tumors of the extremities. BMC Musculoskelet Disord. 2022;23(1):477.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eParmeggiani A, Miceli M, Errani C, Facchini G. State of the art and new concepts in giant cell tumor of bone: imaging features and tumor characteristics. Cancers. 2021;13(24):6298.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOuyang H-Q, Jiang L, Liu X-G, Wei F, Yang S-M, Meng N, et al. Recurrence Factors in Giant Cell Tumors of the Spine. Chin Med J. 2017;130(13):1557\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHe Y, Wang J, Zhang J, Du L, Lu Y-Z, Xu J, et al. Magnetic resonance feature of paintbrush borders sign as a novel way to predict recurrence of giant cell tumor of bone after curettage: a pilot study. J Int Med Res. 2018;46:030006051772034.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVari S, Riva F, Onesti CE, Cosimati A, Renna D, Biagini R et al. Malignant Transformation of Giant Cell Tumour of Bone: A Review of Literature and the Experience of a Referral Centre. Int J Mol Sci [Internet]. 2022; 23(18).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmbrosi F, Righi A, Benini S, Magagnoli G, Chiaramonte I, Manfrini M, et al. Giant cell tumor of bone in patients under 16 years old: A single-institution case series. Cancers. 2021;13(11):2585.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeeson MC, Lippitt SB. Thermal aspects of the use of polymethylmethacrylate in large metaphyseal defects in bone. A clinical review and laboratory study. Clin Orthop Relat Res. 1993(295):239\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeng A, Gao H, Li J, Meng L, Wang Q, Xiang L. Intralesional curettage and surgical adjuvants in the treatment of giant cell tumor of bone: meta-analysis and systematic review. Chin Clin Oncol. 2024;13(2):20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoch B, Inwards C, Sundaram M, Rosenberg AE. Multicentric giant cell tumor of bone: clinicopathologic analysis of thirty cases. 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J Int Med Res. 2018;46(2):710\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Bone tumor, cortical thickness, curettage, giant cell tumor, paintbrush border, recurrence","lastPublishedDoi":"10.21203/rs.3.rs-7108464/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7108464/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eGiant cell tumor of bone (GCTB) is a benign but locally aggressive bone neoplasm with a high risk of local recurrence. Identifying reliable radiological predictors of recurrence can improve surgical planning and patient outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eIn this retrospective study, 27 patients with histopathologically confirmed GCTB who underwent intralesional curettage, thermal cauterization, and PMMA were evaluated. Preoperative imaging parameters, including tumor volume, tumor-to-bone ratio, cortical thickness, subchondral distance, and MRI features such as paintbrush border and peritumoral edema, were analyzed for their association with recurrence, MSTS scores, and complications.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe local recurrence rate was 11.1%. Paintbrush border appearance and increased tumor volume were significantly associated with recurrence (p\u0026thinsp;=\u0026thinsp;0.01 and p\u0026thinsp;=\u0026thinsp;0.009, respectively). Tumor volume showed a negative correlation with both pre- and postoperative MSTS scores. Thinner cortex in tumor-affected areas correlated with lower MSTS scores and higher soft tissue involvement. Tumor-to-bone ratio on AP radiographs also correlated significantly with recurrence, while subchondral distance did not.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003ePreoperative radiological findings such as tumor volume, cortical destruction, and paintbrush border may predict recurrence and functional outcomes in GCTB. Incorporating these parameters into treatment planning may reduce recurrence and improve functional recovery.\u003c/p\u003e","manuscriptTitle":"Preoperative Radiological Parameters May Predict Recurrence in Giant Cell Tumor of Bone","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-28 07:18:05","doi":"10.21203/rs.3.rs-7108464/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"040fd042-c63f-4b23-b361-7ed87123ac63","owner":[],"postedDate":"July 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-11T06:08:41+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-28 07:18:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7108464","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7108464","identity":"rs-7108464","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}