LETTERS TO THE EDITOR Percutaneous Augmented Osteoplasty of the Humeral Bone Using a Combination of MicroNeedles Mesh and Cement From: Alexios Kelekis, MD, PhD, EBIR Dimitrios K. Filippiadis, MD, PhD, EBIR Nikolaos L. Kelekis, MD, PhD Jean-Baptiste Martin, MD, PhD 2nd Radiology Department (A.K., D.K.F., N.L.K.) University General Hospital Attikon Athens, Greece Centre Imagerie Rive Droite & Gauche (J.-B.M.) Geneva, Switzerland
Editor: We report a case of percutaneous augmented osteoplasty in a large, solitary, lytic metastatic lesion of the humeral head by means of a metallic mesh consisting of 25–50 stainless steel microneedles combined with polymethyl methacrylate (PMMA) cement injection. Our hospital’s institutional review board did not require approval for this case report. A 40-year-old man with esthesioneuroblastoma and complaints of significant pain and mobility impairment (score of 10 of 10 on a numeric visual scale [NVS]) secondary to a large, solitary, lytic metastatic lesion in the humeral head was referred to our department. Standard x-rays and computed tomography scan showed the lesion covering the humeral head and extending up to the surgical and anatomic neck of the proximal humerus (Fig, a). The patient had undergone a series of radiotherapy sessions within the last 3 months and was taking opioid analgesics (fentanyl transdermal system delivering 75 μg/h; Janssen-Cilag Pty Limited, North Ryde, New South Wales, Australia) with neither significant pain reduction nor improvement in mobility. Because the patientʼs pain was not reduced after radiotherapy, he was referred to our department for therapy with interventional radiology palliative techniques. A percutaneous augmented osteoplasty was chosen as first-line therapy. Blood count and coagulation laboratory tests were performed 24 hours before the percutaneous augmented osteoplasty session. Under local sterile conditions, following antibiotic prophylaxis (according to the our hospital’s infectious diseases protocol, we administered a single intravenous dose of piperacillin/tazobactam) and administration of anesthesia (the technique was performed under local anesthesia and brachial plexus block) and using cardiovascular monitoring and fluoroscopic guidance, a direct access
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.12.015
to the lesion of interest was obtained by two bone access needles (Parallax CLEAR-VIEW 8-gauge needles; NeuroTherm, Inc, Amsterdam, The Netherlands) (Fig, b). Fluoroscopic guidance in multiple projections including anteroposterior, lateral, and “gun-barrel” view was used for needle advancement. “Gun-barrel” view is achieved by aligning the fluoroscopy beam axis to the needle axis. The final position of the needle inside the lesion was verified fluoroscopically after injection of contrast medium (1–3 mL). Coaxially a coblation (plasma mediated radiofrequency ablation) was used for tumor decompression to create intratumoral channels and render insertion of PMMA cement and microneedles easier (Fig, c). Under fluoroscopic control, 25–50 stainless steel microneedles (22-gauge, 2–6 cm length; HS Hospital Service S.P. A., Rome, Italy) were inserted through the needle’s trocar to create a metallic mesh in the lesion of interest, followed by PMMA (Parallax Acrylic Resin with TRACERS and Tantalum Particles; NeuroTherm, Inc) injection in different orientations (Fig, d, e). The aim was to include the whole lesion, extend to normal bone, and bind the microneedles together; this was achieved (at least in the cephalad part of the lesion toward the humeral head) by changing injection orientation and a twisting motion of the microneedles inside the bone. Owing to extraosseous leakage of the cement, the injection was interrupted before extensive binding of the cement volume in the peripheral humeral bone. The patient was hospitalized overnight, and a computed tomography scan was performed the next day. During clinical examination the morning after augmented osteoplasty, the patient reported a pain score of 6 of 10 NVS units (pain reduction of 4 NVS units) with moderate improvement of mobility impairment. The patient was reexamined 1 week later and reported a pain score of 5 of 10 NVS units with further improvement of mobility impairment. The patient was referred for physiotherapy. He was reexamined 1 month later and reported a pain score of 4 of 10 NVS units with further improvement of mobility impairment. At the follow-up evaluation 3 months after the therapeutic session, the patient reported a pain score of 3 of 10 NVS units with further improvement of mobility impairment. During the follow-up period, x-rays of the shoulder verified the stability of the implant inside bone (Fig, f). Throughout the 3-month follow-up period, the patient occasionally took analgesics (paracetamol 500 mg [Depon]; Bristol-Myers Squibb, New York, New York). According to Mirelsʼ scoring system (1), prophylactic fixation is recommended in cases of a long bone lytic metastasis with a score 4 8. However, apart from the impending fracture risk, the decision to perform surgical fixation also takes into consideration the patient’s performance status and life expectancy because the
596
’
Letters to the Editor
Kelekis et al
’
JVIR
Figure. (a). Computed tomography scan coronal reconstruction illustrating the large lytic metastatic lesion in the humeral head extending up to the surgical and anatomic neck of the proximal humerus (asterisks mark the limits of the lesion). (b) Anteroposterior fluoroscopy view. Two 8-gauge bone access needles (arrows) are advanced within the lesion. (c) Anteroposterior fluoroscopy view. Coaxially a coblation (plasma-mediated radiofrequency ablation) electrode (white arrow) was used for tumor decompression. Note the presence of contrast medium (black arrow) from a previous injection used to verify correct needle positioning and to illustrate possible routes of leakage. (d) Anteroposterior fluoroscopy view. Through the trocar of each needle, 25–50 stainless steel microneedles (arrow) were inserted under fluoroscopic control to create a metallic mesh in the lesion of interest. (e) Anteroposterior fluoroscopy view. PMMA injection (arrow) concluded the session. (f) Shoulder x-ray, anteroposterior projection, obtained 3 months after osteoplasty. Microneedles are in the exact same place (arrow), illustrating no migration of the implant. (Available in color online at www.jvir.org.)
procedure can have significant morbidity. Radiotherapy is advocated in cases in which lesions involve o 30 mm of the bone cortex. We perform augmented osteoplasty in long bone lesions because cement alone seems to be ineffective in the nonaxial, rotational forces applied during weight bearing in these locations, and some intramedullary instrumentation is necessary for sufficient long-term stabilization (2). In addition, in cases of pathologic fracture, case reports describe how the presence of cement may complicate treatment, and application of various therapeutic enhancements has been recommended to prevent such a complication (3). The pathophysiology of pain reduction after augmented osteoplasty of metastatic lesions in peripheral bones is multifactorial, including stabilization of osseous microfractures or macrofractures, destruction of nerve endings, cytotoxicity, and osteolysis treatment. Apart from all the aforementioned factors, stabilization and prevention of impeding pathologic fracture are key elements in the therapy of these patients with a short life expectancy, for
whom surgical options could be considered an aggressive treatment (4). Although vertebroplasty has been proven as an excellent technique for vertebral body fractures (where axial-craniocaudal forces are applied), there are reports of technique failure in peripheral bones (where rotational and shearing forces are applied) (2). Augmented osteoplasty seems to surpass the limitations of cementoplasty alone in the forces applied in peripheral locations. The technique is performed rapidly (total duration of 60 min) with an overnight hospital stay. We have tried to create a metallic mesh within the lesion and to perform cement injection to include the whole lesion, extend to normal tissue, and bind the microneedles together. In conclusion, percutaneous augmented osteoplasty with PMMA combined with a metallic mesh consisting of 25–50 medical-grade stainless steel microneedles (22-gauge, 2–6 cm length) for the treatment of symptomatic metastatic lesions in the long bones may work as an alternative to other percutaneous techniques of augmented osteoplasty.
Volume 26
’
Number 4
’
April
’
2015
REFERENCES 1. Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 1989; 249:256–264. 2. Deschamps F, Farouil G, Hakime A, et al. Cementoplasty of metastases of the proximal femur: is it a safe palliative option? J Vasc Interv Radiol 2012; 23:1311–1316. 3. Dayer R, Peter R. Percutaneous cementoplasty complicating the treatment of a pathologic subtrochanteric fracture: a case report. Injury 2008; 7: 801–804. 4. Anselmetti GC, Manca A, Chiara G, et al. Painful pathologic fracture of the humerus: percutaneous osteoplasty with bone marrow nails under hybrid computed tomography and fluoroscopic guidance. J Vasc Interv Radiol 2011; 22:1031–1034.
Ultrasound-Guided Phrenic Nerve Block for CT-Guided Percutaneous Pulmonary Fine-Needle Aspiration Biopsy From: Enrique Carrero, MD, PhD Pedro Arguis, MD Marcelo Sánchez, MD Xavier Sala-Blanch, MD Radiologic Anesthesia Unit (E.C.) and Orthopedics and Ambulatory Surgery Unit (X. S.-B.) Department of Anesthesiology Thoracic Radiology Unit (P.A., M.S.) Department of Radiology Hospital Clínic Human Anatomy and Embryology Unit (X.S.-B.) Faculty of Medicine University of Barcelona Villarroel 170 Barcelona, Spain
Editor: Computed tomography (CT)–guided percutaneous access to pulmonary lesions closer to the diaphragm is a challenge because of respiratory motion (1). We report two cases of in-plane ultrasound-guided phrenic nerve block (PhNB) to perform CT-guided percutaneous fineneedle aspiration biopsy (FNAB) of pulmonary nodules, while paralyzing the homolateral diaphragm. Our local institutional review board does not require approval for case reports when patients’ anonymity is carefully protected. We asked permission and obtained written consent from the patients for publication. In the first case, a 70-year-old man presented with a history of excised nodular melanoma (stage IIB). A focal and progressive enlargement of the right diaphragmatic pleura was observed on CT images. A right-sided inplane ultrasound-guided PhNB (M-Turbo portable ultrasound two-dimensional/tissue harmonic imaging/ None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.11.031
597
M-mode; SonoSite, Inc, Bothell, Washington) was performed with 2 mL lidocaine 2% (Fig 1a,b). Ultrasound and thoracic CT evaluations (Somatom Emotion 16; Siemens, Erlangen, Germany) showed complete paralysis of the right diaphragm (Fig 2a,b). The patient did not complain of dyspnea. There were no relevant changes in respiratory or hemodynamic parameters. With the patient in a prone position, a CT-guided percutaneous FNAB of the pulmonary nodule was performed 30 minutes after the PhNB (Fig 2c). Estimated right diaphragm paralysis was 90%. CT showed minor pneumothorax. The patient was transferred to the postanesthesia care unit. The CT image obtained 1 hour later showed no progression of the pneumothorax and complete reversal of the phrenic paralysis. The patient recovered with no fever, chest pain, or dyspnea and was discharged the following day. Cytologic analysis ruled out melanoma metastasis and showed mesothelial cells resembling a solitary fibrous tumor; this diagnosis was later confirmed during surgery. In the second case, a 33-year-old woman presented with a smoking history of 15 pack-years and a medical history of antiphospholipid syndrome. Radiographs showed a pulmonary infiltrate on the right lower lobe, in contact with the pleura. Pulmonary gammagraphy was normal. Having developed dyspnea associated with pleuritic pain and a cough with hemoptysis in the previous weeks and showing no signs suggesting pulmonary thromboembolism on CT pulmonary angiography, the patient was scheduled for a CT-guided percutaneous FNAB. Pulmonary function tests revealed an isolated decrease in carbon monoxide diffusion capacity. For ultrasound-guided inplane PhNB, 2 mL mepivacaine 1% was administered, and complete paralysis of the right diaphragm was achieved. The patient developed Horner syndrome and hypoesthesia of the right limb at the level of the C8 dermatome (medial part of hand and forearm). No other clinical or monitoring alterations were registered. CTguided percutaneous FNAB was performed in the prone position (Fig 3) with no pulmonary complications, although the phrenic paralysis had partially reversed. Monitoring showed no significant variations. The patient was transferred to the postanesthesia care unit. A CT scan performed 1 hour later showed no abnormalities and a complete reversal of the phrenic paralysis. Horner syndrome and distal arm hypoesthesia disappeared in a few hours. Cytologic testing ruled out tumoral malignancy, suggesting an inflammatory etiology. An empiric treatment with prednisone was initiated for suspected vasculitis. The patient was discharged 2 days after the procedure without sequelae. PhNB appears to be a feasible technique for CTguided percutaneous FNAB of pulmonary nodules in the inferior lobes and diaphragmatic pleura. Along its path through the anterior belly of the anterior scalene muscle, the phrenic nerve is thin (0.17 cm) and easily identifiable in most patients (4 90%) with a high-resolution
Editor: We report a case of percutaneous augmented osteoplasty in a large, solitary, lytic metastatic lesion of the humeral head by means of a metallic mesh consisting of 25–50 stainless steel microneedles combined with polymethyl methacrylate (PMMA) cement injection. Our hospital’s institutional review board did not require approval for this case report. A 40-year-old man with esthesioneuroblastoma and complaints of significant pain and mobility impairment (score of 10 of 10 on a numeric visual scale [NVS]) secondary to a large, solitary, lytic metastatic lesion in the humeral head was referred to our department. Standard x-rays and computed tomography scan showed the lesion covering the humeral head and extending up to the surgical and anatomic neck of the proximal humerus (Fig, a). The patient had undergone a series of radiotherapy sessions within the last 3 months and was taking opioid analgesics (fentanyl transdermal system delivering 75 μg/h; Janssen-Cilag Pty Limited, North Ryde, New South Wales, Australia) with neither significant pain reduction nor improvement in mobility. Because the patientʼs pain was not reduced after radiotherapy, he was referred to our department for therapy with interventional radiology palliative techniques. A percutaneous augmented osteoplasty was chosen as first-line therapy. Blood count and coagulation laboratory tests were performed 24 hours before the percutaneous augmented osteoplasty session. Under local sterile conditions, following antibiotic prophylaxis (according to the our hospital’s infectious diseases protocol, we administered a single intravenous dose of piperacillin/tazobactam) and administration of anesthesia (the technique was performed under local anesthesia and brachial plexus block) and using cardiovascular monitoring and fluoroscopic guidance, a direct access
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.12.015
to the lesion of interest was obtained by two bone access needles (Parallax CLEAR-VIEW 8-gauge needles; NeuroTherm, Inc, Amsterdam, The Netherlands) (Fig, b). Fluoroscopic guidance in multiple projections including anteroposterior, lateral, and “gun-barrel” view was used for needle advancement. “Gun-barrel” view is achieved by aligning the fluoroscopy beam axis to the needle axis. The final position of the needle inside the lesion was verified fluoroscopically after injection of contrast medium (1–3 mL). Coaxially a coblation (plasma mediated radiofrequency ablation) was used for tumor decompression to create intratumoral channels and render insertion of PMMA cement and microneedles easier (Fig, c). Under fluoroscopic control, 25–50 stainless steel microneedles (22-gauge, 2–6 cm length; HS Hospital Service S.P. A., Rome, Italy) were inserted through the needle’s trocar to create a metallic mesh in the lesion of interest, followed by PMMA (Parallax Acrylic Resin with TRACERS and Tantalum Particles; NeuroTherm, Inc) injection in different orientations (Fig, d, e). The aim was to include the whole lesion, extend to normal bone, and bind the microneedles together; this was achieved (at least in the cephalad part of the lesion toward the humeral head) by changing injection orientation and a twisting motion of the microneedles inside the bone. Owing to extraosseous leakage of the cement, the injection was interrupted before extensive binding of the cement volume in the peripheral humeral bone. The patient was hospitalized overnight, and a computed tomography scan was performed the next day. During clinical examination the morning after augmented osteoplasty, the patient reported a pain score of 6 of 10 NVS units (pain reduction of 4 NVS units) with moderate improvement of mobility impairment. The patient was reexamined 1 week later and reported a pain score of 5 of 10 NVS units with further improvement of mobility impairment. The patient was referred for physiotherapy. He was reexamined 1 month later and reported a pain score of 4 of 10 NVS units with further improvement of mobility impairment. At the follow-up evaluation 3 months after the therapeutic session, the patient reported a pain score of 3 of 10 NVS units with further improvement of mobility impairment. During the follow-up period, x-rays of the shoulder verified the stability of the implant inside bone (Fig, f). Throughout the 3-month follow-up period, the patient occasionally took analgesics (paracetamol 500 mg [Depon]; Bristol-Myers Squibb, New York, New York). According to Mirelsʼ scoring system (1), prophylactic fixation is recommended in cases of a long bone lytic metastasis with a score 4 8. However, apart from the impending fracture risk, the decision to perform surgical fixation also takes into consideration the patient’s performance status and life expectancy because the
596
’
Letters to the Editor
Kelekis et al
’
JVIR
Figure. (a). Computed tomography scan coronal reconstruction illustrating the large lytic metastatic lesion in the humeral head extending up to the surgical and anatomic neck of the proximal humerus (asterisks mark the limits of the lesion). (b) Anteroposterior fluoroscopy view. Two 8-gauge bone access needles (arrows) are advanced within the lesion. (c) Anteroposterior fluoroscopy view. Coaxially a coblation (plasma-mediated radiofrequency ablation) electrode (white arrow) was used for tumor decompression. Note the presence of contrast medium (black arrow) from a previous injection used to verify correct needle positioning and to illustrate possible routes of leakage. (d) Anteroposterior fluoroscopy view. Through the trocar of each needle, 25–50 stainless steel microneedles (arrow) were inserted under fluoroscopic control to create a metallic mesh in the lesion of interest. (e) Anteroposterior fluoroscopy view. PMMA injection (arrow) concluded the session. (f) Shoulder x-ray, anteroposterior projection, obtained 3 months after osteoplasty. Microneedles are in the exact same place (arrow), illustrating no migration of the implant. (Available in color online at www.jvir.org.)
procedure can have significant morbidity. Radiotherapy is advocated in cases in which lesions involve o 30 mm of the bone cortex. We perform augmented osteoplasty in long bone lesions because cement alone seems to be ineffective in the nonaxial, rotational forces applied during weight bearing in these locations, and some intramedullary instrumentation is necessary for sufficient long-term stabilization (2). In addition, in cases of pathologic fracture, case reports describe how the presence of cement may complicate treatment, and application of various therapeutic enhancements has been recommended to prevent such a complication (3). The pathophysiology of pain reduction after augmented osteoplasty of metastatic lesions in peripheral bones is multifactorial, including stabilization of osseous microfractures or macrofractures, destruction of nerve endings, cytotoxicity, and osteolysis treatment. Apart from all the aforementioned factors, stabilization and prevention of impeding pathologic fracture are key elements in the therapy of these patients with a short life expectancy, for
whom surgical options could be considered an aggressive treatment (4). Although vertebroplasty has been proven as an excellent technique for vertebral body fractures (where axial-craniocaudal forces are applied), there are reports of technique failure in peripheral bones (where rotational and shearing forces are applied) (2). Augmented osteoplasty seems to surpass the limitations of cementoplasty alone in the forces applied in peripheral locations. The technique is performed rapidly (total duration of 60 min) with an overnight hospital stay. We have tried to create a metallic mesh within the lesion and to perform cement injection to include the whole lesion, extend to normal tissue, and bind the microneedles together. In conclusion, percutaneous augmented osteoplasty with PMMA combined with a metallic mesh consisting of 25–50 medical-grade stainless steel microneedles (22-gauge, 2–6 cm length) for the treatment of symptomatic metastatic lesions in the long bones may work as an alternative to other percutaneous techniques of augmented osteoplasty.
Volume 26
’
Number 4
’
April
’
2015
REFERENCES 1. Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 1989; 249:256–264. 2. Deschamps F, Farouil G, Hakime A, et al. Cementoplasty of metastases of the proximal femur: is it a safe palliative option? J Vasc Interv Radiol 2012; 23:1311–1316. 3. Dayer R, Peter R. Percutaneous cementoplasty complicating the treatment of a pathologic subtrochanteric fracture: a case report. Injury 2008; 7: 801–804. 4. Anselmetti GC, Manca A, Chiara G, et al. Painful pathologic fracture of the humerus: percutaneous osteoplasty with bone marrow nails under hybrid computed tomography and fluoroscopic guidance. J Vasc Interv Radiol 2011; 22:1031–1034.
Ultrasound-Guided Phrenic Nerve Block for CT-Guided Percutaneous Pulmonary Fine-Needle Aspiration Biopsy From: Enrique Carrero, MD, PhD Pedro Arguis, MD Marcelo Sánchez, MD Xavier Sala-Blanch, MD Radiologic Anesthesia Unit (E.C.) and Orthopedics and Ambulatory Surgery Unit (X. S.-B.) Department of Anesthesiology Thoracic Radiology Unit (P.A., M.S.) Department of Radiology Hospital Clínic Human Anatomy and Embryology Unit (X.S.-B.) Faculty of Medicine University of Barcelona Villarroel 170 Barcelona, Spain
Editor: Computed tomography (CT)–guided percutaneous access to pulmonary lesions closer to the diaphragm is a challenge because of respiratory motion (1). We report two cases of in-plane ultrasound-guided phrenic nerve block (PhNB) to perform CT-guided percutaneous fineneedle aspiration biopsy (FNAB) of pulmonary nodules, while paralyzing the homolateral diaphragm. Our local institutional review board does not require approval for case reports when patients’ anonymity is carefully protected. We asked permission and obtained written consent from the patients for publication. In the first case, a 70-year-old man presented with a history of excised nodular melanoma (stage IIB). A focal and progressive enlargement of the right diaphragmatic pleura was observed on CT images. A right-sided inplane ultrasound-guided PhNB (M-Turbo portable ultrasound two-dimensional/tissue harmonic imaging/ None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.11.031
597
M-mode; SonoSite, Inc, Bothell, Washington) was performed with 2 mL lidocaine 2% (Fig 1a,b). Ultrasound and thoracic CT evaluations (Somatom Emotion 16; Siemens, Erlangen, Germany) showed complete paralysis of the right diaphragm (Fig 2a,b). The patient did not complain of dyspnea. There were no relevant changes in respiratory or hemodynamic parameters. With the patient in a prone position, a CT-guided percutaneous FNAB of the pulmonary nodule was performed 30 minutes after the PhNB (Fig 2c). Estimated right diaphragm paralysis was 90%. CT showed minor pneumothorax. The patient was transferred to the postanesthesia care unit. The CT image obtained 1 hour later showed no progression of the pneumothorax and complete reversal of the phrenic paralysis. The patient recovered with no fever, chest pain, or dyspnea and was discharged the following day. Cytologic analysis ruled out melanoma metastasis and showed mesothelial cells resembling a solitary fibrous tumor; this diagnosis was later confirmed during surgery. In the second case, a 33-year-old woman presented with a smoking history of 15 pack-years and a medical history of antiphospholipid syndrome. Radiographs showed a pulmonary infiltrate on the right lower lobe, in contact with the pleura. Pulmonary gammagraphy was normal. Having developed dyspnea associated with pleuritic pain and a cough with hemoptysis in the previous weeks and showing no signs suggesting pulmonary thromboembolism on CT pulmonary angiography, the patient was scheduled for a CT-guided percutaneous FNAB. Pulmonary function tests revealed an isolated decrease in carbon monoxide diffusion capacity. For ultrasound-guided inplane PhNB, 2 mL mepivacaine 1% was administered, and complete paralysis of the right diaphragm was achieved. The patient developed Horner syndrome and hypoesthesia of the right limb at the level of the C8 dermatome (medial part of hand and forearm). No other clinical or monitoring alterations were registered. CTguided percutaneous FNAB was performed in the prone position (Fig 3) with no pulmonary complications, although the phrenic paralysis had partially reversed. Monitoring showed no significant variations. The patient was transferred to the postanesthesia care unit. A CT scan performed 1 hour later showed no abnormalities and a complete reversal of the phrenic paralysis. Horner syndrome and distal arm hypoesthesia disappeared in a few hours. Cytologic testing ruled out tumoral malignancy, suggesting an inflammatory etiology. An empiric treatment with prednisone was initiated for suspected vasculitis. The patient was discharged 2 days after the procedure without sequelae. PhNB appears to be a feasible technique for CTguided percutaneous FNAB of pulmonary nodules in the inferior lobes and diaphragmatic pleura. Along its path through the anterior belly of the anterior scalene muscle, the phrenic nerve is thin (0.17 cm) and easily identifiable in most patients (4 90%) with a high-resolution
