Image-Guided Bone Consolidation in Oncology

Abstract

Occurrence of bone metastases is a common event in oncology. Bone metastases are associated with pain, functional impairment, and fractures, particularly when weight-bearing bones are involved. Management of bone metastases has been improved by the development of various interventional radiology consolidation techniques. Cementoplasty is based on injection of acrylic cement into a weakened bone to reinforce it and to control pain. This minimally invasive technique has proven its efficacy for flat bone submitted to compression forces. However, resistance to torsion forces is limited and, thus, treatment of long bones should be considered with caution. In recent years, variant techniques of percutaneous bone consolidation have emerged, including expansion devices for vertebral augmentation and percutaneous screw fixation for pelvic bone and proximal femur tumors. Research projects are ongoing to develop drug-loaded cements to use them as therapeutic vectors. However, release of drugs is still poorly controlled and conventional polymethylmethacrylate cement remains the gold standard in oncology. Image-guided consolidation techniques enhance the array of treatments in bone oncology. Multidisciplinary approach is mandatory to select the best indications.

Keywords: bone metastasis; cementoplasty; interventional radiology; screw fixation; vertebroplasty.

Fig. 1

Thoracic multilevel vertebroplasty in a 58-year-old patient treated for myeloma. ( a ) Lateral fluoroscopic view demonstrates a major T8 pathological collapse (arrow) and several adjacent minor fractures. ( b and c ) Six levels are cemented under cone beam-CT guidance, using unilateral intercostopedicular approach. ( d–f ) Control after procedure confirms proper cement distribution without leakage.

Fig. 2

C2 transoral vertebroplasty of osteolytic painful metastasis of leiomyosarcoma. Axial ( a ) and sagittal ( b ) CT demonstrating a major osteolysis of the base of C2 (arrows). ( c and d ) Using an oral retractor (white arrow), a 13-gauge bone trocar (black arrow) is inserted via transoral route. ( e and f ) Lateral fluoroscopy ( e ) and axial cone beam CT reconstruction ( f ) show proper cement distribution.

Fig. 3

Lumbar vertebroplasty with posterior wall rupture in a metastatic lung cancer patient. ( a ) Cone beam CT aquisition with sagittal reconstruction shows a L1 pathological fracture with posterior wall osteolysis (arrow). No neurological symptoms. ( b ) An 11-gauge bone trocar is inserted via transpedicular oblique approach. ( c and d ) Image after cement injection shows no extraosseous leakage. Additional radiotherapy was performed.

Fig. 4

Painful talar metastasis of rhabdomyosarcoma. ( a and b ) Sagittal and coronal CT show a talar osteolysis (arrow) with risk of fracture. ( c–e ) Cone beam CT-guided cementoplasty is performed to consolidate the weakened bone. ( f ) CT with sagittal reconstruction shows filling of the bone defect. Excellent pain control.

Fig. 5

Percutaneous screw fixation and cementoplasty in a 42-year-old patient with multiple metastases of Ewing's sarcoma. Acute mechanical left sciatic pain while standing. ( a and b ) Coronal and axial CT shows a large osteolysis of the sacrum and the right iliac wing. Note the vertical fracture of the sacrum involving the first left sacral hole (arrows). ( c and d ) Cone beam CT-guided consolidation is performed; A trans-sacro-iliac 12-cm screw is inserted. Additional cementoplasty of the iliac wing and the sacral wings is performed to reinforce the bone and to avoid secondary screw displacement.

Fig. 6

Proximal painful tibial metastasis of renal cancer in a 62-year-old patient. ( a and b ) Plain film ( a ) and proton density–weighted MRI sequence show tumor recurrence around surgical material. ( c ) Selective embolization is first performed, using microparticles. ( d–f ) Cone beam CT-guided cementoplasty is then performed to reinforce the proximal tibia and to avoid secondary rupture of the surgical fixation. Planning of the bone trocar trajectories ( d ); insertion of three 11-gauge bone trocars ( e ); control after cement injection ( f ).