Percutaneus osteoplasty in the treatment of extraspinal painful multiple myeloma lesions

Interventional Radiology in the Management of Metastases and Bone Tumors

Interventional Radiology (IR) has experienced an exponential growth in recent years. Technological advances of the last decades have made it possible to use new treatments on a larger scale, with good results in terms of safety and effectiveness. In musculoskeletal field, painful bone metastases are the most common target of IR palliative treatments; however, in selected cases of bone metastases, IR may play a curative role, also in combination with other techniques (surgery, radiation and oncology therapies, etc.). Primary malignant bone tumors are extremely rare compared with secondary bone lesions: osteosarcoma, Ewing sarcoma, and chondrosarcoma are the most common; however, the role of interventional radiology in this fiels is marginal. In this review, the main techniques used in interventional radiology were examined, and advantages and limitations illustrated. Techniques of ablation (Radiofrequency, Microwaves, Cryoablation as also magnetic resonance imaging-guided high-intensity focused ultrasound), embolization, and Cementoplasty will be described. The techniques of ablation work by destruction of pathological tissue by thermal energy (by an increase of temperature up to 90 °C with the exception of the Cryoablation that works by freezing the tissue up to -40 °C). Embolization creates an ischemic necrosis by the occlusion of the arterial vessels that feed the tumor. Finally, cementoplasty has the aim of strengthening bone segment weakened by the growth of pathological tissue through the injection of cement. The results of the treatments performed so far were also assessed and presented focused the attention on the management of bone metastasis.

Percutaneous extra-spinal cementoplasty in patients with cancer: A systematic review of procedural details and clinical outcomes

PURPOSE

To perform a systematic review of technical details and clinical outcomes of percutaneous extra-spinal cementoplasty in patients with malignant lesions.

MATERIALS AND METHODS

PUBMED, MEDLINE, MEDLINE in-process, EMBASE and the Cochrane databases were searched between January 1990 and February 2019 using the keywords «percutaneous cementoplasty», «percutaneous osteoplasty» and «extra-spinal cementoplasty». Inclusion criteria were: retrospective/prospective cohort with more than 4 patients, published in English language, reporting the use of percutaneous injection of cement inside an extra-spinal bone malignant tumour using a dedicated bone trocar, as a stand-alone procedure or in combination with another percutaneous intervention, in order to provide pain palliation and/or bone consolidation.

RESULTS

Thirty articles involving 652 patients with a total of 761 lesions were reviewed. Mean size of lesion was 45mm (range of mean size among publications: 29-73mm); 489 lesions were located in the pelvis, 262 in the long bones of the limbs and 10 in other locations. Cementoplasty was reported as a stand-alone procedure for 60.1% of lesions, and combined with thermal ablation for 26.2% of lesions, implant devices for 12.3% of lesions, and balloon kyphoplasty for 1.4% of lesions. The mean volume of injected cement was 8.8mL (range of mean volume among publications: 2.7-32.2mL). The preoperative visual analogic scores ranged between 3.2 and 9.5. Postoperative scores at last available follow-up ranged from 0.4 to 5.6. Thirteen papers reported a reduction of the visual analogic scores of 5 points or more. Nerve injury was the most frequent symptomatic leakage (0.6%).

CONCLUSION

Percutaneous extra-spinal cementopasty is predominantly performed as a stand-alone procedure and for lesions in the bony pelvis. It appears to be an effective tool to manage pain associated with malignant bone tumours. There is however a lack of standardization of the technique among the different publications.

Evaluating Treatment Strategies for Spinal Lesions in Multiple Myeloma: A Review of the Literature

Background

Vertebral disease is a major cause of morbidity in 70% of patients diagnosed with multiple myeloma (MM). Associated osteolytic lesions and vertebral fractures are well documented in causing debilitating pain, functional restrictions, spinal deformity, and cord compression. Currently, treatment modalities for refractory MM spinal pain include systemic therapy, radiotherapy, cementoplasty (vertebroplasty/kyphoplasty), and radio frequency ablation. Our objectives were to report on the efficacy of existing treatments for MM patients with refractory spinal pain, to determine if a standardized treatment algorithm has been described, and to set the foundation upon which future prospective studies can be designed.

Methods

A systematic search of the PubMed database was performed for studies relevant to the treatment of vertebral disease in MM patients. A multitude of search terms in various combinations were used, including but not limited to: "vertebroplasty," "kyphoplasty," "radiation," "multiple myeloma," "radiotherapy," and "radiosurgery."

Results

Our preliminary search resulted in 219 articles, which subsequently resulted in 19 papers following abstract, title, full-text, and bibliography review. These papers were then grouped by treatment modality: radiotherapy, cementoplasty, or combination therapy. Significant pain and functional score improvement across all treatment modalities was found in the majority of the literature. While complications of treatment occurred, few were noted to be clinically significant.

Conclusions

Treatment options-radiotherapy and/or cementoplasty-for vertebral lesions and pathologic fractures in MM patients demonstrate significant radiographic and clinical improvement. However, there is no consensus in the literature as to the optimal treatment modality as a result of a limited number of studies reporting head-to-head comparisons. One study did find significantly improved pain and functional scores with preserved vertebral height in favor of kyphoplasty over radiotherapy. When not contraindicated, we advocate for some form of cementoplasty. Further prospective studies are required before implementation of a standardized treatment protocol.

Level of Evidence

5.

Percutaneous osteoplasty for extraspinal metastases

As an extension of percutaneous vertebroplasty (PVP), percutaneous osteoplasty (POP) refers broadly to percutaneous bone cement injected into various parts of the body and narrowly to cement injected into extraspinal bone lesions. POP mainly includes such surgeries as percutaneous sacroplasty, percutaneous acetabuloplasty, percutaneous femoral osteoplasty, and percutaneous iliac osteoplasty (Figure 1). Currently, POP is a positive and an effective treatment for extraspinal bone lesions in that it can rapidly relieve pain, effectively prevent pathological fractures, and partially inactivate tumors, with few complications. The aim of this review is to detail the POP techniques and report their safety and efficacy in the treatment of extraspinal metastases.

Vertebral augmentation in patients with multiple myeloma: a pooled analysis of published case series

BACKGROUND AND PURPOSE

Studies examining the efficacy of vertebroplasty and kyphoplasty in patients with vertebral fractures from multiple myeloma are limited. We sought to perform a systematic review of published case studies examining changes in pain, disability, and analgesic drug use in patients with multiple myeloma who have undergone vertebral augmentation.

MATERIALS AND METHODS

We performed a pooled analysis of published case series of vertebral augmentation in patients with multiple myeloma. Twenty-three studies (9 kyphoplasty, 12 vertebroplasty, and 2 of both) with data on 923 patients were identified from a PubMed search. Quantitative outcome data included the Visual Analog Scale, the Brief Pain Inventory, the Short Form 36 Health Survey, and the Owestry Disability Index. Time periods were consolidated into 3: postoperatively ≤1 week, 1 week to 1 year, and ≥1 year. Change in analgesic use was also studied. Data were compared by using nonparametric tests and matched t tests for temporally linked data.

RESULTS

Patients achieved a decrease in pain across all consolidated time periods. Pain, as measured on a 10-point scale, decreased by 4.8 points up to 1 week, 4.6 points up to 1 year, and 4.4 points after a year (P < .001). Decrease in pain was apparent early after treatment and was sustained with time. Kyphoplasty and vertebroplasty were equally effective in reducing pain scores because differences between procedures for each time period were insignificant (P < .9 for <1 week, P < 1.0 for ≤1 year, and P < .9 for >1 year.

CONCLUSIONS

Our analysis demonstrates that vertebral augmentation is effective in patients with multiple myeloma.