Percutaneous consolidation of bone metastases: strategies and techniques

Abstract

Patients with cancer can present with bone metastases (BM), which are frequently complicated by different types of fractures necessitating prompt management to avoid serious impairment in terms of quality of life and survival.Percutaneous image-guided bone consolidation has rapidly emerged as an alternative to surgical fixation and is mainly reserved for patients who are deemed unfit for surgical management. Two percutaneous techniques, osteoplasty and osteosynthesis, are available and are selected based on the biomechanics of the target bones as well as the fracture types.The aim of this narrative review is to present the different types of BM-related fractures and the interventional strategies and techniques underpinning their minimally invasive percutaneous fixation.

Keywords: Bone; Fractures; Metastases; Osteoplasty; Osteosynthesis.

Fig. 1

Eighty-four-year-old female patient with breast cancer, presenting with (a) a painful insufficiency fracture of the right sacral wing (arrow). b Coronal MIP CT image demonstrating the result of the sacroplasty

Fig. 2

Forty-six-year-old female patient with kidney cancer, presenting with (a) a painful metastasis of the diaphysis of the right humerus (arrow head), complicated by a non-displaced pathologic fracture (arrow). b, c Given the hyper-vascular nature of the metastasis, embolization was performed before (d) surgical fixation to limit the risk of intra-operative bleeding

Fig. 3

Eighty-five-year-old male patient presenting with an acute mechanic pain of the right hip. a A CT scan revealed a large lytic lesion of the acetabulum without any sign of pathologic fracture. The patient underwent (b) percutaneous biopsy that revealed a metastasis from kidney cancer; c, d in the same session, the patient received osteoplasty with fast and effective pain relief. Of note, PMMA was anchored in the distal normal bone (arrow) before filling the lytic cavity

Fig. 4

Vertebroplasty performed in a (a) sclerotic vertebral metastasis. b The amount of PMMA injected was very limited, and an early non-symptomatic para-vertebral leakage occurred (arrow)

Fig. 5

Screw components and deployment. k-wire: Kirschner wire

Fig. 6

Same patient as Fig. 1 presenting also with painful pathologic fractures (arrows) of the right (a, b) ischio-pubic and ilio-pubic ramus. c, d Both fractures were fixed percutaneously with the cannulated PMMA-injectable screws

Fig. 7

Seventy-four-year-old male patient affected by lung cancer. The patient underwent radiation therapy of a painful metastasis of the left acromion, which was complicated few weeks later by (a) a secondary bone insufficiency fracture. b, c Percutaneous osteosynthesis was proposed to fix the fracture under combined CT and fluoroscopy guidance; two screws were deployed with subsequent rapid pain relief

Fig. 8

Sixty-three-year-old female patient affected by breast cancer, presenting with (a) painful lytic metastases in the acetabulum (*) and in the proximal femur (Mirels’ score: 10; arrow). b The patient received an osteosynthesis of the femoral neck with an inverted triangle configuration coupled to PMMA injection to fill the lytic cavity. c In the same session, percutaneous osteoplasty of the acetabulum was performed, and a small asymptomatic PMMA leakage in the nearby soft tissues was noted (arrow)