Preoperative embolization for bone metastasis from hepatocellular carcinoma

Palliative Arterial Embolization for Metastases of the Sternum

BACKGROUND

To investigate the safety and efficacy of palliative arterial embolization for metastases of the sternum.

MATERIALS AND METHODS

This study included 10 consecutive patients (5 M, 5 F; mean age 58.1; range 37-70) with metastases of the sternum from different primary tumors, treated with palliative arterial embolization using NBCA-Lipiodol between January 2007 and June 2022. Four patients received a second embolization at the same site, for a total of 14 embolizations. Data on technical and clinical success, as well as changes in tumor size, were collected. All embolization-related complications were evaluated according to the CIRSE classification system for complications.

RESULTS

Post-embolization angiography showed occlusion of more than 90% of the pathological feeding vessels in all procedures. Pain score and analgesic drug consumption were reduced by 50% in all 10 patients (100%, p < 0.05). The mean duration of pain relief was 9.5 months (range 8 to 12 months, p < 0.05). Metastatic tumor size was reduced from a mean of 71.5 cm³ (range 41.6 to 90.3 cm³) pre-embolization to a mean of 67.9 cm³ (range 38.5 to 86.1 cm³) at the 12-month follow-up (p < 0.05). None of the patients experienced embolization-related complications.

CONCLUSION

Arterial embolization is safe and effective as a palliative treatment for patients with metastases of the sternum who did not benefit from radiation therapy or experienced recurrence in symptoms.

Preoperative Arterial Embolization for Heterotopic Ossification of the Hip

PURPOSE

To investigate the efficacy and safety of preoperative arterial embolization for neurogenic heterotopic ossification (NHO) of the hip.

MATERIALS AND METHODS

This single-center retrospective study reviewed outcomes in 16 consecutive patients who had surgical resection of NHO of the hip: 8 of whom underwent preoperative arterial embolization and 8 of whom did not. Both patient cohorts had similar baseline characteristics. A mean of 2.62 ± 1.9 arteries per patient, including the gluteal, lateral circumflex femoral, and deep circumflex iliac branches, were embolized using an n-butyl cyanoacrylate (NBCA)-ethiodized oil mixture. Data from both cohorts regarding intraoperative blood loss, volume of blood transfused, complications, and duration of hospitalization were compared.

RESULTS

A mean of 2.6 ± 1.9 arteries were embolized with NBCA-ethiodized oil, mainly the gluteal arteries, lateral circumflex femoral artery, and deep circumflex iliac artery. In the embolization group, mean intraoperative blood loss was 875 mL ± 320, mean number of units of blood used was 0.5 ± 0.7, and average number of days of hospitalization was 6.4 days ± 1.6. In the control group, mean intraoperative blood loss was 1,350 mL ± 120, mean number of units of blood used was 2 ± 1.1, and average number of days of hospitalization was 11.5 days ± 1.4. The embolization group had an average reduction in blood loss of 40.7% (P = 0.035), reduction in units of blood administered of 75% (P = 0.021), and reduction in days of hospitalization of 44.7% (P = 0.014). No procedural complications were recorded.

CONCLUSIONS

Preoperative arterial embolization is effective and safe in reducing intraoperative blood loss, number of hospitalization days, and need for blood transfusions in surgical resection of NHO of the hip.

Minimally Invasive Interventional Procedures for Metastatic Bone Disease: A Comprehensive Review

Metastases are the main type of malignancy involving bone, which is the third most frequent site of metastatic carcinoma, after lung and liver. Skeletal-related events such as intractable pain, spinal cord compression, and pathologic fractures pose a serious burden on patients’ quality of life. For this reason, mini-invasive treatments for the management of bone metastases were developed with the goal of pain relief and functional status improvement. These techniques include embolization, thermal ablation, electrochemotherapy, cementoplasty, and MRI-guided high-intensity focused ultrasound. In order to achieve durable pain palliation and disease control, mini-invasive procedures are combined with chemotherapy, radiation therapy, surgery, or analgesics. The purpose of this review is to summarize the recently published literature regarding interventional radiology procedures in the treatment of cancer patients with bone metastases, focusing on the efficacy, complications, local disease control and recurrence rate.

The Harrington Plus Reconstruction for Pelvic and Acetabular Metastases

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The Harrington Plus reconstruction is a modification of the original Harrington rod technique for reconstruction of extensive periacetabular metastases. This procedure was developed in our institution.

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An intrapelvic suprapectineal plate is used, with the aim of reconstructing a disrupted anterior column and reducing the risk of failure in cases where there is extensive medial bone loss.

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This paper describes the outcomes of patients who have undergone this procedure to date.

Background

Surgical management of periacetabular bone metastases is challenging. The Harrington Plus reconstruction is a modification of the original Harrington rod technique. An intrapelvic suprapectineal plate is used, with the aim of reconstructing a disrupted anterior column and reducing the risk of failure in cases where there is extensive medial bone loss.

Methods

A retrospective review of the 13 patients who have undergone the Harrington Plus procedure to date was performed. Mobility status, EQ5D and Oxford Hip scores were assessed.

Results

There was a significant improvement in mobility status, EQ5D and Oxford Hip Scores at 6 months postoperatively (p < 0.05). Two patients returned to theatre for debridement of infection. There were no postoperative dislocations, cup medialisation or cases of loosening of the prosthesis. No patient required revision arthroplasty surgery.

Conclusion

The Harrington Plus procedure produces a reliable construct that allows patients with extensive periacetabular metastatic defects to fully weight-bear. Careful patient selection and multidisciplinary management is essential.

Current Overview of Treatment for Metastatic Bone Disease

The number of patients with bone metastasis increases as medical management and surgery improve the overall survival of patients with cancer. Bone metastasis can cause skeletal complications, including bone pain, pathological fractures, spinal cord or nerve root compression, and hypercalcemia. Before initiation of treatment for bone metastasis, it is important to exclude primary bone malignancy, which would require a completely different therapeutic approach. It is essential to select surgical methods considering the patient’s prognosis, quality of life, postoperative function, and risk of postoperative complications. Therefore, bone metastasis treatment requires a multidisciplinary team approach, including radiologists, oncologists, and orthopedic surgeons. Recently, many novel palliative treatment options have emerged for bone metastases, such as stereotactic body radiation therapy, radiopharmaceuticals, vertebroplasty, minimally invasive spine stabilization with percutaneous pedicle screws, acetabuloplasty, embolization, thermal ablation techniques, electrochemotherapy, and high-intensity focused ultrasound. These techniques are beneficial for patients who may not benefit from surgery or radiotherapy.

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

Scapular metastasis of hepatocellular carcinoma presenting as acute bleeding and hematoma: A case report of safe and effective treatment

RATIONALE

The occurrence of bleeding and hematoma from bone metastasis of hepatocellular carcinoma (HCC) is extremely rare.

PATIENT CONCERNS

We present a case of scapular metastasis of HCC in a 69-year-old man who presented with acute bleeding and hematoma.

DIAGNOSES

Chest computed tomography showed a large hematoma within the right pectoral muscle of the right upper chest and an exophytic metastatic mass in the right scapula with bony destruction, which caused the intramuscular hematoma. The final diagnosis was scapular metastasis of HCC presenting as acute bleeding and hematoma.

INTERVENTIONS

Selective right subclavian angiography showed a hypervascular metastatic lesion in the right scapula. Subsequently, embolization of the tumoral feeding artery using a microcoil was performed and tumoral bleeding was stopped.

OUTCOMES

The patient was discharged on hospital day 14 without any complications.

LESSONS

Despite being extremely rare, the possibility of bleeding from bone metastasis of HCC needs to be considered. Transcatheter arterial embolization may be an effective means to treat bleeding from bone metastasis of HCC.

Cone-beam computed tomography with automated bone subtraction in preoperative embolization for pelvic bone tumors

PURPOSE

To evaluate the usefulness of cone-beam computed tomography with automated bone subtraction (CBCT-ABS) in the preoperative embolization of hypervascular tumors located in the pelvic bone.

MATERIALS AND METHODS

This retrospective study included 26 patients with pelvic bone tumors who underwent preoperative embolization between January 2014 and October 2016. A CBCT-ABS scan was taken in a total of 17 patients (CBCT-ABS group), and only a series of digital subtraction angiographies (DSAs) was taken in the remaining 9 patients (DSA group). The percent devascularization, number of angiographic runs, total dose-area product (DAP), fluoroscopy time, interventional procedure time, operative time, and estimated blood loss were compared between the two groups using Mann-Whitney test.

RESULTS

The percent devascularization, interventional procedure time, fluoroscopy time, operative time, and estimated blood loss were not statistically different between the two groups (p > 0.05). On the other hand, the number of angiographic runs in the CBCT-ABS group was significantly lower than that in the DSA group (p = 0.029). The total DAP of the CBCT-ABS group (mean, 17700.7 μGym2) was higher than that of the DSA group (mean, 8939.4 μGym2) (p = 0.002).

CONCLUSIONS

The use of CBCT-ABS during the preoperative embolization of pelvic bone tumors significantly reduces the number of angiographic runs at the cost of an increased radiation dose.

Preoperative transarterial embolization using gelatin sponge for hypervascular bone and soft tissue tumors in the pelvis or extremities

BACKGROUND

Preoperative transcatheter arterial embolization for hypervascular bone and soft tissue tumors plays an important role in reducing intraoperative blood loss (IBL).

PURPOSE

To evaluate the use of a gelatin sponge in preoperative transcatheter arterial embolization for hypervascular bone and soft tissue tumors in the pelvis or extremities.

MATERIAL AND METHODS

Thirty-seven patients (21 men, 16 women; median age, 61 years; age range, 23-79 years) underwent preoperative transcatheter arterial embolization between April 2004 and January 2015. Medical records and images were reviewed, and the technical success rate, clinical success rate, and complications were evaluated. Technical success was defined as a devascularization rate of 75% or higher, and clinical success was defined as intraoperative blood loss (IBL) <1500 mL in cases undergoing surgery within 3 days of transarterial embolization and <3000 mL in cases operated 4 or more days later.

RESULTS

Tumor sizes were in the range of 2.0-13.0 cm (median, 5.0 cm). The devascularization rate was decreased by >75% at follow-up angiography in all cases, and the technical success rate was 100 % (37/37). The median IBL was 491 mL (range, 30-3800 mL), and the clinical success rate was 89% (33/37). The minor complication of local pain was observed in 13 out of 37 cases (35%) during or after embolization, but was controllable by an analgesic.

CONCLUSION

Preoperative transarterial embolization using a gelatin sponge appears to be feasible and safe, and may contribute to decreasing IBL.