A comparison of cyst wall curettage and en bloc excision in the treatment of aneurysmal bone cysts

A New Radiological Scoring System as a Method of Assessing Sclerotherapy Treatment Response for Aneurysmal Bone Cysts: A Retrospective Study

Background  A widely accepted set of imaging criteria or classification has not yet been adopted to evaluate response to treatment by percutaneous sclerotherapy for aneurysmal bone cyst (ABC). In this article, we described and illustrated the Royal Orthopaedic Hospital (ROH) scoring system which is a new, reproducible, and objective tool to evaluate the radiological response. We also reported our institutional experience in the efficacy of computed tomography (CT)-guided sclerotherapy for treating such lesions. Patients and Methods  A retrospective analysis was conducted for 19 patients who underwent CT-guided sclerotherapy with doxycycline and albumin to treat ABC. Follow-up magnetic resonance imaging, at a minimum of 12 months, was assessed according to the four ROH scoring system parameters: cystic component, fluid-fluid level, presence of consolidation, and cortical integrity. The cumulative score was used to grade response as either: excellent, good, equivocal, or poor. Results  Out of 19 patients with a mean age of 17.8 years, 11 cases occurred in the long bones, 5 cases in the pelvis, and 1 in each of the C3 vertebral body, scapula, and talus. The mean parameter of response score for cystic component was 2, fluid-fluid level was 1.3, consolidation was 2, and cortical integrity was 2.1. Four cases showed excellent response, 12 cases showed good response, 2 cases showed equivocal response, and 1 case showed poor response. Interrater reliability was excellent (κ = 0.9). Conclusion  The ROH scoring system provides the radiologist and surgeon with an objective method to score imaging parameters of response independently and achieve a grade based on the cumulative score.

Management of Proximal Femur Aneurysmal Bone Cyst with 10-year Follow-up - A Case Report

Introduction

Aneurysmal bone cyst is a benign, most often non-neoplastic lesion affecting the bone. Malignant transformation is reported in certain cases, although rare. It commonly occurs in young adults with around 75% of the cases occurring in the first two decades and 95% occurring in the first 3 decades. The management depends on the individual case parameters with ABC occurring in a weight-bearing area of a bone warranting an aggressive treatment plan with the consideration of preventing a pathological fracture.

Case Report

A 20-year-old male patient with no other comorbidities presented to us with complaints of atraumatic right hip pain of 9-month duration. On preliminary clinical examination and imaging studies with X-rays, CT scan, and MRI, the patient was diagnosed to have an aneurysmal bone cyst (ABC) of the right proximal femur. The patient was operated with intra-lesional excision with extended curettage and prophylactic fixation with DHS plating and kept on yearly follow-up. 10-year follow-up showed complete resolution of the lesion and implant removal was done after that.

Conclusion

As is clear from this case, the treatment of an aneurysmal bone cyst needs to individualized based on the patient's age, complaints, and tumor behavior in terms of its aggressiveness, size, and its extent. Often, en bloc excision with extensive curettage is required along with bone grafting and prophylactic fixation to support the bone graft and to prevent a pathological fracture and further recurrence. Implant removal if indicated should be done after complete resolution of the lesion, patient willingness, and any other medical indication.

Pathological Fractures in Aneurysmal Bone Cysts: A Systematic Review

Background: Aneurysmal bone cysts (ABCs) are osteolytic, non-malignant, vascular lesions of the bone. Pathological fractures can be a manifestation of the ABCs, which occur in about 8% of ABCs. Different treatments have been described in the literature, but, nowadays, an optimal management of the pathological fractures in patients with ABCs is still a matter of debate and there are no standard guidelines for treatment nor any shared indication about the best surgical intervention. The aim of our study is to review the current literature available on this matter exploring and confronting different surgical treatments for pathological fractures in ABC in order to clarify the surgical approach to these patients. Methods: A systematic review of the literature indexed in PubMed, MEDLINE, and Cochrane Library databases was carried out. The Preferred Reporting Items for Systematically Reviews and Meta-Analyses (PRISMA) were followed. Results: A total of 37 articles were relevant and were finally included in the study. In total, we reached a population of 140 patients. Of the 140 patients included in the review, 124 patients (88.6%) underwent curettage surgery, 15 patients (10.7%) underwent en bloc resection surgery. A total of 47% of patients (70) underwent synthesis surgery with a plate, screw, nail, or external fixator. Adjuvant treatments were used in 8.6% of patients (12). Complications involved 20.7% of the patients (29). Conclusions: In conclusion, the treatment of pathological fractures in aneurysmal bone cysts requires careful patient assessment, considering factors such as age, the presence of open growth plates, the location of the lesion, and the surgeon's expertise.

Management of advanced metacarpal aneurysmal cysts: Surgical technique

The hand is a rare site for aneurysmal bone cysts (ABCs). Depending on their degree of invasiveness, treatment of ABCs ranges from medical therapy to surgical curettage and bone filling. In the most advanced cases, bone resection and reconstruction, with or without adjuvant or neoadjuvant treatment, are indicated. We describe a technique involving segmental bone resection and structural iliac graft reconstruction with carpo-metacarpal plate arthrodesis, for the management of advanced ABC involving the base of the metacarpals. The radio-clinical results of two patients operated on using this technique are presented, at 18 and 36 months. At the last follow-up, the results showed a QDASH of 15 and 10, and a PRWE of 9 and 11. Satisfaction was 10/10 in both cases. Grasp strength was 25 kg and 42 kg versus 28 kg and 40 kg on the opposite side. Pinch strength was 6 kg and 11 kg versus 7 kg and 10 kg. Metacarpophalangeal flexion was 80° and 90°. Extension was complete in both cases. Radiographs showed good graft fusion, with no lysis or signs of ABC recurrence at the last follow-up. Segmental bone resection and iliac autograft reconstruction with carpo-metacarpal plate arthrodesis represents a therapeutic option in the management of advanced ABCs of the metacarpal base.

Aneurysmal bone cyst of the mandible: a rare case report and literature review

Introduction and importance

Aneurysmal bone cysts (ABCs) are benign, non-neoplastic cystic lesions composed of multiple blood-filled cavities, which are separated by connective tissue septa and they constitute ~6 and 1.5% of all cases of the skull and jaws lesions, respectively.

Case presentation

Herein, the case of an 80-year-old male with a histologically confirmed diagnosis of ABC involving the body of the left mandible was presented. The patient underwent partial mandiblectomy after confirmation of the diagnosis using orthopantomography, a computed tomography scan, and a tissue biopsy. The patient was free from pain after 1-year of follow-up, and the control orthopantomography showed no evidence of recurrence. This was followed by reconstruction of the healed part of the bone with titanium plates and a piece of bone from the lateral two-thirds of the left femur and thereafter he was cosmetically well.

Clinical discussion

Patients with ABCs present with expansile and radiolucent bone lesions, which may be associated with displacement and loss of teeth due to alveolar bone erosion. Complete excision of the lesions is mandatory for the prevention of recurrence and increased morbidity.

Conclusion

ABCs that involve the jaws are extremely rare and are more likely to pose a diagnostic challenge as they are more likely to be confused clinically with other expansile radiolucent bone lesions such as ameloblastoma, osteoblastoma, and giant cell tumor among many others. Also, those with extensive bone matrix formation may sometimes be confused histologically with other bone forming tumors including osteosarcoma. Recurrence is common but it can be avoided or minimized by complete resection of the lesion.

Treatment of Aneurysmal Bone Cyst with Endoscopic Resection and Bone Allograft with Platelet-Rich Plasma: A Case Report

An aneurysmal bone cyst (ABC) is a rare bone tumor usually observed in long bones. The surgical treatment of this pathology is often related to high recurrence rates, so novel biological techniques can help to enhance tissue regeneration and bone consolidation. We present a case of a patient with ABC of the calcaneus treated with an endoscopic resection followed by grafting with an autologous-based matrix composed of allograft bone chips and autologous platelet-rich plasma (PRP) in semisolid and liquid states. Patient demonstrated excellent defect filling in both magnetic resonance imaging and radiologic exams and returned to pre-injury activity with no recurrence at 2 years follow-up. Endoscopic curettage together with allograft bone and autologous PRP is effective in treating ABC patients and could be a good adjuvant treatment to prevent reinjury and enhance consolidation.

Aneurysmal bone cyst: a review

Aneurysmal bone cyst (ABC) is a benign locally destructive bone neoplasm composed of multi-loculated blood-filled cystic spaces. The most common sites of involvement are the meta-diaphysis of the long bones and posterior elements of the vertebrae. Secondary, ABC-like changes can complicate a variety of other benign and malignant primary bone neoplasms, including giant cell tumor, fibrous dysplasia, and osteosarcoma. About two-third of primary ABCs have a rearrangement of the USP6 gene, which is not present in the ABC-like changes that occur secondary to other primary bone tumors (i.e., secondary ABC). Primary ABC of bone carries a variable but generally high rate of local recurrence. This paper provides an overview of the pathophysiology, clinical presentation, radiographic and pathologic findings, treatment, and prognosis of ABC.

Results in the surgical treatment of aneurysmal bone cysts - A retrospective data analysis

BACKGROUND

Aneurysmal bone cysts (ABC) are benign tumors mostly occurring in children and young adults. Different open and minimal invasive surgical approaches have been proposed for the treatment of ABCs and yet no consensus is defined to date. The aim of this study was to retrospectively review data of a large single center series of ABCs with patients treated by open curettage with or without filling of the cavity or en-bloc resection. Questions/purposes We asked: (1) What was the local recurrence rate of ABC after surgical treatment at our institution? (2) What were positive or negative predictors for local recurrence? (3) Was there a benefit from adjuvant burring, phenolization or filling, respectively? (4) Where there changes in recurrence free survival in different time periods of primary surgery?

METHODS

By retrospective data analysis of the Vienna Bone and Soft Tissue Tumor Registry, 123 patients surgically treated for primary aneurysmal bone cysts were identified. After exclusion of 33 patients (27%) due to a postoperative follow up below one year, 90 patients who were treated for primary ABCs between 1986 and 2009 were evaluated. These included 50 males and 40 females with a mean age of 16 years (SD 10 years; range: 2 to 51 years). The mean follow-up was 99 months. (SD 72 months, range: 13 to 329 months) RESULTS: Curettage was performed in 84 patients, while 45 patients received adjuvant phenolization. Local recurrence occurred in 28 patients after a mean time of 16 months, with a corresponding local recurrence free survival (RFS) of 83% after one year, 77% after 2 years and 66% after 5 years. ABCs located in hands and feet (p=0.044) showed a superior RFS, while younger patients (p=0.001) displayed an inferior RFS. Regarding adjuvant surgical techniques, mechanical cavity burring (p=0.004) and filling with autologous cancellous bone graft (p=0.024) showed protective effects on RFS. Patients treated between 1986 and 1999 (n=47) had a higher RFS than patients treated between 2000 and 2009 (n=43, p=0.011), as surgeons and surgical indications changed over time.

CONCLUSION

Although curettage, burring, phenolization and reconstruction with bone grafts came with a relatively high risk of local recurrence, open surgery is still justified in aggressively growing ABCs of critical localizations.

LEVEL OF EVIDENCE

IV; therapeutic study.

Aneurysmal bone cysts in the spine, causing neurological compromise: safety and clinical efficacy of sclerotherapy utilizing sodium Tetradecyl sulfate foam

OBJECTIVE

To assess the clinical efficacy, technical feasibility, and safety profile of percutaneous sclerotherapy utilizing sodium tetradecyl-sulfate foam (STS) as a first-line treatment strategy for aggressive spinal aneurysmal bone cysts (sABCs) presenting with neurological compromise.

MATERIALS AND METHODS

Between July 2013 and September 2019, eight consecutive patients (5 males; 3 females; mean age 22±17, range 7-52) underwent fluoroscopic/CT-guided intraosseous sclerotherapy for sABCs. Pain and/or neurological compromise was the primary indications. Procedural data, complications, imaging, and clinical results were analyzed.

RESULTS

Technical success was achieved in all cases. Mean procedure time was 25±15 min (range 6-167); 1 to 5 repeat treatment cycles (mean 3.7±1.2) utilizing a mean 2.6mls±1.3 (range 1-6) of agitated 3% STS, with a DLP mean dose of 158±91 mGy*cm (range 62-331) per procedure. One reported a minor complication (pain), but no significant complications. Two patients had persistent neurological deficit due to cord compression despite successful sclerotherapy, requiring surgical resection (and were thereby excluded from the final outcome analysis). The remaining six patients demonstrated a significant reduction in tumor volume (p = 0.028), pain (p = 0.027), and SINS (spinal instability neoplastic score) (p = 0.027) at up to 5 years of follow-up (mean 20 ± 16.7, range 7-51 months).

CONCLUSION

Percutaneous sclerotherapy with STS is a minimally invasive, technically feasible, safe, and effective first-line treatment for primary sABCs causing pain and neurological compromise, alleviating the need for extensive surgery. It is most effective with three or more treatment cycles, in patients with higher SINS, pain scores, or tumor volumes at the initial presentation.

Denosumab in the management of Aneurysmal bone cyst

BACKGROUND

Aneurysmal bone cyst (ABC) is a benign, locally aggressive tumour that arises predominantly in long bones and spine. Following the encouraging results of denosumab use in Giant Cell Tumors (GCT) and the histological similarities between ABC and GCT, the interest on the role of denosumab in the therapeutic arsenal of the most advanced ABC is growing. The purpose of this literature review is to investigate the current state of knowledge about the use of denosumab in ABCs.

METHODS

A literature research was conducted through PUBMED, COCHRANE and GOOGLE SCHOLAR using the keywords "aneurysmal bone cyst" AND "denosumab". Seventeen articles were included.

RESULTS

A total of 43 cases were reported in the literature. There were 23 males, 20 females. The mean age was 15,9±8,1 year. Pain relief and neurological improvement were rapid and sustained. Radiological assessment showed ossification and/or volume reduction in 36/39 patients. Eight patients (18,6%) presented a recurrence after or during denosumab therapy of whom 7 were adults. Adverse events occurred in 11 patients, 5 of them were admitted to the intensive care unit due to hypercalcemia.

CONCLUSION

Denosumab use in non-surgical ABCs has shown a positive impact in pain and neurological symptoms. The oncological outcome remains unclear with a recurrence rate of 18,6% during/after denosumab therapy, mostly in adults. However, regarding the potential clinical benefits, its use might be discussed in the most advanced cases. Further research and clinical trials are mandatory to precise its belonging in the therapeutic arsenal.

Current strategies for the treatment of solitary and aneurysmal bone cysts: A review of the literature

•

SBCs can mostly be treated conservatively.

•

In ABCs a biopsy is compulsory.

•

ABCs can be treated by polidocanol instillations adequately.

This review of the literature aims to compare the etiology, the pathogenesis, the clinical diagnostics and the relevant treatment options of two different types of cystic bone lesions: the solitary bone cyst (SBC) and the aneurysmal bone cyst (ABC). Whereas the clinical symptoms and the radiographic appearance can be similar, the diagnostic pathway and the treatment options are clearly different.

The solitary bone cyst (SBC) represents a tumor-like bone lesion, occurring most frequently in the humerus and femur in children and adolescents. Pain caused by intercurrent pathological fractures is often the first symptom, and up to 87% of the cysts are associated with pathological fractures. In the majority of cases SBCs can be treated conservatively, especially in the upper extremity. However, if a fracture is completely dislocated, joint affecting, unstable or open, surgical treatment is necessary. Pain under weight bearing or regaining the ability to mobilize after fracture timely can necessitate surgical treatment in SBCs affecting the lower extremity. Spontaneous resolution can be seen in rare cases.

The aneurysmal bone cyst (ABC) is a benign, locally aggressive tumor that occurs in childhood and early adulthood. It usually affects the metaphysis of long bones but can also occur in the spine or the pelvis. ABC can be primary but also secondary to other bone pathologies. The diagnosis has to be confirmed by biopsy and histopathological examinations. With cytogenetic studies and the detection of specific translocations of the ubiquitin-specific protease (USP) 6 gene primary ABCs can be differentiated from secondary ABCs and other bone lesions. Among various modalities of treatment i.e. en bloc resection, intralesional curettage with adjuvants, embolization or the systemic application of denosumab, intralesional sclerotherapy using polidocanol is an effective and minimally invasive treatment of primary ABCs.

Primary Aneurysmal Bone Cyst and Its Recent Treatment Options: A Comparative Review of 74 Cases

(1) Background: An aneurysmal bone cyst (ABC) is a benign, locally aggressive tumor. Different treatment modalities are described in the literature i.e., en bloc resection, intralesional curettage and percutaneous sclerotherapy. (2) Methods: This single-center study is a review of 74 patients with primary ABCs who underwent a surgical treatment or polidocanol instillation. Cyst volume measurements using MRI and conventional radiographs are compared. (3) Results: The mean pre-interventional MRI-based cyst volume was 44.07 cm³ and the mean radiographic volume was 27.27 cm³. The recurrence rate after intralesional curettage with the need for further treatment was 38.2% (13/34). The instillation of polidocanol showed a significant reduction of the initial cyst volume (p < 0.001) but a persistent disease occurred in 29/32 cases (90.6%). In 10 of these 29 cases (34.5%) further treatment was necessary. After en bloc resection (eight cases) a local recurrence occurred in two cases (25%), in one case with the need for further treatment. (4) Conclusions: MRI scans are superior to biplanar radiographs in the examination of ABCs. Sequential percutaneous instillations of polidocanol are equally effective in the therapy of primary ABCs compared to intralesional curettage. However, several instillations have to be expected. In a considerable number of cases, a conversion to intralesional curettage or en bloc resection may be necessary.

Medial malleolar osteotomy for intralesional curettage and bone grafting of primary aneurysmal bone cyst of the talus

Access to the cystic lesion of the talar body without damage to the articular surface is difficult. This case report is about a 23-year-old man who had a symptomatic huge cystic lesion in the left-sided talus bone. Radiograph and CT scan showed an expansile lytic lesion within the talar body. The MRI revealed a well-defined lesion with fluid-fluid levels. The needle biopsy aspirate was haemorrhagic, and hence a diagnosis of the aneurysmal bone cyst was made. As the lesion was beneath the talar dome with an intact neck and head, a medial approach with medial malleolar osteotomy was performed. The lesion was curetted out, and the cavity was filled up with a morselised bone graft. The limb was splinted for 6 weeks, and complete weight bearing was started after 3 months. At 1-year follow-up, the lesion was found to be healed up, and the patient was pain-free with no recurrence.

Efficacy of treatment interventions for primary aneurysmal bone cysts: a systematic review

AIMS

Aneurysmal bone cysts (ABCs) are locally aggressive lesions typically found in the long bones of children and adolescents. A variety of management strategies have been reported to be effective in the treatment of these lesions. The purpose of this review was to assess the effectiveness of current strategies for the management of primary ABCs of the long bones.

METHODS

A systematic review of the published literature was performed to identify all articles relating to the management of primary ABCs. Studies required a minimum 12-month follow-up and case series reporting on under ten participants were not included.

RESULTS

A total of 28 articles meeting the eligibility criteria were included in this review, and all but one were retrospective in design. Due to heterogeneity in study design, treatment, and outcome reporting, data synthesis and group comparison was not possible. The most common treatment option reported on was surgical curettage with or without a form of adjuvant therapy, followed by injection-based therapies. Of the 594 patients treated with curettage across 17 studies, 86 (14.4%) failed to heal or experienced a recurrence. Similar outcomes were reported for 57 (14.70%) of the 387 patients treated with injection therapy across 12 studies. Only one study directly compared curettage with injection therapy (polidocanol), randomizing 94 patients into both treatment groups. This study was at risk of bias and provided low-quality evidence of a lack of difference between the two interventions, reporting success rates of 93.3% and 84.8% for injection and surgical treatment groups, respectively.

CONCLUSION

While both surgery and sclerotherapy are widely implemented for treatment of ABCs, there is currently no good quality evidence to support the use of one option over the other. There is a need for prospective multicentre randomized controlled trials (RCTs) on interventions for the treatment of ABCs. Cite this article: Bone Jt Open 2021;2(2):125-133.

Aneurysmal bone cyst in the pelvis of a cat: successful outcome of partial iliectomy with limb preservation

Case summary

A 3-year-old spayed female domestic shorthair indoor cat presented with a 3-week history of pain from the pelvic region. Physical examination revealed pain elicited on palpating the pelvic area and right hip. Radiographs and CT showed an expansile, osteolytic process with intact cortex in the right wing of the ilium. CT revealed a monostotic and soft tissue-attenuating process with clear margins. Preoperative histopathological diagnosis of aneurysmal bone cyst was made from incisional biopsies. The cyst was removed en bloc with limb-sparing partial iliectomy. Histopathology confirmed the diagnosis of aneurysmal bone cyst. Recovery from surgery was uneventful. At re-examination 8 weeks and 8 months postoperatively, the cat was pain free and physical examinations were within normal limits.

Relevance and novel information

Feline aneurysmal bone cysts are rare and reported cases are few. To our knowledge, this is the first report describing the CT appearance of a pelvic aneurysmal bone cyst and partial iliectomy with limb preservation in a cat with successful short-term outcome.

French Multidisciplinary Approach for the Treatment of MSK Tumors

Several interventional treatments have recently been integrated into the therapeutic armamentarium available for the treatment of bone tumors. In some scenarios (e.g., osteoid osteoma), interventional treatments represent the sole and definitive applied treatment. Due to the absence of widely shared protocols and the complex multivariate scenarios underlying the clinical presentation of the remaining bone tumors including metastases, therapeutic strategies derived from a multidisciplinary tumor board are essential to provide effective treatments tailored to each patient. In the present review, we present the multidisciplinary therapeutic strategies commonly adopted for the most frequent bone tumors.

Bone Marrow Concentrate in the Treatment of Aneurysmal Bone Cysts: A Case Series Study

Introduction

A recent attractive option regarding mesenchymal stem cells (MSC) application is the treatment of bone cystic lesions and in particular aneurysmal bone cysts (ABC), in order to stimulate intrinsic healing. We performed a retrospective evaluation of the results obtained at our institution.

Methods

The study group consisted of 46 cases with an average follow-up of 33 months. Forty-two patients underwent percutaneous treatment as the first approach; four patients had curettage as first treatment. In all cases, autologous bone marrow concentrate (BMC) was associated too. The healing status was followed up through a plain radiograph 45 days and 2 months after the procedure. Results and Conclusions. At the final follow-up, thirty-six patients healed with a Neer type II aspect, nine healed with a type I aspect, and one patient was not classified having total hip arthroplasty. Bone marrow concentrate is easy to obtain and to manipulate and can be immediately available in a clinical setting. We can assert that the use of BMC must be encouraged being harmless and having an unquestionable high osteogenic and healing potential in bone defects.

Tailored treatment of aneurysmal bone cyst of the scapula: en bloc resection for the body and extended curettage for the neck and acromion

BACKGROUND

The acromion and neck of the scapula are essential components of shoulder function, but the body section is less critical. We treated aneurysmal bone cysts (ABCs) of the neck and ‏acromion with extended curettage and ABCs of the body with en bloc resection.‏ This article reports on local recurrence and the functional outcomes of this approach.

MATERIALS AND METHODS

Seventeen patients with primary ABCs of the scapula were included in this retrospective study. We treated 10 patients with extended curettage and bone grafting and 5 patients with en bloc resection. In 2 cases, both the body and neck were involved. We treated these patients with a combination of curettage and resection. We used the Musculoskeletal Tumor Society score for functional assessment of outcomes.

RESULTS

The mean age of the patients was 20.5 ± 7.4 years. One local recurrence occurred in patients who underwent extended curettage and bone grafting (1 of 12 cases, 8.3%). No recurrence was observed in patients who underwent en bloc resection alone. The mean Musculoskeletal Tumor Society score was 27.9 ± 1 in patients who underwent curettage alone and 24.86 ± 0.7 in patients who underwent en bloc resection alone or in combination with curettage (P < .001).

CONCLUSION

Despite the higher risk of local recurrence after curettage, this method can be selected for the treatment of ABCs of the acromion and neck of the scapula to minimize shoulder disability. For the body of the scapula, en bloc resection is a more reasonable treatment, despite a higher rate of functional impairment.

Aneurysmal bone cyst: A review of 65 patients

Background

Aneurysmal bone cysts (ABC) are benign but locally aggressive lesions. The treatment of ABC has evolved over the years, but curettage with or without local adjuvants still represents the standard. Less invasive methods such as embolization, sclerotherapy or RANKL inhibitors (Denosumab) are also established. The aim of this study was to report and compare the results of a series of patients mainly treated with curettage with and without subsequent phenolization.

Methods

65 patients with the unequivocal diagnosis of primary ABC were treated. 61 of them were located within the bone whereas 4 patients had an ABC of the soft tissues. All patient were treated surgically by means of curettage with or without adjuvants, resection, or with minimally invasive methods such as Polidocanol injections, embolizations or Denosumab treatment. In total 80 procedures had been performed.

Results

Our patients had a mean age of 25.3 ± 16.0 years, ranging from 4 to 74 years. The most common skeletal locations were the pelvis in 23%, the femur in 18%, the tibia in 16% and the spine in 10%. Six lesions were resected and showed no recurrence. 5 patients were treated with polidocanol injections (n = 3) or embolization plus systemic treatment with Denosumab (n = 2). With embolization and Denosumab both patients showed stable disease and required no further treatment. Polidocanol injections resulted in stable disease with no further treatment required in one patient and in subsequent curettage with adjuvant phenolization in two other patients.

In 54 initial curettages 21 were performed with adjuvant phenolization. In this group, 16 lesions healed (76%), 3 showed persistent disease and 2 patients had a local recurrence (9%). Out of 33 patients without phenolization 21 (64%) healed, 3 showed stable persistent disease and 9 (27%) experienced a recurrence. In total we performed 66 curettages, 27 with and 39 without adjuvant phenol treatment. Resolution was achieved in 19 (70%) and 25 (64%) of cases. respectively. Persistent disease was evident in 5 cases each and recurrence in 3 and 9 cases, respectively (n.s.).

Conclusion

Curettage is still the standard of treatment for ABC. Local recurrence does not depend on the use of adjuvant phenol as shown in this and other studies. Minimally invasive methods such as selective embolization and injections of sclerosing agents may result in healing or at least in tolerable persistence of residual lesions but needs repetitive treatments and does not show homogenous results throughout the institutions. Denosumab appears to be an additional option, especially in surgically critical locations such as the spine or the sacrum.

Challenges in the Diagnosis and Treatment of Aneurysmal Bone Cyst in Patients with Unusual Features

Objectives

Aneurysmal bone cyst (ABC) is a benign but locally aggressive tumor. It has several challenging features. The aim of this study is to identify challenges in the diagnosis and treatment of ABC especially in patients with unusual features.

Methods

This retrospective study involved medical record review of primary ABC patients with one or more of the following features: unusual clinical presentation with a mass or a pathological fracture especially at an unusual age, rare locations, radiological findings suggesting other diagnoses especially sarcoma, and a nondiagnostic histopathology of biopsy samples.

Results

25 patients (17 males and 8 females) were included. Most patients were either younger than 10 or older than 20 years. 10 patients presented with a mass or a pathological fracture. Unusual locations include the scapula, the olecranon, the hamate, the calcaneus, and the first metatarsal bone. Extension into the epiphysis occurred in 2 patients with proximal fibula and olecranon ABCs. Two separate synchronous cysts existed in the proximal epiphysis and middiaphysis of one humerus. Radiological imaging suggested other primary diagnoses in 8 patients. Core needle biopsy was diagnostic in only 2 of 7 patients. The main treatment was intralesional resection/curettage with bone grafting. Wide resection was performed in 4 patients. Recurrence rate was 28%. Recurrence risk factors included the following: age less than 10 years, male gender, and proximal femur location. Late recurrence occurred in 3/7 patients. One patient with asymptomatic radiological recurrence showed subsequent spontaneous resolution one year later.

Conclusions

This study presented multiple unusual features of ABC including: unusual age, rare locations, and nondiagnostic radiological and histopathological findings. These features can complicate the diagnosis and management. Given these features, especially with pathological fractures, a well-planned incision, the use of frozen section examination, and the application of either external fixation or plate osteosynthesis for fracture fixation can be recommended.

Percutaneous Treatments of Benign Bone Tumors

Benign bone tumors consist of a wide variety of neoplasms that do not metastasize but can still cause local complications. Historical management of these tumors has included surgical treatment for lesion resection and possible mechanical stabilization. Initial percutaneous ablation techniques were described for osteoid osteoma management. The successful experience from these resulted in further percutaneous image-guided techniques being attempted, and in other benign bone tumor types. In this article, we present the most common benign bone tumors and describe the available results for the percutaneous treatment of these lesions.

Spinal tumors in children

Summary Introduction: Spinal tumors are rare in the pediatric population, presenting many specific peculiarities when compared to adults. We have performed a broad narrative review to describe the most common spinal tumors in children, discussing their main characteristics and management options. Method: The authors have performed an extensive review of the peer-reviewed literature addressing the aforementioned objectives. Results: Multimodality radiological studies (plain films, 3D computed tomography scan and magnetic resonance imaging) are necessary for proper evaluation and differential diagnosis of spinal tumors in children. In selected cases nuclear medicine imaging is used to improve the chances of a more accurate diagnosis. As a general rule, a fine needle biopsy is recommended after radiological evaluation to confirm the tumor's histology. Primary bone tumors can be divided into benign bone tumors, mostly represented by vertebral hemangiomas, osteoid osteomas, osteoblastomas, aneurismal bone cysts, and eosinophilic granulomas, and malign or aggressive tumors, such as Ewing's or osteogenic sarcomas. Secondary bone tumors (spinal metastases) comprise different tumor histologies, and treatment is mainly based on tumor's radiosensitivity. The characteristics and treatment options of the main spinal tumors are discussed in details. Conclusion: Spinal tumors in children are rare lesions that demand a thorough understanding of their main characteristics for their proper management. Understanding the nuances of spinal tumors in children is of paramount importance for improving outcomes and chances of cure.

Current management of aneurysmal bone cysts

Aneurysmal bone cysts (ABCs) are benign bone lesions arising predominantly in the pediatric population that can cause local pain, swelling, and pathologic fracture. Primary lesions, which constitute roughly two thirds of all ABCs, are thought to be neoplastic in nature, with one third of ABCs arising secondary to other tumors. Diagnosis is made with various imaging modalities, which exhibit characteristic features such as "fluid-fluid levels," although biopsy is critical, as telangiectatic osteosarcoma cannot be excluded based on imaging alone. Currently, the standard of care and most widely employed treatment is intralesional curettage. However, tumor recurrence with curettage alone is common and has driven some to propose a multitude of adjuvants with varying efficacy and risk profiles. Historically, therapies such as en bloc resection or radiation therapy were utilized as an alternative to decrease the recurrence rate, but these therapies imposed high morbidity. As a result, modern techniques now seek to simultaneously reduce morbidity and recurrence, the pursuit of which has produced preliminary study into minimally invasive percutaneous treatments and medical management.

[Aneurysmal bone cyst: A rare cause of orbital disease]

Aneurysmal bone cyst is a rare benign bone neoplasm of unknown cause. The most commonly affected anatomical sites are the vertebral column and long bones. We report two uncommon cases of primary orbital aneurysmal bone cyst presenting as an acute orbital compartment syndrome due to subperiosteal hemorrhage. Case 1 is a 45-year-old woman. Imaging studies revealed a small cystic frontal bone tumour associated with a subperiosteal hematoma. The patient achieved full visual recovery after drainage of the hematoma, with no recurrence after treatment. Case 2 is a 74-year-old woman whose visual acuity was light perception due to severe papilledema. Imaging studies of the orbit revealed a large cystic frontal bone tumor associated with a subperiosteal hematoma causing globe and optic nerve compression. Preoperative arteriography showed a moderate vascular blush. Drainage of the hematoma was performed. A local recurrence with hematoma formation occurred two years after the surgery.

Current Strategies for the Treatment of Aneurysmal Bone Cysts

Aneurysmal bone cysts are benign bone tumors that usually present in childhood and early adulthood. They usually manifest as expansile osteolytic lesions with a varying potential to be locally aggressive. Since their first description in 1942, a variety of treatment methods has been proposed. Traditionally, these tumors were treated with open surgery. Either intralesional surgical procedures or en bloc excisions have been described. Furthermore, a variety of chemical or physical adjuvants has been utilized in order to reduce the risk for local recurrence after excision. Currently, there is a shift to more minimally invasive procedures in order to avoid the complications of open surgical excision. Good results have been reported during percutaneous surgery, or the use of embolization. Recently, sclerotherapy has emerged as a promising treatment, showing effective consolidation of the lesions and functional results that appear to be superior to the ones of open surgery. Lastly, non-invasive treatment, such as pharmaceutical intervention with denosumab or bisphosphonates has been reported to be effective in the management of the disease. Radiotherapy has also been shown to confer good local control, either alone or in conjunction to other treatment modalities, but is associated with serious adverse effects. Here, we review the current literature on the methods of treatment of aneurysmal bone cysts. The indication for each type of treatment along reported outcome of the intervention, as well as potential complications are systematically presented. Our review aims to increase awareness of the different treatment modalities and facilitate decision-making regarding each individual patient.

Extended curettage and adjuvant therapy for benign tumors of the talus

PURPOSE

Benign tumors of the talus are rare, and their management is controversial. Recent efforts have extended the safety margin of intralesional excision and curettage by chemical and physical means. Cryotherapy as adjuvant therapy is associated with risks of local wound and bony complications (delayed healing, potential for pathological fractures).

METHODS

We retrospectively reviewed six cases of benign talar tumors (three giant cell tumors, two aneurysmal bone cysts, one osteoblastoma) treated by extended curettage and adjuvant cryotherapy. Talar bone stock was restored by bone grafting the residual cavity with fibular strut grafts and/or cancellous bone grafts. Patients were followed for a mean of 40 months.

RESULTS

At latest follow-up, each patient had a mobile painless ankle and good functional outcome. No patient experienced recurrence or complications related to cryotherapy.

CONCLUSIONS

Intralesional extended curettage with bone grafting and cryotherapy is a successful, safe, and efficient treatment of benign tumors of the talus.

Fibular strut graft for humeral aneurysmal bone cyst with varus deformity

PURPOSE

Proximal humerus is a common site for ABC and frequently associated with varus deformity that limits shoulder abduction. A prospective study was conducted to evaluate the use of intramedullary non-vascularised autogenous fibular strut graft for reconstruction without internal fixation.

METHODS

A total of 20 patients (12 girls, 8 boys) were managed for proximal humeral ABC with varus deformity by extended curettage, osteotomy, intramedullary fibular graft and composite bone substitute. Their ages ranged from 10 to 17 years (average, 13.3 years). The lesion was juxtaphyseal in 16 patients and metaphyseal in 4. All cysts were active and centrally located type 2. The modified Enneking scoring system was used for final functional evaluation. Radiological assessment was done for the extent of defect healing, incorporation of the fibula and correction of the deformity.

RESULTS

After a mean follow-up of 41.2 months (range, 24-74) most of patients were satisfied and resumed daily activities without pain and with good range of shoulder movement. One patient complained of shoulder pain 10 months after surgery and was attributed to local recurrence. Limitation of recreational activity was experienced by one patient. There were no cases of deep infection, nerve deficit or pathological fracture. No cases of failed healing or incorporation of the fibula was detected. The improved shoulder abduction was closely related to the mean correction of the neck shaft angle.

CONCLUSIONS

The technique is proved to be effective in controlling disease, correcting deformity and improving function.

Treatment of a spinal aneurysmal bone cyst using combined image-guided cryoablation and cementoplasty

The authors describe the case of a 6.6-cm symptomatic spinal aneurysmal bone cyst (ABC) in a 17-year-old athlete treated percutaneously. Surgical treatment was not considered as the first option owing to its invasiveness and associated morbidity. CT-guided cryoablation of the expansile part of the ABC was performed for tumour shrinkage and nerve decompression. Thermal insulation, temperature monitoring and functional control/electrostimulation of the neural structures at risk were applied. Finally, the bony defect was cemented. No complications occurred during the procedure. Complete resolution of the ABC on imaging and clinical improvement were achieved. Percutaneous cryoablation should be considered as an alternative treatment option, especially when tumour size reduction is desired.