Percutaneous osteoplasty for hypervascular bone metastasis

We report three cases of percutaneous osteoplasty for the treatment of hypervascular bone metastasis. Four hypervascular bone metastases were treated in three consecutive patients by percutaneous osteoplasty under fluoroscopic or computed tomographic guidance. Primary malignant tumors included pheochromocytoma and renal cell carcinoma. Pain relief after osteoplasty was achieved in all three patients. There was no major complication. Projectile bleeding and subcutaneous hematoma were noted during or after osteoplasty but were easily controlled conservatively. Percutaneous osteoplasty for hypervascular bone metastases is not only a highly effective but also a minimally invasive technique that provides immediate pain relief without major complication.     

Percutaneous treatment of insufficiency fractures

Insufficiency fractures of the pelvis, sacrum, spine, and long bones are painful, debilitating, and are common consequences of osteoporosis. Conventional treatment for these fractures varies from conservative therapy to surgery with plate and screw fixation. The former fails to address the underlying problem of fracture and frequently does not alleviate symptoms, while the latter is invasive and not always possible in older populations with low bone density and numerous co-morbidities. Osseous augmentation with polymethylmethacrylate (PMMA) has been used for over two decades to treat fractures related to osteoporosis, but has not been commonly used to treat fractures outside of the vertebral bodies. Osseous augmentation with PMMA is an image-guided procedure and various techniques have been utilized to treat fracture in different locations. We describe various techniques for image-guided osseous augmentation and treatment of insufficiency fractures with bothPMMA and allograft bone for fractures of the pelvis including sacrum, acetabulum, pubic symphysis, pubic rami ilium; appendicular skeleton including distal radius, proximal femur, and vertebral body. We also describe the potential risks and complications associated with percutaneous treatment of insufficiency fractures and techniques to avoid the pitfalls of the various procedures. We will present the process for patient follow-up and data regarding the pre- and postprocedure pain response in patients undergoing treatment for pelvic insufficiency fractures.     

Minimally Invasive Image-Guided Ablation,Osteoplasty, Reinforcement,and Internal Fixation (AORIF) for Osteolytic Lesions in the Pelvis and Periarticular Regions of Weight-Bearing Bones

PurposeTo assess early outcome, safety, and complications of an alternative to open surgical treatments of osteolytic lesions in periarticular load-bearing bones.Materials and MethodsA single-center, prospective clinical cohort study of 26 lesions in 23 consecutive patients with painful osteolytic skeletal lesions was performed. Patients were followed for an average of 7 mo (1–18 mo). Lesions were targeted from the most intact bone via minimally invasive percutaneous approach for stable anchorage of internal fixation screws using fluoroscopic guidance. Cannulated screws served as universal portals for ablation, balloon osteoplasty, and delivery of bone cement in addition to internal fixation for cement anchoring and prophylactic stabilization of uninvolved bone.ResultsThere were 19 osteolytic lesions in the pelvis, 4 in the proximal femur, 2 in the proximal tibia, and 1 in the calcaneus. All defects were associated with severe pain or fractures. There were no conversions to open surgery and no infection or bleeding requiring transfusion, embolization, or additional procedures. There was significant improvement in visual analogue scale (VAS) pain score from 8.32 ± 1.70 to 2.36 ± 2.23, combined pain and functional ambulation score from 4.48 ± 2.84 to 7.28 ± 2.76, and Musculoskeletal Tumor Society score from 45% to 68% (P < .05).ConclusionsAblation, osteoplasty, reinforcement, and internal fixation is a safe and effective minimally invasive percutaneous image-guided treatment option for functional improvement or palliation of painful osteolytic lesions in the pelvis and periarticular loadbearing bones.     

Pubic bone cement osteoplasty for pubic insufficiency fractures

The purpose of this report is to describe two cases of pubic bone insufficiency fractures refractory to conservative management treated with percutaneous cement osteoplasty. Both patients initially presented with severe pelvic pain and immobility and were treated conservatively without relief. The patients subsequently underwent percutaneous cement osteoplasty of the pubic bone and experienced complete pain relief immediately after the procedures. Both patients were followed up to 1 year, and were pain free throughout. Percutaneous cement osteoplasty may be an effective treatment for pubic bone insufficiency fractures.     

Percutaneous Osteoplasty for the Management of a Femoral Head Metastasis: a Case Report

Percutaneous osteoplasty (POP) as a technical extension of percutaneous vertebroplasty (PVP) has been used to treat malignant disease that affects the skeletal system. POP has demonstrated good outcome for pain relief and functional improvement. Few studies have reported on the efficiency of POP to treat malignancies located in the femoral head. We designed a pilot study with the use of POP to treat intractable pain caused by a femoral head metastatic tumor in a 43-year-old man. During the follow-up period, the patient experienced sustained pain relief and improvement of quality of life that persisted for more than three months.     

Percutaneous osteoplasty with use of a cement-filled catheter for a pathologic fracture of the humerus

Percutaneous osteoplasty has been used for pathologic fractures of long bones as an adjunct to orthopedic surgery. The present report describes a case of percutaneous osteoplasty with a cement-filled catheter and cement augmentation as the principal therapy to unite a painful pathologic fracture of the humerus. After the procedure, the patient experienced immediate pain relief and improved limb mobility. Percutaneous osteoplasty with this method holds promise as a treatment for pathologic fractures of the humerus that are not amenable to surgical repair.     

彩色多普勒超声引导下经皮骨骼病变穿刺活检术的应用

目的探讨彩色多普勒超声引导下经皮骨骼病变穿刺活检术的应用价值.资料与方法35例经影像学诊断的骨骼病变患者,在彩色多普勒超声引导下,采用 Bard 活检枪配备16G 或18G 活检针行经皮穿刺活检,比较穿刺活检病理诊断结果与术后组织病理诊断结果.结果35例患者中,31例取材成功,4例取材失败,成功率为88.6%.骨骼病变穿刺活检病理诊断转移瘤22例,骶骨良性病变3例,髂骨恶性肿瘤2例,股骨、肋骨、坐骨、腰椎恶性肿瘤各1例;与手术病理符合率为87.1%(27/31),二者诊断一致性较好(Kappa=0.633, P <0.01),诊断差异无统计学意义(P>0.05).结论彩色多普勒超声引导下经皮骨骼病变穿刺活检术安全,成功率及诊断准确率高,可在一定程度上代替手术活检,值得临床推广应用.     

Percutaneous embolization of bony pelvic neoplasms with tissue adhesive

Eight patients with tumors of the bony pelvis underwent embolization with isobutyl-2-cyanoacrylate (IBCA). Five patients had primary bone tumors, of which 2 were malignant and 3 were benign; 3 patients had metastases to the bony pelvis from the thyroid gland, kidney, and femur, respectively. Embolization was performed to minimize blood loss during resection of a giant-cell tumor in one patient and insertion of a hip prosthesis in another who had metastatic renal carcinoma. It was also done prior to scheduled surgery in one of the patients with aneurysmal bone cyst, but healing was sufficient to cancel the operation; in the other patient, embolization was the only therapy. Palliative embolization was performed in 4 patients with malignant tumors after other means failed to control pain or slow progression. IBCA appears to be an efficient means of occluding the vessels feeding selected primary bone tumors and metastases.     

Systemic bone marrow disorders: characterization with proton chemical shift imaging

In a prospective clinical study, 26 patients (22 with malignant lymphoma and 4 with myelofibrosis) and 9 healthy volunteers were examined by conventional magnetic resonance and proton chemical shift imaging (CSI; modified Dixon method). On the basis of the CSI data, a quantitative evaluation of the relative fat and water signal fractions in regions of interest of the femur, pelvis, and spine was performed. In 16 of 17 patients with biopsy-proven bone marrow disorders, CSI revealed a significant reduction in the fat fraction of the bone marrow relative to that of normal volunteers. The visual assessment could detect only 14 of the 17 pathological cases.     

多发性骨髓瘤MRI和X线诊断价值

目的　进一步研究多发性骨髓瘤 (multiplemyeloma ,MM )的MRI表现特点并与X线检查相比较其优缺点 ,同时探讨MRI分型与临床分期的联系。材料与方法　选择 19例经骨髓穿刺证实的MM患者的下胸椎至股骨上段行X线与MRI检查 ,对相同患者相同时间相同部位的X线平片与MRI表现、临床分期、MRI分型与骨髓浆细胞百分比进行比较。结果　MM的MRI据T1 WI骨髓信号减低的形态分为以下类型 :正常型 ,弥漫型 ,局灶型 ,混合型 ,“盐和胡椒”型。腰椎以弥漫型多见占 47.3% ,局灶型、混合型各占15 .8% ;骨盆及股骨近段以局灶型多见占 5 7.9% ,弥漫型占 2 1.1% ,无混合型。MM的X线表现 :未见异常 7例 ,骨质疏松的基础上病理性骨折或骨质破坏 12例。腰椎、骨盆及股骨近段各部位检查的阳性率MRI均为 84.2 % ,X线平片分别为 63.2 %、42 .1%和31.6%。MRI表现 :正常型及“盐和胡椒”型的病例其骨髓浸润较轻 ,均见于临床Ⅰ期MM ,其骨髓浆细胞的百分比较低 ( 8.4± 2 .5 ) ;而弥漫型、局灶型、混合型均见于Ⅱ、Ⅲ期MM ,其骨髓浸润程度相对较重 ,骨髓浆细胞的百分比较高 ( 30 .5± 6.7、45 .2± 11.2 )。结论　MM的MRI表现可分为正常型、弥漫型、局灶型、混合型、“盐和胡椒”型。MRI对MM的敏感性明显高于X线检查 ,但两者的特异性较差     

Pelvic osteoplasty in osteolytic metastases: technical approach under fluoroscopic guidance and early clinical results

PURPOSE: To describe a new fluoroscopically guided technique for osteoplasty (or cementoplasty) of the superior and inferior pubic rami and ischial tuberosities and to provide information about the access routes and initial results on pain management after this technique. MATERIALS AND METHODS: Twenty-three lytic metastases of the superior and inferior pubic rami and ischial tuberosities were treated in 14 consecutive patients. Percutaneous access of the bones was performed under fluoroscopy. All patients had pain refractory to radiation and narcotic therapy and were unsuitable candidates for surgery according to multidisciplinary consensus. RESULTS: Technical success was achieved in all cases. Clinically, effective pain relief was obtained in 92% of patients. One intraarticular asymptomatic minor complication and one major complication resulting from leakage near the pudendal nerve were observed. The latter was subsequently treated by radiofrequency ablation. CONCLUSION: Pelvic osteoplasty appears to be a safe and highly effective palliative therapy for painful osteolytic malignant bone metastases.     

Correlation of multimodality imaging in Paget's disease of bone

PURPOSE: The aim of this study is double: 1. to review the known and less known radiographic patterns of Paget's disease of bone, employing the most recent imaging techniques; 2. to propose a rationale algorithm for the diagnosis and management of the disease. considering its inconsistency and clinical variability. MATERIALS AND METHODS: Forty-eight patients with Paget's disease of bone (30 males and 18 females, aged 45 and 88 years, mean age 71) were examined in the period 1999-2003. The patients were classified into two groups: symptomatic and asymptomatic. The first group, comprising 32 patients with generic 'low back pain' with or without sciatica, or 'coxarthritis' underwent conventional radiography. In the second group (16 patients), bone disease was discovered in course of radiological and/or scintigraphic examinations performed for other conditions. Subsequently, all the patients completed the diagnostic algorithm, consisting of radiographs of the remaining skeletal areas and those segments with abnormal scintigraphic uptake. RESULTS: Monostotic Paget's disease was observed in 31 cases (64.6%), of whom 20 males (64.6%) and 11 females (35.4%), whereas polyostotic disease was found in 17 cases (35.4%), of whom 10 males (58.8%) and 7 females (41.2%). The sites most frequently affected in the monostotic form were: pelvis, 13 cases (43.3%); femur, 5 cases (16.7%); lumbar spine, 5 cases (16.7%); humerus, 2 cases (6.7%); tibia, 2 cases (6.7%); dorsal spine, skull, radius, patella, 1 case respectively (3.3%). In the polyostotic disease (17 cases), the affected bones were predominantly the skull, vertebral spine and pelvis (see text for their variable association). Pathologic fractures of the femur were found in two males. Osteogenic sarcoma (histological diagnosis) developed in the proximal femur in a 81 year-old male. CONCLUSIONS: Paget's disease is asymptomatic in the majority of affected individuals, and may be discovered incidentally with diagnosis being made on routine radiographs obtained for other purposes. Sometimes the x-ray features are so typical that the diagnosis is straightforward. Bone scan should be the imaging technique of choice, because tracer uptake is directly related to degree of activity of disease, and it may advance any radiographic evidence. Vertebral involvement is better evaluated by CT. Both CT and MRI are recommended in spine complications (pathological fractures, radicular or cord compression syndromes, malignant degeneration).     

Screening for skeletal metastases of the spine and pelvis: gradient echo opposed-phase MRIcompared with bone scintigraphy

Opposed-phase gradient eho (GRE) MRI at 0.5 T was compared with T1-weighted GRE MRI and bone scintigraphy regarding the detection of malignant bone marrow infiltrates of the spine and pelvis. Seventeen control patients and 41 patients with suspected skeletal metastases were studied with plain and gadolinium-enhanced MRI. In the control group only a vertebral haemangiona showed contrast enhancement, while all metastases (confirmed histologically or by follw-up) were enhancing. Opposed-phase surface coil MRI showed a significantly higher contrast-to-noise ratio of 56 metastases than T1-weighted images. In 28 patients body coil opposed-phased MRI detectedmore metastatic foci of the spine and pelvis than did bone scintigraphy (84 vs 56). No scintigraphically visualised lesion was missed by MRI. In conclusion,body coil gadolinium-enhanced opposed-phase GRE MRI may be applied as a screning method for skeletal metastases of the spine and pelvis at intermediate field strengths. Correspondence to: K. Neumann     

Painful pathologic fracture of the humerus: percutaneous osteoplasty with bone marrow nails under hybrid computed tomography and fluoroscopic guidance

A case of a 75-year-old patient with a painful pathologic humeral shaft fracture, with unacceptably high surgical risk and unsatisfactory analgesia is reported. In this case, impaired arm function and persistent pain with conservative management resulted in a poor quality of life. Palliation with image-guided percutaneous osteoplasty was considered. Because of potential cement leakage, inadequate fracture reduction, the site of the fracture, and the mobility of the joints in that area, image-guided percutaneous delivery of metallic bone marrow nails implanted together with polymethyl methacrylate (PMMA) osteoplasty was performed. This procedure achieved humeral shaft stabilization, bone fragment alignment, fracture reduction, and pain relief.     

(99m)Tc-MDP scintigraphic findings in children with leukemia: value of early and delayed whole-body imaging.

The purpose of this study was to reveal the bone scan abnormalities in children with leukemia and to show the value of whole-body scanning in early and delayed phases. METHODS: From a database of all patients with a diagnosis of leukemia from January 1990 to April 2000, 12 children (9 male, 3 female; mean age, 8.0 y; age range, 4.7--13.2 y) were identified for whom the diagnosis of leukemia was suggested on the basis of bone scans obtained as part of the initial work-up for unexplained skeletal pain. Early and delayed whole-body bone scans and radiographs were reviewed retrospectively. Areas of abnormal uptake on early and delayed phases were categorized into locations: metaphysis--diaphysis--epiphysis (MDE), pelvis, ribs, spine, and others. MDE lesions included abnormalities in the metaphysis extending into the diaphysis for some length: metaphysis/diaphysis, metaphysis only, diaphysis only, epiphysis only, and the entire bone. Pelvic and spine lesions were further characterized as focal or diffuse. RESULTS: Ten patients had lesions in 2 or more locations on both phases. Two patients had multiple lesions on the early scans but only rib lesions on the delayed scans. Lesions correlated with symptomatic sites in 8 patients on the delayed scans and in 11 patients on the early scans. The most common sites of abnormalities on the delayed scans were metaphyseal/diaphyseal, pelvis (focal), and ribs. The most common locations of lesions on the early scans were metaphyseal/diaphyseal, pelvis (diffuse or focal), and spine. More metaphyseal/diaphyseal lesions were seen on the early scans than on the delayed scans. Diffuse involvement of the pelvis and spine was seen only on the early phase. However, rib lesions were seen more frequently on the delayed scan. CONCLUSION: Early whole-body imaging in conjunction with delayed whole-body scanning may enhance the diagnostic accuracy of bone scanning in the evaluation of children with skeletal pain of obscure etiology, such as that associated with leukemia.     

Combination Radiofrequency Ablation and Percutaneous Osteoplasty for Palliative Treatment of Painful Extraspinal Bone Metastasis: A Single-Center Experience

PurposeTo evaluate combined radiofrequency (RF) ablation and percutaneous osteoplasty (POP) in patients with painful extraspinal bone metastases.Materials and MethodsIn a retrospective study, 38 patients with 54 extraspinal bone metastases (ilium, n = 24; acetabulum, n = 21; femur, n = 7; ischium, n = 1; tibia, n = 1) were treated with RF ablation and POP. All patients had pain refractory to analgesic medication with intensity > 3 on a visual analog scale (VAS). Changes in quality of life were evaluated based on pain relief (VAS score), function on a Karnofsky performance scale, and analgesic dose before and immediately after the procedure and during follow-up. VAS score was the primary outcome, and the others were secondary outcomes.ResultsTechnical success was achieved in 37 patients (97.4%). Mean VAS score declined significantly from 7.1 ± 1.5 before treatment to 2.2 ± 2.0 at 24 hours after treatment (P < .05), 1.6 ± 1.8 at 3 months after treatment (P < .05), and 1.3 ± 1.8 at 6 months after treatment (P < .05). Pain relief immediately after the procedure was reported by 35 patients (92.1%); pain regressed completely in 7 (18.4%) patients. After 6 months, narcotic analgesia had been suspended in 32 of 33 patients (97.0%). Pain was controlled by nonsteroidal antiinflammatory drugs in 8 patients (24.2%), and no analgesia was necessary in 24 patients (72.7%). Mean Karnofsky performance scale score after treatment was higher than before treatment (P < .05). The major complication rate was 2.6% (1 of 38 patients), with one case of vasovagal shock. The minor complication rate was 23.7% (9 of 38 patients).ConclusionsRF ablation with POP is effective for pain relief and functional recovery in patients with painful extraspinal bone metastases and can significantly improve quality of life.     

Skeletal metastases from hepatoma: frequency, distribution, and radiographic features

Over the past 6 years, the authors evaluated 300 patients with hepatoma as part of phase 1 and 2 treatment protocol trials. Analysis of the available clinical data and radiographic studies revealed 22 patients (7.3%) with skeletal metastases demonstrated by radiography, computed tomography (CT), and/or nuclear scintigraphy. The plain film appearance of skeletal metastases from hepatoma was osteolytic in all cases. CT scanning best demonstrated the expansile, destructive nature of these metastases, which were often associated with large, bulky soft-tissue masses. Skeletal metastases from hepatomas demonstrated increased radiotracer uptake on standard bone scans and were gallium avid, similar to the hepatoma itself. In addition, they could be targeted therapeutically with I-131 antiferritin immunoglobulin. The most frequent sites of skeletal metastases were the ribs, spine, femur, pelvis, and humerus. An initial symptom in ten patients was skeletal pain corresponding to the osseous metastases. In five patients, pathologic fractures of the proximal femur or humerus developed and required total hip replacement or open-reduction internal fixation. Patients with long-standing cirrhosis or known hepatocellular carcinoma who also have skeletal symptoms should be evaluated for possible osseous metastases.     

Use of Cryoablation and Osteoplasty Reinforced with Kirschner Wires in the Treatment of Femoral Metastasis

Purpose

We report the case of a 43-year-old man with metastatic breast carcinoma to the proximal right femur resulting in severe painful pathological fracture. The patient experienced severe pain despite large doses of analgesia, resulting in impaired functionality and quality of life. The patient had significant comorbidities, making him a high surgical risk.

Materials and Methods

The patient was treated with cryoablation and osteoplasty, followed by a novel technique consisting of osteoplasty reinforced with bone marrow Kirschner wires (K-wires) which will be described in details in this report.

Results

The patient reported significant pain relief after the procedure, and gained right lower extremity functionality, as compared to total immobility before the procedure.

Conclusion

Our technique offers an alternative feasible treatment for patients at high surgical risk with pathological fractures in weight-bearing bones, in which osteoplasty alone has a high risk of cement leakage, inadequate fracture reduction, and early refracture. To our knowledge, our technique has not been previously described.     

Percutaneous treatment of bone tumors by radiofrequency thermal ablation

We present our experience of the treatment of bone tumors with radiofrequency thermal ablation (RFTA). Over the past 4 years, we have treated 26 cases (22 benign and 4 malignant) using CT-guided RFTA. RFTA was the sole treatment in 19 cases and was combined with percutaneous cementation during the same session in the remaining seven cases.Our approach to the tumors was simplified, using a single point of entrance for both RFTA and percutaneous osteoplasty.In the benign cases, clinical success was defined as resolution of pain within 1 month of the procedure and no recurrence during the follow-up period. It was achieved in 19 out of the 21 patients in which curative treatment was attempted. The two non-resolved cases were a patient with osteoid osteoma who developed a symptomatic bone infarct after a symptom-free period of 2 months and another with femoral diaphysis osteoblastoma who suffered a pathological fracture after 8 months without symptoms.The procedure was considered clinically successful in the five cases (4 malign and 1 benign) in which palliative treatment was attempted, because there was a mean (±SD) reduction in visual analogue scale (VAS) pain score from 9.0 ± 0.4 before the procedure to <4 during the follow-up period.