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Clin Cases Miner Bone Metab. 2010 May-Aug; 7(2): 145–152.
PMCID: PMC3004463

Giant cell tumor in a case of Paget's disease of bone: an aggressive benign tumor exhibiting a quick response to an innovative therapeutic agent


Giant cell tumor of bone, also called osteoclastoma, is a rare skeletal complication of Paget’s disease of bone. We here report a patient from Southern Italy who developed a GCT infiltrating the neighboring tissues. We will focus on either a review on this rare bone tumor, including some genetic aspects, or the current established therapies. Since this case has been published in International literature, here we report the updated clinical findings on it. Finally, we will describe the therapeutic outcomes of this unique complication of Paget’s disease of bone as a rapid response to an innovative therapeutic agent.

Keywords: Paget’s disease of bone; giant cell tumors; osteoclastoma; RANKL/RANK/OPG; anti-RANKL antibody.


Paget’s disease of bone (PDB) is an alteration of the focal bone remodeling in which the normal skeletal architecture is replaced by a not organized bone tissue, with a tendency to deformities and fractures. Although reported, the occurrence of malignancies, including osteosarcoma, chondrosarcoma and fibrosarcoma, as a complication of PDB, is an uncommon event (<1%).

The giant cell tumor (GCT) is a rare complication of PDB (1), usually associated with long standing polyostotic disease (2-5). Compared to the traditional, nonpagetic, form, PDB-GCT reaches a peak of incidence at older ages (third vs. sixth decade), with a slight predilection for males and more frequently localizes in the craniofacial bones, less often pelvic and vertebral. Its location at the ends, typical of traditional GCT, is unusual (5-10) (Table (Table11).

Table I
- Main features of PDB-GCT vs. traditional GCT

Solitary or multiple forms have been described, sometimes exhibiting a peculiar geographical distribution and/or a familial pattern. In particular, some studies report a significant increase in the prevalence of PDB-GCT in Campania, specifically nearby Avellino (6, 11, 12); the patient, object of this study, comes from Naples, the capital town of Campania.

Although GCT is usually a histologically benign tumor confined to the bone, along with indolent behavior, it may sometimes show an infiltrative pattern of growth with an involvement of soft and/or visceral tissues (3, 13-17). However, an its malignant degeneration appears to be a rare event (4).

Hypotheses for the etiopathogenesis of PDB

Currently, the primary cause of PDB is still unknown and viral and genetic hypotheses need of clear demonstration.

Viral hypothesis

A viral etiology has been proposed for many years, based on the discovery of virus-like intranuclear inclusion bodies in osteoclasts (OCLs) of pagetic bone (18-21). Myrrh and Gold also reported a case where virus-like intranuclear inclusion bodies were found in the OCL of PDB-GCT (22). Unfortunately, many other reports have not replicated similar findings in their analyzed series (23-26).

Genetic hypothesis: all the gene products involved in the pathogenesis of PDB and PDB-like syndromes are important regulators/modulators of osteoclastogenesis and/or metabolic osteoclast activity.

Recently, germline mutations in the gene encoding p62 protein (SQSTM1/p62 gene) have been identified in patients with sporadic and familial PDB (15, 27-30). In general, it has been demonstrated that 12-40% of PDB index cases have at least 1 first degree relative affected by PDB (31), who exhibit a 7–10 times increased risk to develop PDB with respect to general population. This risk is even greater in relatives of patients with deforming disease and those with an early age at diagnosis (32).

The protein p62 is involved in the signal cascade that involves the RANK-dependent signaling, essential for osteoclastogenesis (33). In particular, protein p62 is involved in signal transduction along the NFkB pathway and an abnormal functioning of this protein may result in abnormal activation of NFkB and hence in increased of both osteoclastogenesis and metabolic activity of OCL (34).

In addition to SQSTM1/p62 gene, mutations and polymorphisms in several other genes, encoding components of the “RANKL-RANK-NFkB pathway, have been identified in patients with PDB and correlated syndromes (35-40) described in Table Table2.2.

Table II
- Mutations and polymorphisms in other genes than SQSTM1/p62 gene identified in patients with PDB and correlated syndromes.

However, how PDB-GCT may develop is not clear yet. It is reasonable to assume that PDB-GCT may develop as a result of abnormal and excessive localized osteoclastogenesis, associated with stromal cell proliferation with possible additional molecular alterations, not defined (2).

Hypothesis for the etiopathogenesis of GCT: RANKL-RANK-NFkB pathway and the development of GCT

After the identification of the cytokine Receptor Activator of Nuclear factor kB ligand (RANKL), an important osteoclastic differentiating factor, great advances have been achieved in understanding the pathogenesis of GCT, in general (15).

Many studies would identify RANKL as highly expressed by stromal cells within the GCT tissue (41, 43, 38-40): stromal cell would be the “neoplastic driver” and RANKL would appear to be essential in the pathogenesis of GCT (15). The genetic basis underlying RANKL overexpression by stromal cells have not been identified, and abnormalities of the RANKL gene have not been found in GCT specimen (15).

It is possible that reciprocal, unidentified, signals from giant cells may be involved in maintaining an immature state of the stromal cell and would be required for the expression of RANKL (15).

GCT is clinically characterized by osteolytic lesions able to spread out, and histologically by the presence of multi-nucleated giant cells similar to OCLs. Several authors believe that the mononuclear stromal cells represent the neoplastic component of GCT able to produce molecular signals which promote the formation of multinucleated osteoclast-like cells. The benign multinucleated giant cells, stimulated by the neoplastic mesenchymal component of GCT, promote the process of osteolysis (7, 44, 45). The tumor cells express RANKL and its receptor RANK. Thus, the pathway RANKL/RANK is an essential mediator for the activity, the formation and survival of OCLs (46-52).

GCT: Instrumental diagnosis, current therapeutical approaches and future perspectives

The instrumental diagnosis of GCT mainly relies on radiological surveys such as conventional X-rays (2), CT (2, 53) and MR (2, 54-56).

The therapeutic management of GCT is not well codified and may be represented by surgical removal of the mass (15, 57-64) and/or radiotherapy (15, 19, 45, 65-68), and/or selective arterial embolization (69-71) and/or pharmacotherapy (Interferon-a) (65, 72, 73) and/or amino-bisphosphonates (15, 74-79) and/or steroids (9-11, 18, 79, 80).

However, as above reported, the increased knowledge on the RANKL-RANK pathway has allowed the development of new therapeutic modalities such as the one represented by human monoclonal antibody anti-RANKL agent: denosumab (47).


It is a fully human monoclonal antibody, IgG2, specific against RANKL, able to: 1) prevent its binding to RANK; 2) inhibit the development of OCLs and their activity; 3) reduce bone resorption; and 4) increase the bone density (81-86). Denosumab is therefore an innovative therapeutic agent for the management of patients with post-menopausal osteoporosis (86) and conditions with bone loss or destruction (86-92), as reported at Table Table33.

Table III
- Denosumab: an innovative drug for the management of patients with post-menopausal osteoporosis and the following conditions with bone loss or destruction.

Based on these considerations, it is expected that denosumab will represent a well-tolerated therapy for patients with GCT, relapsed or not surgically treatable, or for patients with surgically treatable disease whose surgery, originally scheduled during the study, is associated with severe morbidity.

This evaluation is still ongoing in a multicentre, international, open phase II trial on patients with bone GCT receiving 120 mg of denosumab, sub-cutaneously (SC) administered, every 4 weeks (Q4W) with a loading dose of 120 mg, SC at day 8 and 15 of the study, in combination with daily 500 mg of calcium and 400 IU of vitamin D (EudraCT Code: 2008-001606-16).

Previously, Thomas et al. (85, 86), in 37 patients with surgically untreatable or recurrent GCT, showed a good tumor response and a good tolerability to denosumab in 86% of cases, as reported at Table Table4.4. In 33 patients (89%) minor adverse events occurred (the most commonly represented by headache and nasopharyngitis), no serious adverse events related to the form of treatment or death were reported during this study. No patients developed antibodies anti-denosumab (85, 86).

Table IV
- Results of treatment with denosumab on 37 patients with surgically untreatable or recurrent GCT.

Therefore, further studies on denosumab, as a new therapeutic agent for GCT, are needed (85, 86).

Case Report

The clinical description of this PDB-GCT case has been recently published (93). Tables Tables55--88 summarize the main clinical and therapeutical features reported (93). Figures Figures11--3,3, unpublished, described the findings of technetium-99m-labeled bisphosphonate bone scintigraphy, abdomen-pelvic CT and 3D-CT scan of the tumor lesion, respectively.

Figure 1
- Initial total body bone scintigraphy, performed before any therapy, evidenced several hyperactive areas: skull, vertebral bodies, pelvis and both femurs. All these data were suggesting a polyostotic pagetic involvement.
Figure 3
- First 3D- pelvic CT scan. It confirms the presence of a huge expansive solid lesion, highly vascularized, in the pelvis, diameter >8 cm., not dissociable from the left ilium and pelvic bones. The lesion, including the presence of bone spicules ...
Table V
- Clinical features of the male patient exhibiting PDB-GCT. The age of the diagnosis of PDB was 38 years whereas the GCT developed at 68 years. Her daughter was also affected by polyostotic PDB at 20 years.
Table VIII
- Treatments initially performed on PDB-GCT subject (93): positive and negative results.
Figure 2
- First pelvic MR shows an extended osteo-destroying lesion of left ileal and ischio-pubic branch associated with a huge solid neoformation mostly occupying the pelvis and compressing local muscles, prostate and bladder. The diffuse abnormal signal of ...
Table VI
- Physical, radiological and bone turnover examinations in the PDB-GCT case (93).
Table VII
- Findings at biopsy of pelvis and bladder (cystoscopy for hematuria) reported in the PDB-GCT case (93).

Genetic analysis

Since in recent studies it has been demonstrated a relatively frequent involvement of SQSTM1/p62 gene mutations in Italian patients with sporadic and familial PDB (28-30), in the original paper by Nuzzo et al., DNA test has been performed only to search germline mutations of SQSTM1/p62 gene in the proband (P-1) and his PDB affected daughter (P-2), with a negative result (93).

However, since the proband and his daughter had a very precocious occurrence of polyostotic PDB, at age of 30 and 20 years respectively, we estimated correct to exclude/assess the possibility of a Paget-like disease.

Consequently, we performed also a genetic study in the search of germline activating mutations of TNFRSF11A gene (Table (Table9),9), encoding RANK, which has been reported as causal of Familial Expansile Osteolysis (FEO), Skeletal Expansile Hyperphosphatasia (ESH), and early onset PDB (EO-PDB), considered being allelic diseases (Table (Table10)10) (35-39). Again, no germline mutations were detected. Unfortunately, no tissue samples were available for this analysis.

Table IX
- Scheme of the protocol of the RANK exon 1 mutational analysis
Table X
- FEO, ESH and EO-PDB are allelic diseases.

Current Therapy

Due to the persistence of the negative or unsatisfactory results, described at Table Table8,8, the patient was included in a multicentre, Phase 2 open-study using denosumab specifically designed for patients affected by GCT, at a dose of 120 mg, SC, Q4W, with a loading dose of 120 mg, SC, at day 8 and 15 of the study. The maximum extension period allowed is 54 months, with 36 months of enrolment, 12 months of treatment and 6 months of follow up.

As soon as after 15 days from the beginning of treatment, the patient achieved a weight loss of about 25 kg, a reduction of both pain and abdominal mass, a resumption of ambulation and self-stabilization of both serum Alkaline Phosphatase (after 3 months: 398 IU/L – normal range: 64-300) and MR imaging. Indeed, the last control (Figure (Figure4),4), at month 6, showed no substantial changes compared to the one at month 3.

Figure 4
- Pelvic and proximal femurs MR performed after denosumab therapy. It confirms the presence of multiple osteo-structural alterations with extensive bone erosion of both iliac wings, sacral wings, L4-L5-S1 vertebral bodies, the ischiopubic left branch, ...

A periodically performed compilation of the Health Assessment Questionnaire for the assessment of daily capabilities and ability of the upper and lower limbs in action (disability assessed by 8 categories of activities: dressing, arising, eating, walking, hygiene, reach, grip, and common activities), showed a transition from an initial score of 3 (indicative of maximum disability), at the beginning of this treatment, to a current score of 0 (no significant disability and no need of aid), at the follow-up visits.


The history of our patient was positive for a familial form of PDB. However, considering the following issue: 1) very early age at diagnosis (PDB-1 and PDB-2 respectively at 33 and 20 years) in comparison to what generally reported for the classical PDB (>55 years); 2) negative result of the mutational analysis of SQSTM1/p62 and TNFRSF11A genes, it seems appropriate to suspect the involvement of other molecular anomalies/alterations, mutations not yet defined or currently identifiable, as also of other not identified pathways.

The treatment of GCT is problematic and more difficult could be the one of PDB-GCT that could exhibit a more severe behavior.

In general, a response to corticosteroids therapy was reported in a few cases of GCT and a fairly rapid recovery of the disease was found after discontinuation of steroid therapy.

As previously reported, also in our case the continuous corticosteroids administration has helped to stabilize the disease clinically, biochemically and radiographically. Unfortunately, the lack of mass reduction and the occurrence of side effects due to use of corticosteroids, required discontinuation of treatment with relapse of pain, claudicatio of the lower left and increase of alkaline phosphatase.

Moreover, the selective arterial embolization, justified by the rich vascularization of the tumor, angiographically shown, had not cytoreductive results, while intravenous infusion of zoledronic acid resulted in a good clinical outcome in terms of response to pain control and reduction of serum alkaline phosphatase.

Currently, the patient is treated with denosumab 120 mg, SC, Q4W, (loading dose of 120 mg at day 8 and 15 of the protocol). A significant response to the drug was early evidenced and after only 15 days of treatment, the patient achieved a weight loss of 25 Kg, a reduction of both pain and abdominal mass, a complete recovery of autonomous walking and improved his daily-life relationships.


At present, there is no standard therapy for this disease, either traditional GCT or PDB-GCT, and the treatment has to be evaluated from time to time depending on the characteristics of the tumor and patient’s clinical condition.

However, the validity of a new drug such as denosumab may be clearly shown, particularly in recurrent or surgically unresectable GCT, even when associated to PDB. The validity of this drug may be also linked to its good tolerance. In fact, no patient reported significant adverse events to therapy or development of antibodies to denosumab in clinical trials. Specifically, in our patient a rapid and immediate response to treatment with tumor regression, stabilization of blood levels of alkaline phosphatase and improvement of the quality of life, with return to common-relational daily activities, have been reported.

The possible role of denosumab and other new therapeutic targets in the treatment of GCT, PDB-GCT and related disorders, is currently object of worldwide active studies.


This study has been made possible by an unrestricted grant from F. I. R. M. O. Fondazione Raffaella Becagli (to MLB). No conflict of interest has to be declared.


1. Pathak H.J., Mardi P.M., Thornhill B. Multiple Giant Cell Tumors Complicating Paget’s Disease. AJR. 1999;172 [PubMed]
2. Hoch B, Hermann G, Klein MJ, et al. Giant cell tumor complicating Paget disease of long bone. Skeletal Radiol. 2007;36:973–978. [PubMed]
3. Turcotte RE. Giant Cell Tumor of Bone. Orthopedic Clinics of North America. 2006;37:35–51. [PubMed]
4. Hadjipavlou A, Lander P, Srolovitz H, Enker IP. Malignant transformation in Paget disease of bone. Cancer. 1992;70(12):2802–2808. [PubMed]
5. Smith SE, Murphey MD, Motamedi K, et al. Radiologic spectrum of Paget’s disease of bone and its complications with pathologic correlation. Radiographics. 2002;22:1191–1216. [PubMed]
6. Jacobs TP, Michelsen J, Polay JS, D’Adamo AC, Canfield RE. Giant cell tumor in Paget’s disease of bone: Familial and geographic clustering. Cancer. 1979;44:742–747. [PubMed]
7. Anwar UI Haque, Ambreen Moatasim. Giant Cell Tumor of Bone: A Neoplasm or a Reactive Condition? Int J Clin Exp Pathol. 2008;1:489–501. [PMC free article] [PubMed]
8. Schajowicz F, Slullite I. Giant cell tumor associated with Paget’s disease of bone. A case report. J Bone Joint Surg Am. 1966;48:1340–1349. [PubMed]
9. Dixon GR, Ritchie DA, Myskow MW. Case report: Benign giant cell tumor associated with Paget’s disease of bone. Clin Radiol. 1995;50:269–271. [PubMed]
10. Gebhart M, Vandeweyer E, Nemec E. Paget’s disease of bone complicated by giant cell tumor. Clin Orthop Relat Res. 1998;352:187–193. [PubMed]
11. Magitsky S, Lipton JF, Reidy J, Vigorita VJ, Bryk E. Ultrastructural Features of Giant Cell Tumors in Paget’s Disease. Clinical Orthopaedics and Related Research. 2002;42:213–219. [PubMed]
12. Rendina D, Mossetti G, Soscia E, et al. Giant Cell Tumor and Paget’s Disease of Bone in One Family. Geografic Clustering. Clinical Orthopaedics and Related Research. 2004;421:218–224. [PubMed]
13. Rendina D, Gennari L, De Filippo G, et al. Evidence for increased clinical severity of familial and sporadic Paget’s disease of bone in Campania, southern Italy. J Bone Miner Res. 2006;21:1828–1835. [PubMed]
14. Zheng MH, Robbins P, Xu J, Huang L, Wood DJ, Papadimitriou JM. The histogenesis of giant cell tumor of bone: a model of interaction between neoplastic cells and osteoclasts. Histol Histopathol. 2001;16:297–307. [PubMed]
15. WHO. WHO. Pathology and genetics of tumors of soft tissue and bone. Lyon. IARC Press. 2002
16. Thomas DM, Skubitz KM. Giant cell tumor of bone. Current Opinion in Oncology. 2009;21:338–344. [PubMed]
17. Werner M. Giant cell tumor of bone: morphological, biological and histogenetical aspects. Int Orthop. 2006;30:484–489. [PMC free article] [PubMed]
18. De Chiara A, Apice G, Fazioli F, et al. Multicentric giant cell tumor with viral-like inclusions associated with Paget’s disease of bone: a case treated by steroid therapy. Oncol Rep. 1998;5:317–320. [PubMed]
19. Potter HG, Schneider R, Ghelman B, et al. Multiple giant cell tumors and Paget disease of bone: radiographic and clinical correlation. Radiology. 1991;180:261–264. [PubMed]
20. Welsh RA, Meyer AT. Nuclear fragmentation and associated fibrils in giant cell tumor of bone. Lb Invest. 1970;22:63. [PubMed]
21. Baslè MF, Rebel A, Fournier JG, et al. On the trail of paramyxoviruses in Paget’s disease of bone. Clin Orthop. 1987;217:9. [PubMed]
22. Mirra JM, Gold RH. Case Report 186. Skeletal Radiol. 1982;8:67–70. [PubMed]
23. Helfrich MH, Hobson RP, Grabowski PS, et al. A negative search for a paramyxoviral etiology of Paget’s disease of bone: Molecular, immunological, and ultrastructural studies in UK patients. J. Bone Miner. Res. 2000;15(12):2315–29. [PubMed]
24. Ooi CG, Walsh CA, Gallagher JA, Fraser WD. Absence of measles virus and canine distemper virus transcripts in long-term bone marrow cultures from patients with Paget’s disease of bone. Bone. 2000;27(3):417–21. [PubMed]
25. Ralston SH, Afzal MA, Helfrich MH, et al. Multicenter blinded analysis of RT-PCR detection methods for paramyxoviruses in relation to Paget’s disease of bone. J. Bone Miner. Res. 2007;22(4):569–77. [PubMed]
26. Matthews BG, Afzal MA, Minor PD, et al. Failure to detect measles virus ribonucleic acid in bone cells from patients with Paget’s disease. J. Clin. Endocrinol. Metab. 2008;93(4):1398–1401. [PubMed]
27. Laurin N, Brown JO, Morisette J, Raymond V. Recurrent mutation of the gene encoding sequestosome 1 (SQSTM1/p62) in Paget disease of bone. Am J Hum Genet. 2002;70:1582–1588. [PubMed]
28. Falchetti A, Di Stefano M, Marini F, et al. Two novel mutations at exon 8 of the Sequestosome 1 (SQSTM1) gene in an Italian series of patients affected by Paget’s disease of bone. J Bone Miner Res. 2004;19(6):1013–1017. [PubMed]
29. Falchetti A, Di Stefano M, Marini F, et al. Segregation of a M404V mutation of the p62/sequestosome 1 (p62/SQSTM1) gene with polyostotic Paget’s disease of bone in an Italian family. Arthritis Res Ther. 2005;7(6):R1289–95. [PMC free article] [PubMed]
30. Falchetti A, Di Stefano M, Marini F, et al. Genetic epidemiology of Paget’s disease of bone in Italy: sequestosome1/p62 gene mutational test and haplotype analysis at 5q35 in a large representative series of sporadic and familial Italian cases of Paget’s disease of bone. Calcif Tissue Int. 2009;84(1):20–37. [PubMed]
31. Langston AL, Campbell MK, Fraser WD, Maclennan G, Selby P, Ralston SH. Clinical determinants of quality of life in Paget’s disease of bone. Calcif Tissue Int. 2007;80:1–9. [PubMed]
32. Siris ES, Ottman R, Flaster E, Kelsey JL. Familial aggregation of Paget’s disease of bone. J. Bone Miner Res. 1991;6:495–500. [PubMed]
33. Reddy S. Etiology of Paget’s disease and Osteoclast abnormalities. J Cell Biochem. 2004;93:688–696. [PubMed]
34. Goode A, Layfield R. Recent advances in understanding the molecular basis of Paget disease of bone. J Clin Pathol. 2010;63(3):199–203. [PubMed]
35. Ralston SH. Pathogenesis of Paget’s disease of bone. Bone. 2008;43:819–825. [PubMed]
36. Osterberg PH, Wallace RG, Adams DA, et al. Familial expansile osteolysis. A new dysplasia. J Bone Joint Surg Br. 1988;70:255–60. [PubMed]
37. Whyte MP, Mills BG, Reinus WR, et al. Expansile skeletal hyperphosphatasia: a new familial metabolic bone disease. J Bone Miner Res. 2000;15:2330–44. [PubMed]
38. Nakatsuka K, Nishizawa Y, Ralston SH. Phenotypic characterization of early onset Paget’s disease of bone caused by a 27-bp duplication in the TNFRSF11A gene. J Bone Miner Res. 2003;18:1381–85. [PubMed]
39. Whyte MP, Obrecht SE, Finnegan PM, et al. Osteoprotegerin deficiency and juvenile Paget’s disease. N Engl J Med. 2002;347:175–84. [PubMed]
40. Kovach MJ, Waggoner B, Leal SM, et al. Clinical delineation and localization to chromosome 9p13.3–p12 of a unique dominant disorder in four families: hereditary inclusion body myopathy, Paget disease of bone, and frontotemporal dementia. Mol Genet Metab. 2001;74:458–75. [PubMed]
41. Morgan T, Atkins GJ, Trivett MK, et al. Molecular profiling of giant cell tumor of bone and the osteoclastic localization of ligand for receptor activator of nuclear factor kappaB. Am J Pathol. 2005;167:117–128. [PubMed]
42. Skubitz KM, Cheng EY, Clohisy DR, et al. Gene expression in giant-cell tumors. J Lab Clin Med. 2004;144:193–200. [PubMed]
43. Atkins GJ, Haynes DR, Graves SE, et al. Expression of osteoclast differentiation signals by stromal elements of giant cell tumors. J Bone Miner Res. 2000;15:640–649. [PubMed]
44. Gamberi G, Serra M, Ragazzini P, et al. Identifications of markers of possible prognostic value in 57 giant cell tumors of bone. Oncol Reports. 2003;10:351–356. [PubMed]
45. Mendenhall WM, Zlotecki RA, et al. Giant Cell Tumor of Bone. Am J Clin Oncol. 2006;29:96–99. [PubMed]
46. Menaa C, et al. (2000) Enhanced RANK ligand expression and responsivity of bone marrow cells in Paget’s disease of bone. J Clin Invest. 1005:1833–1838. [PMC free article] [PubMed]
47. Vega D, Maalouf NM, Sakhaee K. The Role of Receptor Activator of Nuclear Factor-k B (RANK)/RANK Ligand/Osteoprotegerin: Clinical Implications. The Journal of Clinical Endocrinology & Metabolism. 2007;92(12):4514–4521. [PubMed]
48. Boyle WJ, Simonet WS, Lacey DL. Osteoclast differentiation and activation. Nature. 2003;423:337–42. [PubMed]
49. Neale SD, Smith R, Waas JA, Athanasou NA. Osteoclast differentiation from circulating mononuclear precursors in Paget’s disease is hypersensitive to 1,25-dihydroxyvitamin D(3) and RANKL. Bone. 2000;27:417–21. [PubMed]
50. Kurihara N, Reddy SV, Araki N, et al. Role of TAFII-17, a VDR binding protein, in the increased Osteoclast formation in Paget’s Disease. J. Bone Miner Res. 2004;19:1154–64. [PubMed]
51. Thomas D, Chawla SP, Skubitz K, et al. Denosumab treatment of giant cell tumor of bone: Interim analysis of an open-label phase II study. J Clin Oncol. 2008;26 Abstract 10500.
52. Thomas D, Chawla SP, Skubitz K, et al. Denosumab for the treatment of giant cell tumor (GCT) of bone: Final results from a proof-of-concept, phase II study. J Clin Oncol. 2009;27:15s. S Abstract 10510.
53. Mooney WWW, Bridger GP, Baldwin M, Donellan M. Recurrent Giant Cell Tumor of Maxilla Associated with both Paget’s Disease and Primary Hyperparathyroidism. ANZ J. Surg. 2003;73:863–864. [PubMed]
54. Sundaram MG, Khanna G, el-Koury GY. T1-weighted MR imaging for distinguishing large osteolysis of Paget’s disease from sarcomatous degeneration. Skeletal Radiol. 2001;30:378–383. [PubMed]
55. Murphey MD, Nomikos GC, Flemming DJ, Gannon FH, Temple HT, Kransdorf MJ: From the archives of the AFIP: imaging of giant cell tumor and giant cell reparative granuloma of bone-radiologic-pathologic correlation. Radiographics. 2001;21:1283–1309. [PubMed]
56. Resnick D. Paget’s disease. In: Saunders WB, Diagnosis of bone and joint disorders. Philadelphia. 1995. pp. 1923–1968.
57. Pathak H.J., Mardi P.M., Thornhill B. Multiple Giant Cell Tumors Complicating Paget’s Disease. AJR. 1999;172 [PubMed]
58. Campanacci M, Baldini N, Boriani S, Sudanese A. Giant-cell tumor of bone. J Bone Joint Surg Am. 1987;69:106–114. [PubMed]
59. Becker WT, Dohle J, Bernd L, et al. Local recurrence of giant cell tumor of bone after intralesional treatment with and without adjuvant therapy. J Bone Joint Surg Am. 2008;90:1060–1067. [PubMed]
60. Vult von Steyern F, Bauer HC, Trovik C, et al. Treatment of local recurrences of giant cell tumour in long bones after curettage and cementing. A Scandinavian Sarcoma Group study. J Bone Joint Surg Br. 2006;88:531–535. [PubMed]
61. Turcotte RE, Wunder JS, Isler MH, et al. Giant cell tumor of long bone: a Canadian Sarcoma Group study. Clin Orthop Relat Res. 2002;397:248–258. [PubMed]
62. Zhen W, Yaotian H, Songjian L, et al. Giant-cell tumour of bone. The long-term results of treatment by curettage and bone graft. J Bone Joint Surg Br. 2004;86:212–216. [PubMed]
63. Durr HR, Maier M, Jansson V, et al. Phenol as an adjuvant for local control in the treatment of giant cell tumour of the bone. Eur J Surg Oncol. 1999;25:610–618. [PubMed]
64. Cheng EY, Zwolak P, Manivel C, et al. Zoledronic acid release from polymethylmethacrylate carrier and in vitro activity against giant cell tumor of bone. In: Proceedings of the Musculoskeletal Tumor Society Annual Meeting. Phoenix: Musculoskeletal Tumor Society; 2008:67.
65. Malawer MM, Bickels J, Meller I, et al. Cryosurgery in the treatment of giant cell tumor. A long-term followup study. Clin Orthop Relat Res. 1999;359:176–188. [PubMed]
66. Caudell JJ, Ballo MT, Gunar K, Zagars GK, et al. Radiotherapy in the management of giant cell tumor of bone. Int. J. Radiation Oncology Biol. Phys. 2003;57(1):158–165. [PubMed]
67. Feigenberg SJ, Marcus Jr RB, Zlotecki RA, et al. Radiation therapy for giant cell tumors of bone. Clin Orthop Relat Res. 2003;411:207–216. [PubMed]
68. Malone S, O’Sullivan B, Catton C, et al. Long term follow-up of efficacy and safety of megavoltage radiotherapy in high-risk giant cell tumour of bone. Int J Radiat Oncol Biol Phys. 1995;33:689–94. [PubMed]
69. Malone S, O’Sullivan B, Catton C, et al. Long-term follow-up of efficacy and safety of megavoltage radiotherapy in high-risk giant cell tumors of bone. Int J Radiat Oncol Biol Phys. 1995;33:689–694. [PubMed]
70. Lackman RD, Khoury LD, Esmail A, et al. The treatment of sacral giant cell tumours by serial arterial embolisation. J Bone Joint Surg Br. 2002;84:873–7. [PubMed]
71. Hosalkar HS, Jones KJ, King JJ, Lackman RD. Serial Arterial Embolization for Large Sacral Giant-Cell Tumors. SPINE. 2007;32(10):1107–1115. [PubMed]
72. Owen RJ. Embolization of musculoskeletal tumors. Radiol Clin North Am VI. 2008;46:535–43. [PubMed]
73. Kaiser U, Neumann K, Havemann K. Generalised giant-cell tumour of bone: successful treatment of pulmonary metastases with interferon alpha, a case report. J Cancer Res Clin Oncol. 1993;119:301–303. [PubMed]
74. Kaban LB, Troulis MJ, Wilkinson MS, et al. Adjuvant antiangiogenic therapy for giant cell tumors of the jaws. J Oral Maxillofac Surg. 2007;65:2018–2024. [PubMed]
75. ChengYY ChengYY, HuangL HuangL, LeeKM LeeKM, et al. Bisphosphonates induce apoptosis of stromal tumor cells in giant cell tumor of bone. Calcif Tissue Int. 2004;75:71–77. [PubMed]
76. Chang SS, Suratwala SJ, Jung KM, et al. Bisphosphonates may reduce recurrence in giant cell tumor by inducing apoptosis. Clin Orthop Relat Res. 2004;426:103–109. [PubMed]
77. Arpornchayanon O, Leerapun T. Effectiveness of intravenous bisphosphonate in treatment of giant cell tumor: a case report and review of the literature. J Med Assoc Thai. 2008;91:1609–1612. [PubMed]
78. Fujimoto N, Nakagawa K, Seichi A, et al. A new bisphosphonate treatment option for giant cell tumors. Oncol Rep. 2001;8:643–647. [PubMed]
79. Tse LF, Wong KC, Kumta SM, et al. Bisphosphonates reduce local recurrence in extremity giant cell tumor of bone: a case–control study. Bone. 2008;42:68–73. [PubMed]
80. Franchi A. Pathology of Paget’s disease of bone. Clinical Cases in Mineral and Bone Metabolism. 2004;1(3):203–207.
81. Ziambaras K, Totty WA, Teitelbaum SL, Dierkes M, Whyte MP. Extraskeletal osteoclastomas responsive to dexamethasone treatment in Paget bone disease. J Clin Endocrinol Metab. 1997;82(11):3826–34. [PubMed]
82. Lewiecki EM. Denosumab update. Current Opinion in Rheumatology. 2009;21:369–373. [PubMed]
83. Athanasios D Anastasilakis, et al. RANKL inhibition for the management of patients with benign metabolic bone disorders. Expert Opin Investig Drugs. 2009;18:1085. [PubMed]
84. Cummings SR, San Martin J, McClung MR, et al. Denosumab for Prevention of Fractures in Postmenopausal Women with Osteoporosis. The New England Journal of Medicine. 2009;361:756–765. [PubMed]
85. Thomas D, Chawla SP, Skubitz K, et al. Denosumab treatment of giant cell tumor of bone: Interim analysis of an open-label phase II study. J Clin Oncol. 2008;26 Abstract 10500.
86. Thomas D, Chawla SP, Skubitz K, et al. Denosumab for the treatment of giant cell tumor (GCT) of bone: Final results from a proof-of-concept, phase II study. J Clin Oncol. 2009;27:15s. S; Abstract 10510.
87. Hofbauer LC, Schoppet M. Clinical implications of the osteoprotegerin/RANKL/RANK system for bone and vascular diseases. JAMA. 2004;292:490–495. [PubMed]
88. Hofbauer LC, et al. Stimulation of osteoprotegerin ligand and inhibition of osteoprotegerin production by glucocorticoids in human osteoblastic lineage cells: potential paracrine mechanisms of glucocorticoid-induced osteoporosis. Endocrinology. 1999;140:4382–4389. [PubMed]
89. Theriault RL. Pathophysiology and implications of cancer treatment-induced bone loss. Oncology. 2004;18(3):11–15. [PubMed]
90. Gravallese EM, Manning C, Tsay A, et al. Synovial tissue in rheumatoid arthritis is a source of osteoclast differentiation factor. Arthritis Rheum. 2000;43:250–258. [PubMed]
91. Kong YY, Feige U, Sarosi I, et al. Activated T cells regulate bone loss and joint destruction in adjuvant arthritis through osteoprotegerin ligand. Nature. 1999;402:304–309. [PubMed]
92. Roodman GD. Mechanisms of bone metastasis. N Engl J Med. 2004;350:1655–1664. [PubMed]
93. Nuzzo V, Ferrara T, Zuccoli A, Brunetti-Pierri R, De Rosa R, Falchetti A, Franco R, Brunetti-Pierri N. Infiltrating giant cell tumor in a case of Paget’s disease of bone. Arch Osteoporos. 2009;4(1-2):91–94. [PMC free article] [PubMed]

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