Cementoplasty for painful bone metastases: a series of 42 cases

Evaluation of Intramedullary Methods with Polymethylmethacrylate for Fixation of Bone Lesions of the Extremities

Objective  To evaluate the better potential and functional results in pain control in the treatment of pathological fractures and prophylactic fixation with an intramedullary nail associated with polymethylmethacrylate, compared with the utilization of an intramedullary nail in long bone tumor lesions.

Methods  From January 2012 to September 2017, 38 patients with 42 pathological lesions (fractures or impending fractures according to the Mirels criteria) were treated surgically. Sixteen patients allocated to the control group underwent a locked intramedullary nail fixation, and 22 patients with pathological lesions were allocated to treatment with an intramedullary nail associated with polymethylmethacrylate. Postoperatively, the patients were submitted to the Musculoskeletal Tumor Society (MSTS) rating scale, radiographic assessment, and to the assessment of events and complications related to the treatment.

Results  The evaluation using the MSTS questionnaire showed better functional results in the group associated with polymethylmethacrylate, in comparison with the control group, which obtained an average score of 16.375 out of a maximum of 30 points (54.6%). The group studied with association with polymethylmethacrylate obtained a mean of 22.36 points (74.5%). The procedure proved to be safe, with similar complication and severity rates, and with no statistical difference in comparison with the standard treatment.

Conclusion  Stabilization of tumor lesions with an internal fixation associated with the polymethylmethacrylate demonstrated early rehabilitation and improved the quality of life, allowing rapid functional recovery. The use of polymethylmethacrylate has advantages such as reduced bleeding, tumor necrosis and higher mechanical stability.

Computed Tomography‒Guided Microwave Ablation Combined with Osteoplasty for the Treatment of Bone Metastases: A Multicenter Clinical Study

PURPOSE

To evaluate the efficacy and safety of combined microwave ablation (MWA) and osteoplasty as a palliative therapy for painful bone metastases.

MATERIALS AND METHODS

As an extension of a previous limited single-center study, a retrospective review was conducted for 147 patients (77 male, 70 female) with painful bone metastases who underwent MWA combined with osteoplasty. In total, 102 (69.4%), 41 (27.9%), and 4 (2.7%) patients had spinal metastases, extraspinal metastases, and both, respectively. Treatment efficacy was determined by comparing visual analog scale (VAS) scores, daily morphine equivalent opioid consumption, and Oswestry disability index (ODI) scores before treatment and during the follow-up period (mean follow-up, 9.8 months; range 3-16).

RESULTS

The mean VAS score significantly declined from 6.4 ± 2.3 before treatment to 3.2 ± 2.1, 1.9 ± 1.6, 1.8 ± 1.6, 1.8 ± 1.6, and 1.9 ± 1.6 at 24 hours, 1 week, 4 weeks, 12 weeks, and 24 weeks after treatment, respectively (P < .01). Furthermore, the mean daily morphine equivalent opioid consumption was significantly reduced from 81.5 ± 32.8 mg before treatment to 40.0 ± 20.6, 32.4 ± 10.2, 26.4 ± 10.0, 21.5 ± 8.3, and 19.3 ± 7.4 mg. The mean ODI score also declined after treatment (P < .0001). Major complications occurred in 4 of 147 patients, with 1 pathologic fracture, 1 nerve injury, and 2 mild skin infections. Minor cement leakages were observed at 69 sites (32.8%).

CONCLUSIONS

MWA combined with osteoplasty is an effective and safe treatment for painful bone metastases.

Cementoplasty of pelvic bone metastases: systematic assessment of lesion filling and other factors that could affect the clinical outcomes

OBJECTIVES

To evaluate lesion filling and other factors that could affect the clinical outcomes of cementoplasty for pelvic bone metastases.

METHODS

We retrospectively reviewed the files of 40 patients treated for 44 pelvic bone metastases, collected the parameters related to patients (pain relief evaluated on a visual analog scale, subsequent fractures, and need for surgery), lesions (size, cortical breach score, fracture, soft-tissue extension), and cementoplasty procedures (number of needles, volume of cement, percentage of lesion filling, cement leaks, residual acetabular roof defect), and performed a statistical analysis.

RESULTS

The lesions were on average 43.2 mm in diameter and the mean cortical breach score was 2.5 out of 6, with a pathological fracture in 14 lesions. The number of needles inserted was one in 32 out of 44, two in 10 out of 44, and three in 2 out of 44. On average, the volume of cement injected per lesion was 10.3 ml and the filling was 54.8%. Mild or moderate asymptomatic cement leakage occurred in 20 lesions (45.5%). The mean pain score was 84.2 mm before the procedure (with no correlation with lesion size, cortical breach score or fracture) and 45.6 mm at follow-up. The pain relief of 38.6 mm was statistically significant (p < 0.001) and did not correlate with the filling percentage. There were no fractures of the treated lesions at a mean follow-up of 355 days.

CONCLUSIONS

Cementoplasty of pelvic bone metastases appears effective for providing pain relief and may prevent subsequent fractures. We were unable to demonstrate a correlation between the lesion filling and the degree of pain relief.

Vertebroplasty or kyphoplasty as palliative treatment for cancer-related vertebral compression fractures: a systematic review

BACKGROUND CONTEXT

Percutaneous vertebroplasty (PVP) and kyphoplasty (KP) are minimally invasive treatment options for vertebral compression fractures (VCFs) due to malignancy.

PURPOSE

To perform a systematic review evaluating the effectiveness and safety of vertebral augmentation for malignant VCFs.

STUDY DESIGN

Systematic review.

STUDY SAMPLE

Studies on PVP or KP for VCFs in patients with malignant spinal lesions.

OUTCOME MEASURES

Visual Analog Scale (VAS) for pain, Oswestry Disability Index (ODI), Karnofsky Performance Score (KPS), and complications were extracted from eligible studies.

METHODS

Using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, studies published between January 1, 2000 and January 3, 2018 were identified by combining the results of a report by Health Quality Ontario with an updated literature search.

RESULTS

The review identified two randomized controlled trials, 16 prospective studies, 44 retrospective studies, and 25 case series for a patient sample size of 3,426. At the earliest follow-up, pain improved from 7.48 to 3.00 with PVP, and from 7.05 to 2.96 with KP. ODI improved from 74.68 to 17.73 with PVP, and from 66.02 to 34.73 with KP. KPS improved from 66.99 to 80.28. Cement leakage was seen in 37.9% and 13.6% of patients treated with PVP and KP, respectively. Symptomatic complications (N = 43) were rare.

CONCLUSIONS

This review showed clinically relevant improvements in pain, ODI, and KPS in patients with VCFs due to malignancy treated with either PVP or KP. Cement leakage is common, but rarely symptomatic. Percutaneous vertebroplasty and KP are safe and effective palliative procedures for painful VCFs in patients with malignant spinal lesions.

A review and update of vertebral fractures due to metastatic tumors of various sites to the spine: Percutaneous vertebroplasty

Background

Vertebral fractures (VFs) are the most usual convolution of metastatic tumors and the vertebral column is the third most ordinary site for painful bone metastases and remains a chief factor of morbidity in cancer patients.

Methods

In this paper, we investigated the previous literature on the status of clinical and prospects for the use of percutaneous vertebroplasty (PVP) with polymethylmethacrylate as a remedial alternative for the therapy of refractory pain resulting from malignant vertebral compression and pathologic fractures associated with metastatic tumors of various sites in numerous studies. The scientific document for this remedy, containing safety, immediate and long-term efficacy, and outcome measures, and also the risks of complications, was analyzed in detail.

Results

PVP is a safe, feasible, reliable, effective, and useful procedure, a minimally invasive treatment, and a significant tool for reduction of pain and the relief of pain symptoms.

Conclusions

This method can be employed as a further or narcotic remedy in elected patients. The techniques of PVP present a novel alternative therapy for diverse metastases with potentially large application.

Percutaneous Palliative Surgery for Femoral Neck Metastasis Using Hollow Perforated Screw Fixation and Bone Cement

Background:

We introduced a new surgical method of percutaneous hollow perforated screw (HPS) fixation with concomitant bone-cement injection for the treatment of femoral neck metastasis and evaluated its efficacy for the palliative treatment of patients with advanced cancer.

Methods:

The study included 87 patients (39 men and 48 women; mean age [and standard deviation], 64.2 ± 10.2 years; mean body mass index, 24.3 ± 3.2 kg/m²) who underwent percutaneous HPS fixation and cementoplasty (mean cement amount, 19.8 ± 8.3 mL) for the treatment of unilateral or bilateral femoral neck metastasis (total, 95 sites). Anesthesia type, operative time, operative blood loss, pain score changes (according to a visual analog scale [VAS]), walking status, and complications were assessed. The mean duration of follow-up was 10.1 ± 10.8 months (range, 2 to 43 months).

Results:

The majority of procedures were performed with local (3 patients) or spinal (72 patients) anesthesia (total, 75 patients; 86.2%). The mean operative time was 35.9 minutes, and the mean operative blood loss was 97.0 mL. The VAS score for pain improved significantly, from 6.8 ± 2.8 preoperatively to 2.8 ± 2.3 and 2.9 ± 2.8 at 1 and 6 weeks postoperatively (p < 0.001). At 6 weeks postoperatively, 63 (80.8%) of 78 patients were able to walk (with either normal or limping gait, a cane or crutch, or a walker). The prevalence of major local complications (cement leakage into the hip joint, fixation failure) was 10.5% (10 of 95), but major systemic complications (distant cement embolism) were not found.

Conclusions:

Percutaneous HPS fixation and cementoplasty for the treatment of femoral neck metastasis is a minimally invasive technique that provides effective pain relief and early stabilization. This technique seems to be useful for patients with advanced cancer for whom open surgery would be hazardous.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

CT-guided percutaneous screw fixation plus cementoplasty in the treatment of painful bone metastases with fractures or a high risk of pathological fracture

OBJECTIVE

To evaluate the feasibility and effectiveness of computed tomography (CT)-guided percutaneous screw fixation plus cementoplasty (PSFPC), for either treatment of painful metastatic fractures or prevention of pathological fractures, in patients who are not candidates for surgical stabilization.

MATERIALS AND METHODS

Twenty-seven patients with 34 metastatic bone lesions underwent CT-guided PSFPC. Bone metastases were located in the vertebral column, femur, and pelvis. The primary end point was the evaluation of feasibility and complications of the procedure, in addition to the length of hospital stay. Pain severity was estimated before treatment and 1 and 6 months after the procedure using the visual analog scale (VAS). Functional outcome was assessed by improved patient walking ability.

RESULTS

All sessions were completed and well tolerated. There were no complications related to either incorrect positioning of the screws during bone fixation or leakage of cement. All patients were able to walk within 6 h after the procedure and the average length of hospital stay was 2 days. The mean VAS score decreased from 7.1 (range, 4-9) before treatment to 1.6 (range, 0-6), 1 month after treatment, and to 1.4 (range 0-6) 6 months after treatment. Neither loosening of the screws nor additional bone fractures occurred during a median follow-up of 6 months.

CONCLUSIONS

Our results suggest that PSFPC might be a safe and effective procedure that allows the stabilization of the fracture and the prevention of pathological fractures with significant pain relief and good recovery of walking ability, although further studies are required to confirm this preliminary experience.

Modern Palliative Treatments for Metastatic Bone Disease: Awareness of Advantages, Disadvantages, and Guidance

BACKGROUND

Metastatic disease is the most common malignancy of the bone. Prostate, breast, lung, kidney, and thyroid cancer account for 80% of skeletal metastases. Bone metastases are associated with significant skeletal morbidity including severe bone pain, pathologic fractures, spinal cord or nerve roots compression, and malignant hypercalcemia. These events compromise greatly the quality of life of the patients. The treatment of cancer patients with bone metastases is mostly aimed at palliation.

OBJECTIVE

This article aims to present these palliative treatments for the patients with bone metastases, summarize the clinical applications, and review the techniques and results.

METHODS

It gives an extensive overview of the possibilities of palliation in patients with metastatic cancer to the bone.

RESULTS AND DISCUSSION

Currently, modern treatments are available for the palliative management of patients with metastatic bone disease. These include modern radiation therapy, chemotherapy, embolization, electrochemotherapy, radiofrequency ablation, and high-intensity focused ultrasound. As such it is of interest for all physicians with no experience with these developments to make palliative procedures safer and more reliable.

Colon cancer metastasis to the sternum: palliative treatment with radiofrequency ablation and cement injection

Colon cancer metastasis to bone is extremely rare and has devastating consequences on patients' quality of life. Furthermore, radiofrequency ablation in conjunction with cementoplasty to nonweight bearing, flat bones has not been widely reported as palliative treatment for pain as a result of bone metastasis. Here, we present a case of a 47-year-old man who developed a sternal metastasis from an invasive adenocarcinoma of the colon originally diagnosed several years prior. The pain from the metastasis was originally treated with external beam radiation therapy, but after 6 weeks of continuous pain, it was retreated using radiofrequency ablation in conjunction with cementoplasty.

Closed intramedullary nailing with percutaneous cement augmentation for long bone metastases

Aims

The purpose of the study was to investigate whether closed intramedullary (IM) nailing with percutaneous cement augmentation is better than conventional closed nailing at relieving pain and suppressing tumours in patients with metastases of the femur and humerus.

Patients and Methods

A total of 43 patients (27 men, 16 women, mean age 63.7 years, standard deviation (sd) 12.2; 21 to 84) underwent closed IM nailing with cement augmentation for long bone metastases. A further 27 patients, who underwent conventional closed IM nailing, served as controls. Pain was assessed using a visual analogue scale (VAS) score pre-operatively (pre-operative VAS), one week post-operatively (immediate post-operative VAS), and at six weeks post-operatively (follow-up post-operative VAS). Progression of the tumour was evaluated in subgroups of patients using F-18-fludeoxyglucose (F-18-FDG) positron emission tomography (PET)/computed tomography (CT) and/or bone scintigraphy (BS), at a mean of 8.8 and 7.2 months post-operatively, respectively.

Results

The mean pain scores of patients who underwent closed nailing with cement augmentation were significantly lower than those of the control patients post-operatively (immediate post-operative VAS: 3.8, sd 0.9 versus 6.0, sd 0.9; follow-up post-operative VAS: 3.3, sd 2.5 versus 6.6, sd 2.2; all p < 0.001). The progression of the metastasis was suppressed in 50% (10/20) of patients who underwent closed nailing with augmentation, but in only 8% (1/13) of those in the control group.

Conclusion

Percutaneous cement augmentation of closed IM nailing improves the relief of pain and limits the progression of the tumour in patients with metastases to the long bones. Take home message: Percutaneous cement augmentation while performing closed IM nailing has some advantages for long bone metastases. Cite this article: Bone Joint J 2016;98-B:703–9.

Cementoplasty of bone metastases

Cementoplasty is a palliative treatment for bone metastases. It can be performed alone or in addition to other treatments, such as radiotherapy, radiofrequency ablation or cryotherapy. It is usually performed to reduce pain where the metastases involve the spine and pelvis. It can also be used to stabilise bones in the event of lytic metastases with a risk of fracture. Unlike ablation techniques, it should not be considered a cancer treatment.