Embolization of bone tumors

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.

Scheduling surgery after transarterial embolization: does timing make any difference to intraoperative blood loss for renal cell carcinoma bone metastases?

PURPOSE

Our purpose is to clarify the optimal timing of surgery after transarterial embolization (TAE) for renal cell carcinoma (RCC) bone metastases.

METHODS

This retrospective study included 41 patients with RCC bone metastases embolized between 2013 and 2019. Different-sized particulate and/or liquid embolic agents were used for TAE. Embolizations were categorized into groups 1-3 according to the interval between TAE and surgery (group 1: <1 day, group 2: 1-3 days, group 3: >3 days). Degree of embolization after TAE was graded visually based on angiographic images (<50%, 50%-75%, 75%-90%, >90%). The relationship between the TAE-surgery interval and intraoperative blood loss (IBL) and the correlation between IBL and embolization grade were examined. Lesion sizes and the relationships among lesion localizations and contrast media usage, intervention time, and IBL were also analyzed.

RESULTS

Forty-six pre-operative TAEs (single lesion at each session) were performed in this study (26 in group 1, 13 in group 2, 7 in group 3). Lesion sizes and distributions were similar between groups (p = 0.897); >75% devascularization was achieved in 40 (TAEs 86.96%), but the IBL showed no correlation with the embolization rate (r=0.032, p = 0.831). The TAE-surgery interval was 1-7 days. The median IBL in group 1 (750 mL; range, 150-3000 mL) was significantly lower than those in the other groups (p = 0.002). Contrast media usage (p = 0.482) and intervention times (p = 0.261) were similar for metastases at different localizations. IBL values after TAE were lower for extremity metastases (p = 0.003).

CONCLUSION

Bone metastases of RCC are well-vascularized, and to achieve lowest IBL values, surgery should preferably be performed <1 day after TAE.

Radiological Assessment of Giant Cell Tumour of Bone in the Sacrum: From Diagnosis to Treatment Response Evaluation

Giant cell tumour of bone (GCTB) typically occurs in young adults from 20-40 years old. Although the majority of lesions are located in the epi-metaphyses of the long bones, approximately one third of tumours is located in the axial skeleton, of which only 4% in the sacrum. Sacral tumours tend to be large at the time of presentation, and they present with aggressive features such as marked cortical destruction and an associated soft tissue component. The 2020 World Health Organisation classification of Soft Tissue and Bone Tumours describes GCTB as neoplasm which is locally aggressive and rarely metastasizing. The tumour contains three different cell types: neoplastic mononuclear stromal cells, macrophages and osteoclast-like giant cells. Two tumour subtypes were defined: conventional GCTB and malignant GCTB. Only 1-4% of GCTB is malignant. In this review article, we will discuss imaging findings at the time of diagnosis to guide the musculoskeletal radiologist in reporting these tumours. In addition, imaging for response evaluation after various treatment options will be addressed, such as surgery, radiotherapy, embolization and denosumab. Specific findings will be presented per imaging modality and illustrated by cases from our tertiary sarcoma referral center. Common postoperative and post radiotherapy findings in GCTB of the sacrum on MRI will be discussed.

Preoperative embolization in surgical treatment of long bone metastasis: a systematic literature review

Surgery of long bone metastases is associated with a significant risk of perioperative blood loss, which may necessitate blood transfusion.

Successful embolization (> 70% obliteration of vascularity) can be achieved in 36–75% of cases.

The reported rate of embolization-related complications is 0–9%.

Three out of six level III evidence studies showed a reduction in perioperative blood loss and/or blood transfusion requirement after preoperative embolization of renal cell carcinoma metastasis in long bones; three out of six studies did not.

One level III evidence study did not show a reduction in perioperative blood loss and/or transfusion requirement after preoperative embolization of hepatocellular carcinoma metastases in long bones.

There were no studies found that support preoperative embolization of thyroid metastases or other frequent long bone metastases (e.g. mamma carcinoma, lung carcinoma, or prostate carcinoma).

The clinical level of evidence of the studies found is low and randomized studies taking into account primary tumour, location of metastases and type of surgery are therefore desired.

Cite this article: EFORT Open Rev 2020;5:17-25. DOI: 10.1302/2058-5241.5.190013

Giant sacrococcygeal chordoma: A case report

RATIONALE

Chordoma is a relatively rare tumor that accounts for 1% to 4% of all malignant bone tumors, with an annual incidence of <0.1 per 100,000 people. Although chordoma is aligned with the axis of the spine and most commonly develops in the sacrum, to the best of our knowledge, giant sacrococcygeal chordoma is extremely rare.

PATIENT CONCERNS

A 61-year-old Chinese man presented with a massive dorsal sacral mass. The patient's primary complaint was that, during the last two months, the mass had been increasing in size and his right lower extremity was uncomfortable while he was sitting, although the discomfort was relieved when he was standing.

DIAGNOSES

Based on the imaging findings, we suspected that the sacrococcygeal mass was a chordoma, and a postoperative pathological examination confirmed the diagnosis of a sacral chordoma.

INTERVENTION

The patient underwent extensive open surgery to achieve complete resection of the sacrococcygeal mass. An occlusion balloon catheter was used in the abdominal aorta to minimize intraoperative bleeding and maintain a clear surgical field.

OUTCOMES

The patient was discharged without complications at 27 days after surgery. The 3-month follow-up revealed that the patient had recovered well, the discomfort in his right lower extremity while standing had completely resolved and that there was no evidence of recurrence.

LESSONS

The development of chordoma is not associated with clear symptoms, although early diagnosis and treatment are needed to prevent invasion of the nearby tissues and organs. Therefore, we believe that surgical treatment of sacral chordoma is effective, although care must be taken to completely remove all residual tumor tissue and reduce the risk of recurrence. Besides, This report adds to our limited understanding of the rare giant sacrococcygeal chordoma.

Sacral chordoma : A review of literature

Chordoma is a rare malignant tumor with predilection for the sacrum. A favorable outcome depends on early diagnosis and surgical excision with tumor free margins.

Aim

To review the incidence and prevalence of sacral chordoma and the appropriate surgical management and formulate a criteria for early diagnosis.

Materials and methods

Thirty eight articles on the subject of sacral chordoma and extrapolated data of clinical and surgical significance.

Results

The commonest presenting feature in patients with sacral chordoma was lower back pain which was worse on sitting and up to a third of these patients had associated urinary tract infections, constipation or symptoms of disc herniation. The hallmark of sacral chordoma is lower back pain with poor response to non-steroidal anti-inflammatory drugs.Disease free eradication in chordoma is rare and not without neurological deficit. The common sacral levels involved ie. S2,3 have to be sacrificed to achieve adequate margins4. Whilst wide excision via posterior surgery shows a decrease in recurrence, the overall survival still remains low.

The Value of MRI in Distinguishing Subtypes of Lipomatous Extremity Tumors Needs Reassessment in the Era of MDM2 and CDK4 Testing

Introduction

Extremity lipomas and well-differentiated liposarcomas (WDLs) are difficult to distinguish on MR imaging. We sought to evaluate the accuracy of MRI interpretation using MDM2 amplification, via fluorescence in-situ hybridization (FISH), as the gold standard for pathologic diagnosis. Furthermore, we aimed to investigate the utility of a diagnostic formula proposed in the literature.

Methods

We retrospectively collected 49 patients with lipomas or WDLs utilizing MDM2 for pathologic diagnosis. Four expert readers interpreted each patient's MRI independently and provided a diagnosis. Additionally, a formula based on imaging characteristics (i.e. tumor depth, diameter, presence of septa, and internal cystic change) was used to predict the pathologic diagnosis. The accuracy and reliability of imaging-based diagnoses were then analyzed in comparison to the MDM2 pathologic diagnoses.

Results

The accuracy of MRI readers was 73.5% (95% CI 61-86%) with substantial interobserver agreement (κ=0.7022). The formula had an accuracy of 71%, which was not significantly different from the readers (p=0.71). The formula and expert observers had similar sensitivity (83% versus 83%) and specificity (64.5% versus 67.7%; p=0.659) for detecting WDLs.

Conclusion

The accuracy of both our readers and the formula suggests that MRI remains unreliable for distinguishing between lipoma and WDLs.

Not All Patients Undergoing Stabilization of Impending Pathologic Fractures for Renal Cell Carcinoma Metastases to the Femur Need Preoperative Embolization

BACKGROUND

Preoperative transarterial embolization has been utilized in the surgical treatment of metastatic renal cell carcinoma of the femur to decrease perioperative blood loss. However, few studies have documented its efficacy in decreasing the proportion of patients receiving transfusions in the setting of prophylactic treatment of impending pathologic femur fractures.

QUESTIONS/PURPOSES

In a population of patients with metastatic renal cell carcinoma of the femur who underwent prophylactic fixation, the purpose of this study was to quantify and compare the proportion of patients who received at least one transfused unit of blood between a group treated with preoperative embolization and a group without preoperative embolization.

METHODS

A retrospective study was performed using a Medicare claims-based database. International Classification of Diseases, 9 Revision and Current Procedural Terminology codes were used to identify 1285 patients with metastatic renal cell carcinoma of the femur who underwent prophylactic fixation. The proportion of patients who received one or more blood transfusions was compared between 135 patients who underwent preoperative embolization and a group of 1150 concurrent control patients who did not undergo preoperative embolization. The control group was older than the embolization group, with 44% of these patients > 75 years old and 33% of the embolization group > 75 years. There was no difference in the female:male ratio between groups. Statistical comparisons of outcomes related to transfusion percentages were performed using Pearson chi square analysis with p < 0.05 considered significant. With the numbers available, we had 80% power to detect a difference in the percentage of patients transfused of 11% between the study groups at α = 0.05.

RESULTS

No difference in transfusion percentage was observed between preoperative transarterial embolization (41 of 135 [30%]) and the control group (359 of 1150 [31%]; relative risk, 0.973; 95% confidence interval, 0.743-1.274; p = 0.84). The percentage of all patients who received a transfusion was 31% (400 of 1285).

CONCLUSIONS

Preoperative embolization may not be mandatory in the prophylactic treatment of metastatic renal cell carcinoma of the femur, as demonstrated by the 69% of patients who received zero units of blood despite not receiving embolization. However, assessment of the efficacy of embolization in decreasing blood loss in the current study is limited as a result of biases associated with the database design of the study; the decision of whether to send a patient for embolization should be made on a case-by-case basis. The current study does not identify specific risk factors that should factor into this decision and underscores the need for further research in this regard. A plausible future research design to account for the low numbers and selection bias that limited the current study as well as the existing studies might be a multicenter, retrospective case-control study.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Successful selective arterial embolizations for bone metastases in renal cell carcinoma integrated with systemic therapies: A case report

Herein is described the case of a 64-year-old patient affected by metastatic clear-cell carcinoma, with exclusive bone disease, subjected after the initial cytoreductive nephrectomy to 3 successive lines of medical treatment (sunitinib, everolimus, and sorafenib) and multiple locoregional treatments (spinal surgery, radiation therapy, and selective arterial embolization), resulting in a surprisingly long survival of over 75 months. In the era of target therapy, integration strategies, including additional locoregional treatment to medical therapy, are essential to optimize the clinical benefit, to maximize treatment duration overcoming focal progressive disease, and to improve the quality of life. In this context, we would highlight that selective transcatheter embolization of bone metastases from renal cell carcinoma should be considered as an effective and safe option in the palliative setting for patients with bone metastasis, especially for pain relief.

Lower Limb Reconstruction with Tibia Allograft after Resection of Giant Aneurysmal Bone Cyst

Aneurysmal bone cysts (ABCs) are benign, expansible, nonneoplastic lesions of the bone, characterized by channels of blood and spaces separated by fibrous septa, which occur in young patients and, occasionally, with aggressive behavior. Giant ABC is an uncommon pathological lesion and can be challenging because of the destructive effect of the cyst on the bones and the pressure on the nearby structures, especially on weight-bearing bones. In this scenario, en bloc resection is the mainstay treatment and often demands complex reconstructions. This paper reports a difficult case of an unusual giant aneurysmal bone cyst, which required extensive resection and a knee fusion like reconstruction with tibia allograft.

Metachronous multicentric giant cell tumour in a young woman

Multicentric giant cell tumours (GCTs) are very rare and account for less than 1% of all GCTs of bone. We report a case of a young woman with metachronous multicentric GCTs with 5 documented lesions in the same lower limb. The initial lesion started during the first trimester of pregnancy around her right pelvis, which rapidly progressed as a painful swelling with gradually restricted mobility of her right hip joint. The radiological appearance of this tumour was that of a GCT and biopsy confirmed the diagnosis. The role of positron emission tomography (PET) has been highlighted to detect occult lesions. A possible hormonal correlation for these tumours has been discussed. The patient was managed successfully by an aggressive surgical approach for knee and talar lesions, whereas repeated embolisation and denosumab injections were given to treat her pelvic lesion.

Aneurysmal bone cyst involving the c2 vertebra

A 9-year-old boy presented with a 3-month history of cervical pain, limited range of motion, and a palpable "bump" in his posterior neck. After treatment with antibiotics for presumptive adenopathy and progression of the palpable finding, radiographs were obtained.

Background acetabular aneurysmal bone cyst in a 7 year-old: Presentation of a case

The bone cyst is a rare benign tumor that usually develops in childhood. There are several treatment options, however when it is located within the pelvis treatment is complex. A 7 year-old patient who presented with 3 months of right hip pain and limping. The initial radiograph showed a discrete periostic reaction and acetabulum effacement. The MRI and CT scans suggested the diagnosis of aneurysmal bone cyst and was confirmed by open biopsy. Two serial embolizations were performed with good results, the patient was asymptomatic one year after.

Current treatment modalities for spinal metastases secondary to thyroid carcinoma

BACKGROUND

The spine is the most common site of bone metastases due to thyroid cancer, which develop in more than 3% of patients with well-differentiated thyroid cancer. Nearly half of patients with bone metastases from thyroid cancer develop vertebral metastases. Spinal metastases are associated with significantly reduced quality of life due to pain, neurological deficit, and increased mortality.

SUMMARY

Treatment options for patients with thyroid spinal metastases include radioiodine therapy, pharmacologic therapy, and surgical treatments, with recent advances in radiosurgery and minimally invasive spinal surgery as well. Therapeutic interventions require a multidisciplinary approach and aim to control pain, preserve or improve neurologic function, optimize local tumor control, and improve quality of life. We have proposed a three-tiered approach to the management and practical algorithms for patients with spinal metastases from thyroid carcinoma.

CONCLUSIONS

The introduction of novel and improved techniques for the treatment of spinal metastases has created the opportunity to significantly improve control of metastatic tumor growth and the quality of life for the patients with spinal metastases from thyroid cancer. In order for these options to be effectively used, a multidisciplinary approach must be applied in the management of the patients with thyroid spinal metastases.

Osteoblastoma of the sacrum: report of 18 cases and analysis of the literature

STUDY DESIGN

Retrospective case series.

OBJECTIVE

(1) To analyze clinical and radiographical characteristics, treatment, and outcome in patients with sacral osteoblastoma, (2) to evaluate progression-free survival and local recurrence rate, and (3) to identify prognostic factors.

SUMMARY OF BACKGROUND DATA

Osteoblastoma is a rare tumor that has been reported to affect the sacrum from 7% to 17%. Symptoms are various and the diagnosis is often delayed.

METHODS

From 1980 to 2010, 18 patients with sacral osteoblastoma (16 males and 2 females) were treated at Rizzoli Institute. Lesion involved S1 (2 cases), S1-S2 (3 cases), S2 (1 case), S2-S3 (1 case), S2-S4 (1 case), S3 (2 cases), S3-S4 (5 cases), S4 (1 case), and almost the entire sacrum in 2 cases. According to Enneking classification for benign bone tumors, 13 (72%) were diagnosed at stage 2 and 5 (28%) at stage 3. Mean tumor volume was 64 cm (range, 2-441 cm). Nine patients had preoperative magnetic resonance imaging. Five patients had a previous inadequate intralesional surgery elsewhere. Treatment consisted in intralesional surgery (16 cases), intralesional surgery and radiotherapy (1 case), and wide resection (1 case). Local adjuvants used were phenol (7 patients), cryocoagulation with "iceball" technique (1 case). Embolizations were performed in 7 patients.

RESULTS

At a mean of 8.4 years (range, 1-28 yr), 15 patients (83%) remained continuously disease free, whereas 3 patients had local recurrence (17%). Progression-free survival was 87% at 5 years and 74% at 10 years. No statistical difference was found between patients who received or not local adjuvants (P = 1.254), older or younger than 20 years (P = 0.970), at stage 2 or 3 (P = 0.826), evaluated preoperatively with or without magnetic resonance imaging (P = 0.160), primarily treated versus patients with previous intralesional surgery elsewhere (P = 0.131).

CONCLUSION

In our series, curettage was successful in most of the patients. Local adjuvants did not seem to reduce the risk of local recurrence when combined with intralesional surgery.

LEVEL OF EVIDENCE

4.

Chondroblastoma of the Lumbar Vertebra Associated with Cauda Equina Compression

Chondroblastoma is a benign tumour, most often affecting the epiphyses of long tubular bones such as the proximal end of the humerus, femur, and tibia, as well as the distal end of the femur. Vertebral involvement is extremely rare. We report a case of chondroblastoma of the second lumbar vertebra associated with cauda equina compression. Complete excision is necessary to relieve the compression and ensure surgical clearance.

Embolisation of hypervascular bone tumours: a pictorial essay with literature review

Bone tumours, either primary or secondary, can present in various debilitating manners, including pain and pathological fracture. The situation is particularly problematic when the tumours are hypervascular, and located in regions where a high risk of neurological compromise is anticipated during operation, such as in the spine or sacrum. In such situations, bone tumour embolisation is a useful and effective adjunctive treatment for reducing intra-operative blood loss. This is particularly relevant in primary bone tumours such as giant cell tumours and metastatic renal cell and thyroid tumours. With a proper pre-embolisation angiogram and knowledge of anatomy, careful selective cannulation of the arterial supplies and experience in using embolic agents, the risks of non-target embolisation can be kept to minimum and the best result achieved.

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.