Type:
Educational Exhibit
Keywords:
Musculoskeletal system, Interventional non-vascular, Interventional vascular, Catheter arteriography, Percutaneous, CT, Ablation procedures, Embolisation, Chemotherapy, Cancer
Authors:
V. Bhargavi1, I. Subbanna2, S. S. Shivalingappa3; 1Bangalore, Ka/IN, 2BANGALORE/IN, 3BANGALORE, KARNATAKA/IN
DOI:
10.1594/ecr2018/C-1461
Background
Management of orthopedic oncology cases are complex necessitating a multidisciplinary approach.
Interventional radiology is emerging as an adjuvant tool to orthopedic oncology forming an important part of the integrated team.
Image guided interventional procedures in orthopedic oncology includes:
- Biopsies
- Tumour ablation
- Trans arterial embolization - pre-operative,
palliative or curative
- Intra-arterial chemotherapy
- Cementoplasty
- Injections: joints,
tendons ,
bursa etc
- Nerve blocks
- Aspirations and drainages
Image guided Biopsies [1,2] :
- Percutaneous biopsy is less invasive,
requires smaller dose of anaesthetics and analgesics,
causes minimal bleeding and biopsy tract contamination,
and is a cost-effective method compared to surgery.
- Advantages of Image guidance :
- Needle guidance during lesion approach and also accurate needle placement
- Selective sampling of areas within the tumor that will provide the highest diagnostic yield (e.g.,
avoidance of cystic or necrotic areas).
- Excellent spatial localization of the lesion (superficial,
deep,
invasive,
compartments involves,
etc.),
which helps determine the route that safely avoids vital neurovascular structures ,
avoids crossing of more than one anatomic compartment important in limb-salvage surgical plan.
- Determination of the density of the osseous lesion as well as the amount and degree of dense osseous or chondroid matrix that will be targeted for biopsy.
- Percutaneous biopsies have a lower risk (0 to 10%) of complications than do open biopsies (16%).
Fig. 1: Bone marrow biopsy
References: 2006-2017 Healthwise, Incorporated
Fig. 2: Indications and Contraindications for MSK biopsy
References: Lee Et Al. Image-Guided Musculoskeletal Biopsies . Semin Intervent Radiol 2010;27:191–198
Percutaneous Tumour ablation [3,4] :
- Image-guided ablative procedures have been used to treat some benign bone conditions such as osteoid osteoma,
chondroblastoma,
aneurysmal bone cyst,
enchondroma,
eosinophilic granuloma,
bone hemangioma and giant cell tumors .
- Percutaneous ablation of malignant musculoskeletal lesions may result in significant pain palliation,
prevention of morbidity from skeletal-related events,
and local tumor control.
- Ablation as a curative treatment is the only option for intraarticular and other surgically hard-to-reach lesions.
- The advantages of ablation over surgery are short procedure,
possibility of outpatient treatment,
favorable morbidity rate,
and overall cost.
Fig. 3: Radiofrequency ablation of spinal bone tumours procedure
References: http://www.sirweb.org/patients/bone-cancer/
Trans arterial embolization of tumors [5,6]:
- The primary aim is to devascularize the tumor with subsequent tissue necrosis and tumor lysis,
avoiding non target embolization.
- The procedure may be used in the setting of a palliative procedure to alleviate symptoms,
as a preoperative measure to reduce operative blood loss,
to allow more definitive surgery,
or in some cases as a sole or adjunctive curative therapy.
- Outcomes will vary from complete tumor necrosis to degrees of ischemia and hypo vascularity.
- Increase tumor sensitivity to chemotherapy or radiation therapy
- Tumor types treated include vascular metastatic lesions,
commonly renal cell or thyroid,
particularly in locations prone to fracture; giant cell tumors; aneurysmal bone cysts; vertebral hemangiomas,
osteosarcomas; arteriovenous malformations; and osteoblastomas.
- Specific benefit is present where there is a high risk of bleeding at surgery,
where there is spinal involvement and neural encroachment,
where active bleeding is present or in awkward surgical locations where prolonged surgery is anticipated
Intra-arterial chemotherapy [7]:
- Intra-arterial chemotherapy has been found to reduce tumour size,
cause significant tumour necrosis,
make previously unresectable tumours amenable to limb salvage procedures.
- The main advantage is larger quantity of dose of the chemotherapeutic agent can be administered with less systemic side-effects.
Cementoplasty [2]:
- This involves injecting bone cement in the weakened weight-bearing bones to relieve pain.
The procedure is usually named after the bone,
which is treated.
- Vertebroplasty and khyphoplasty,
also know of vertebral augmentation techniques,
involve injection of bone cement in the vertebral body to relieve pain and restore the height of the vertebral body.
Fig. 4: Schematic representation of vertebroplasty and kyphoplasty procedures
References: Chunxia Gao et al. Nanotechnology for treating osteoporotic vertebral fractures. International Journal of Nanomedicine . 2015 august volume 10.
Joint injections [8]:
- It can be used for therapeutic injections or for diagnostic purposes,
such as injections for MR and CT arthrography,
anesthetic testing for pain relief,
and aspiration for fluid analysis.
- Therapeutic joint injections most commonly are performed with corticosteroids,
an anesthetic,
or a viscosupplement such as hyaluronic acid.
Fig. 5: USG guided injection therapy for joints, tendons, bursa
References: @Affinity Team
Nerve blocks [9]:
- As peripheral nerves are well visualized under both MRI and US guidance,
MRI and USG are the most frequently used modalities for image-guided nerve blocks.
- The precise targeting afforded by US guidance decreases the amount of injectant needed to produce an effective nerve block.
- Improve the accuracy of nerve injections compared with nerve stimulation or blind injections.
- Allows the operator to avoid the critical vascular structures that often accompany nerves and may decrease the risk of intraneural injection.
Fig. 6: Peripheral nerve block
References: Copyright © 2014 EIDO Healthcare Limited