Arterial embolization of a secondary aneurysmatic bone cyst of the thoracic spine prior to surgical excision in a 15-year-old girl

Interest of preoperative embolization of aneurysmal bone cyst (ABC): A case report

Aneurysmal bone cyst (ABC) is a rare lesion that primarily affects young adults and children. The optimal treatment approach for ABC remains controversial and varies depending on the preferences of the medical team. While some advocate for surgery as the treatment of choice, others recommend a less invasive first-line option such as selective embolization. In this case report, we present the case of a 41-year-old female patient with an ABC in the right iliac bone who underwent surgical treatment following preoperative selective embolization. Additionally, we provide a literature review on the topic.

Primary Benign Neoplasms of the Spine

Benign tumours comprise the majority of primary vertebral tumours, and these are often found incidentally on imaging. Nonetheless, accurate diagnosis of these benign lesions is crucial, in order to avoid misdiagnosis as more ominous malignant lesions or infection. Furthermore, some of these tumours, despite their benign nature, can have localised effects on the spine including neural compromise, or can be locally aggressive, thus necessitating active management. Haemangiomas and osteomas (enostosis) are the commonest benign tumours encountered. Others include osteoid osteoma, osteoblastoma, fibrous dysplasia, osteochondroma, chondroblastoma, haemangioma, simple bone cysts, aneurysmal bone cysts, giant cell tumours, eosinophilic granuloma and notochordal rests. The majority of lesions are asymptomatic; however, locally aggressive lesions (such as aneurysmal bone cysts or giant cell tumours) can present with nonspecific symptoms, such as back pain, neurological deficits and spinal instability, which may be indistinguishable from more commonly encountered mechanical back pain or malignant lesions including metastases. Hence, imaging, including radiography, computed tomography (CT) and magnetic resonance imaging (MRI), plays a critical role in diagnosis. Generally, most incidental or asymptomatic regions are conservatively managed or may not require any follow-up, while symptomatic or locally aggressive lesions warrant active interventions, which include surgical resection or percutaneous treatment techniques. Due to advances in interventional radiology techniques in recent years, percutaneous minimally invasive techniques such as radiofrequency ablation, sclerotherapy and cryoablation have played an increasing role in the management of these tumours with favourable outcomes. The different types of primary benign vertebral tumours will be discussed in this article with an emphasis on pertinent imaging features.

Surgical Excision of Thoracic Osteoblastoma with Secondary Aneurysmal Bone Cyst from a 12-Year-Old Child

INTRODUCTION

Osteoblastoma is a primary benign tumour which commonly presents in the younger population during the second decade of life. However, more aggressive osteoblastomas may present with features of aneurysmal bone cyst, and these can occur at uncommon locations.

CASE PRESENTATION

We report the case of a 12-year-old child having an osteoblastoma on the left side of T11 with secondary aneurysmal bone cyst presenting with neurological deficits and myelopathic symptoms. Surgical debulking of the lesion with decompression laminectomy and posterior instrumentation of the spine was performed. The child is currently recovering well with improvement of neurological deficits.

DISCUSSION/CONCLUSION

Osteoblastoma with aneurysmal bone cyst of the thoracic spine is a rare condition with few reports in the literature, and surgical intervention with complete excision has been demonstrated here with recovery of neurological function.

Preoperative Embolization and Complete Tumoral Resection of a Cervical Aggressive Epithelioid Osteoblastoma

BACKGROUND

Epithelioid "aggressive" osteoblastoma (EOB) is a rare and more aggressive subtype of osteoblastoma (OB) with a higher recurrence rate, greater risk of malignant transformation, larger size, and greater intraoperative blood loss. The present case report illustrates that preoperative angioembolization of an EOB can be safely performed with low intraoperative blood loss.

CASE DESCRIPTION

A 21-year-old male patient presented to our institution with a 4-month history of neck discomfort, radicular pain in the proximal right arm, and mild weakness of the right biceps and triceps muscles. Imaging was suggestive of EOB, and computed tomography-guided biopsy confirmed the diagnosis. The patient underwent same-day preoperative angioembolization of the major feeding vessels and subsequent complete tumor resection. During the procedure, he experienced minimal blood loss and did not require blood transfusion.

CONCLUSIONS

EOB is a highly vascular primary bony lesion. To minimize intraoperative blood loss, preoperative angioembolization should be considered in the treatment of cervical spine EOB.

Successful treatment of aggressive aneurysmal bone cyst of the pelvis with serial embolization

Intralesional surgery is most commonly used for aneurysmal bone cysts. Rarely is en bloc resection used for active, aggressive, recurrent lesions and those located in expendable bones. However, persistence or recurrence of aneurysmal bone cysts is common. The clinical behavior of aneurysmal bone cysts is more aggressive in younger patients. Selective embolization is used as the primary treatment for aneurysmal bone cysts in surgically difficult anatomical locations and as an adjuvant to surgical treatment to reduce intraoperative blood loss and facilitate curettage.This article describes a 3-year-old boy with an aggressive aneurysmal bone cyst of the pelvis involving the right ischiopubic rami that achieved curative treatment with 3 embolizations with N-2-butyl-cyanoacrylate. Biopsy was diagnostic; however, the clinical course was misleading. Twenty days after the first embolization, despite complete occlusion of the feeding vessels, the patient experienced severe pain, increased size of the lesion, and lateral subluxation of the right hip. Based on the imaging and histological diagnosis, intralesional hemorrhage was assumed, and repeat embolization was performed. After the second embolization, the patient experienced perineal skin necrosis from normal vessel embolization; it was treated with wound dressing changes and healed uneventfully. A third embolization was performed because of a persistent lesion. Six years after treatment, the patient was symptom free, and imaging showed complete ossification of the cyst.Selective catheterization and occlusion of the feeding arteries with the appropriate embolic agent provide tumor devascularization, size reduction, pain relief, and induction of new bone formation. Multiple procedures are often necessary, and complications may occur.

Advance in the treatment of aneurysmal bone cyst of the sacrum

OBJECTIVE

The objective of this study was the review of 11 patients with two different treatment methods used historically for aneurysmal bone cyst in the sacrum. The outcome of both procedures is reported. In addition, the treatment technique of CT-guided percutaneous injections of demineralized bone matrix mixed with bone marrow concentrate is described.

MATERIALS AND METHODS

From 1997 to 2008, 11 patients with sacral aneurysmal bone cyst were treated at the Rizzoli Institute, Bologna, Italy. The first seven patients had surgical curettage without bone grafting, chemical adjuvants, or arterial embolization. The last four patients had arterial embolization. The last patient did not respond to arterial embolization and was treated by CT-guided injection of demineralized bone matrix mixed with bone marrow concentrate.

RESULTS

Curettage was successful in five out of seven patients. Two patients suffered complications, and two cases had recurrence. Arterial embolization was successful in three of four patients. The patient treated with injection had a good clinical and radiographic result.

CONCLUSION

Both surgical and arterial embolization are effective for aneurysmal bone cyst in the sacrum. However, these treatments may lead to complications and recurrence. The use of CT-guided injections of demineralized bone matrix mixed with bone marrow concentrate may be a safe and effective alternative for treatment of these destructive and problematic lesions.

Aneurysmal bone cyst of the acromion treated by selective arterial embolization

Aneurysmal bone cysts are rarely located in the scapula and are especially rare in the acromion. We present an 8-year-old boy with a large aneurysmal bone cyst of the acromion that achieved curative treatment with one selective transcatheter arterial embolization. Five years after the procedure, healing of the lesion and remodeling of the acromion was observed without any evidence of recurrence.

Selective arterial embolisation for bone tumours: experience of 454 cases

PURPOSE

The authors present the experience of a single institution with selective arterial embolisation for primary and metastatic bone tumours.

MATERIALS AND METHODS

A total of 365 patients were treated with 454 embolisation procedures from December 2002 to April 2010. Embolisation was the primary treatment for benign bone tumours, adjuvant treatment to surgery for benign and malignant bone tumours and palliative treatment for bone sarcomas and metastases. Indications for repeat embolisation included pain or imaging evidence of progressive disease: 105 patients had repeat embolisation at the same location at an interval of 1-3 months; 260 patients had one embolisation, 78 had two and 29 had three or more. In all patients, N-2-butyl cyanoacrylate (NBCA) in 33% lipiodol was the embolic agent used.

RESULTS

A total of 419 of the 454 embolisations (93%) were technically successful. In 35 cases, embolisation was not feasible because of poor lesion vascularisation (21 patients with bone metastases and two with aneurysmal bone cysts), origin of the Adamkiewicz artery in the embolisation field (four patients with bone metastases and one with aneurysmal bone cyst), atheromatosis and arteriosclerosis (five patients with bone metastases) and anatomical and technical problems such as small-calibre vessels, many branches and acute vessel angles (two patients with bone metastases). A clinical response was achieved in 406 of the 419 procedures (97%), and no response in 13 procedures in patients with pelvis and sacrum tumours. Complications included postembolisation syndrome in 81 patients (22%), transient paraesthesias in 41 (11%), skin breakdown and subcutaneous necrosis at the shoulder and pelvis in five (1.4%) and paresis of the sciatic nerve in one (0.3%).

CONCLUSIONS

We recommend embolisation as primary or palliative treatment or an adjunct to surgery for tumours of variable histology. Strict adherence to the principles of transcatheter embolisation is important. Arteries feeding the tumour and collaterals must be evaluated carefully and catheterised superselectively to protect the normal tissues. NBCA is considered the most appropriate embolic agent for small-vessel occlusion without major complications.

Selective arterial embolization of 36 aneurysmal bone cysts of the skeleton with N-2-butyl cyanoacrylate

BACKGROUND

Aneurysmal bone cyst (ABC) is a lytic benign bone lesion representing about 1% of all primary bone tumors. The lesion causes pain and swelling, which are generally present for less than 3 months.

METHODS

From April 2003 to April 2008 36 patients affected by aneurysmal bone cysts were treated by selective arterial embolization with N-2-butyl cyanoacrylate. The study population comprised 20 male and 16 female patients with an age range of 3.3-60.8 years. Nine lesions were localized in the appendicular skeleton (1 in the upper and 8 in the lower limb), 4 in the thoracic cage (1 rib lesion and 3 scapular lesions), 17 in the pelvis and 6 in the spine (1 thoracic and 5 sacral localizations).

RESULTS

A total of 55 embolizations were performed: in 22 cases (61%) only one embolization was needed, whilst two embolizations were necessary in 9 cases (25%) and 3 in the remaining 5 patients (14%). The treatment was effective in 32 patients (94% ): follow-up was 0.9-5 years. In one patient, previously surgically treated, only the cyanoacrylate embolization turned out to be useful for healing the lesion. Another 7 patients underwent surgery during the study period. In the 55 procedures we performed we had 3 complications (5%): 2 cases of skin necrosis and 1 of transient paresis.

CONCLUSIONS

Arterial embolization with cyanoacrylate may be the treatment of choice for aneurysmal bone cysts. Embolization is a less invasive, lower cost, simpler procedure than surgery and is easily repeatable.

Treatment of osteoblastoma at C7: a multidisciplinary approach. A case report and review of the literature

Osteoblastoma is a rare benign bone tumor that presents with back pain and occurs in the spine approximately 40% of the time. The time from onset of symptoms to diagnosis is typically several months because it is a rare entity and radiographic studies are often negative early in the course of the disease. These highly vascular and locally aggressive tumors require complete and precise resection. The patient presented is a 15-year-old boy with a 14-month history of right-sided neck and shoulder pain. Computerized tomography and magnetic resonance imaging demonstrated a lesion in the posterior elements of C7 which extended through the pedicle and into the body. Preoperative angiography confirmed a hypervascular lesion which was successfully embolized. He subsequently underwent piecemeal tumor resection and instrumented fusion. Immediate postoperative imaging demonstrated complete resection. At 18 months follow up the patient has maintained resolution of preoperative symptoms and demonstrates evidence of solid fusion on CT. This multidisciplinary approach markedly decreased blood loss and improved visualization to help achieve complete surgical resection and resolution of clinical symptoms.

[Vertebral aneurysmatic bone cyst: study of three cases]

Aneurysmatic bone cyst is a hypervascularized, benign lesion locally destructive by its progressive growth with greater incidence in the second decade of life. It lodges preferably in the long bones and vertebrae. The clinical picture varies from pain to local edema and even neurological symptoms when in vertebral location. Three cases of vertebral aneurysmatic bone cyst occurring in childhood and all with neurologic deficit symptoms are described. Computerized tomography and/or magnetic resonance imaging confirmed the diagnosis. Patients underwent surgery to remove the tumor. In one of the cases, pre-operative selective arterial embolization of the lesion was performed. The three patients progressed satisfactorily with neurological improvement, which demonstrated the efficiency of the microsurgical technique for the resection of the spinal tumor. The evolution of the cases and the current treatment are discussed.