Alexis Kelekis

Randomized, open label, prospective study on the effect of zoledronic acid on the prevention of bone metastases in patients with recurrent solid tumors that did not present with bone metastases at baseline

AbstractObjectives: Bisphosphonates have been used successfully in the treatment of hypercalcemia and to reduce skeletal-related complications of bone metastases. Recent in vitro and in vivo evidence suggest that they may also have direct antitumor effects via induction of apoptosis, inhibition of the invasive potential of tumor cell lines in vitro, inhibition of angiogenesis, and reduction in tumor growth indirectly via effects on accessory cells. This is a randomized, open label, prospective study that examined the effect of preventive zoledronic acid treatment on the development of bone metastases in patients with recurrent solid tumors, without bone metastases at the time of randomization. Methods: Forty patients with recurrent or metastatic advanced cancer, without bone metastases, were randomized into the trial to either receive zoledronic acid or no treatment. Patients were followed up until bone metastases were established. Results: The percentage of patients being bone metastases free at 12 mo was 60% in the zoledronic acid and 10% in the control group (p<0.0005), while the percentages at 18 mo were 20% and 5% respectively (p=0.0002). Conclusions: The results have shown that bisphosphonates as adjuvant treatment might be useful for the prevention of bone metastases; however, there is need for blinded randomized data before such an approach would be confirmed. In the meantime preventive use of bisphosphonates in patients without any bone metastases should not be used outside the scope of a clinical trial.

Pelvic Osteoplasty in Osteolytic Metastases: Technical Approach under Fluoroscopic Guidance and Early Clinical Results

PURPOSE To describe a new fluoroscopically guided technique for osteoplasty (or cementoplasty) of the superior and inferior pubic rami and ischial tuberosities and to provide information about the access routes and initial results on pain management after this technique. MATERIALS AND METHODS Twenty-three lytic metastases of the superior and inferior pubic rami and ischial tuberosities were treated in 14 consecutive patients. Percutaneous access of the bones was performed under fluoroscopy. All patients had pain refractory to radiation and narcotic therapy and were unsuitable candidates for surgery according to multidisciplinary consensus. RESULTS Technical success was achieved in all cases. Clinically, effective pain relief was obtained in 92% of patients. One intraarticular asymptomatic minor complication and one major complication resulting from leakage near the pudendal nerve were observed. The latter was subsequently treated by radiofrequency ablation. CONCLUSION Pelvic osteoplasty appears to be a safe and highly effective palliative therapy for painful osteolytic malignant bone metastases.

Patient and staff dosimetry in vertebroplasty.

Study Design. Eleven vertebroplasty operations were studied in terms of radiation dose. Objective. Doses to patients and staff associated with vertebroplasty were measured. Occupational doses were compared with the annual dose limits, and the effectiveness of the used radiation protection means was estimated. Patient dose was estimated by means of both surface and effective dose, and the radiation-induced risk was evaluated. Summary of Background Data. Vertebroplasty is a recent minimally invasive technique for the restoration of vertebral body fractures. It involves fluoroscopic exposure, and so, it demands dose measurements for both patient and staff exposed to radiation. Methods. Thermoluminescent dosimeters (TLDs) were placed on the medical personnel and the effective dose was derived. Slow films were placed to patients’ skin to measure entrance surface dose. Furthermore, a Rando phantom loaded with TLDs was irradiated under conditions simulating vertebroplasty, in order to estimate effective dose to the patient. Results. Mean fluoroscopy time was 27.7 minutes. Patient’s mean skin dose was 688 mGy, while effective dose was calculated to be 34.45 mGy. It was estimated that the primary operator can perform about 150 vertebroplasty operations annually without exceeding the annual dose constraints, whereas occupational dose can be reduced by 76% using mobile shielding. Conclusions. Measures have to be taken to reduce patient’s skin dose, which, in extreme cases, may be close to deterministic effects threshold. The highest dose rates, recorded during the procedure, were found for primary operator’s hands and chest when no shielding was used.

Standards of Practice: Quality Assurance Guidelines for Percutaneous Treatments of Intervertebral Discs

Percutaneous treatments are used in the therapy of small- to medium-sized hernias of intervertebral discs to reduce the intradiscal pressure in the nucleus and theoretically create space for the herniated fragment to implode inward, thus reducing pain and improving mobility and quality of life. These techniques involve the percutaneous removal of the nucleus pulposus by using a variety of chemical, thermal, or mechanical techniques and consist of removal of all or part of nucleus pulposus to induce more rapid healing of the abnormal lumbar disc. These guidelines are written to be used in quality improvement programs for assessing fluoroscopy- and/or computed tomography-guided percutaneous intervertebral disc ablative techniques.

Percutaneous bone lesion ablation

Benign tumors and metastatic bone lesions can be treated by ablation techniques performed either alone or in combination with other percutaneous techniques. Ablation techniques include ethanol or acetic acid injection and thermal ablation by means of energy deposition [including laser, radiofrequency, microwave, cryoablation, radiofrequency ionization and magnetic resonance (MR)-guided high-intensity focused ultrasound (HIFU)]. Goal definition of the therapy is crucial: ablation techniques can be proposed as curative treatments in benign bone tumors or oligometastatic disease (<3 lesions). Alternatively, these techniques can be proposed as palliative treatments aiming at reduction of pain, local control of the disease and tumor decompression. Depending on the lesion’s location ablation can be combined with cementation with or without further metallic augmentation; local tumor control can be enhanced by combining ablation with transarterial bland embolization or chemoembolization. Thermal ablation of bone and soft tissues is characterized by high success and relatively low rates of potential complications, mainly iatrogenic thermal damage of surrounding sensitive structures. Successful thermal ablation requires a sufficient ablation volume and thermal protection of the surrounding vulnerable structures. This article will describe the general principles governing ablation and the mechanism of action for each technique and in addition will review the literature about safety and effectiveness of percutaneous imaging-guided ablation for benign and malignant (primary and metastatic) lesions.

Comparative prospective randomized study comparing conservative treatment and percutaneous disk decompression for treatment of intervertebral disk herniation.

PURPOSE To compare short-, intermediate-, and long-term functional results concerning pain reduction and mobility improvement between conservative therapy and percutaneous disk decompression (PDD) in patients with intervertebral disk herniations. MATERIALS AND METHODS The study received approval from both the university ethics panel and the institutional review board. Patients provided informed consent for the study. Over the past 4 years, two randomized groups of 31 patients with sciatica due to intervertebral disk herniation were prospectively studied and compared with the t test. The control group underwent conservative therapy (administration of analgesics, antiinflammatory drugs, muscle relaxants, and physiotherapy) for 6 weeks. The decompression group underwent fluoroscopically guided PDD. Pain reduction and mobility improvement were recorded at 3-, 12-, and 24-month follow-up on a numeric visual scale (NVS) (range, 0-10). RESULTS The control group had a mean pain score of 6.9 NVS units ± 1.9 prior to conservative therapy. This was reduced to 0.9 NVS units ± 2.0 3 months after therapy; however, it increased to 4.0 NVS units ± 3.4 at 12-month follow-up and further increased to 4.0 NVS units ± 3.4 at 24-month follow-up. The decompression group had a mean pain score of 7.4 NVS units ± 1.4 prior to PDD. This was reduced to 3.0 NVS units ± 2.4 at 3-month follow-up and further reduced to 1.7 NVS units ± 2.4 at 12-month follow-up and 1.6 NVS units ± 2.5 at 24-month follow-up. No complications were noted. CONCLUSION When compared with conservative therapy, PDD shows improved amelioration of symptoms at 12- and 24-month follow-up.

Interventional procedures of the spine.

Different interventional procedures performed under imaging guidance permit the diagnosis and treatment of the many causes of back pain. Sources of pain amenable to be treated include facet joints, vertebral body, intervertebral disk, and paraspinal structures including nerves and ganglion roots. These procedures may be merely diagnostic, therapeutic, or intended for both purposes. We review the main indications, advantages, and complications of these techniques.

Percutaneous treatment of cervical and lumbar herniated disc

Therapeutic armamentarium for symptomatic intervertebral disc herniation includes conservative therapy, epidural infiltrations (interlaminar or trans-foraminal), percutaneous therapeutic techniques and surgical options. Percutaneous, therapeutic techniques are imaging-guided, minimally invasive treatments for intervertebral disc herniation which can be performed as outpatient procedures. They can be classified in 4 main categories: mechanical, thermal, chemical decompression and biomaterials implantation. Strict sterility measures are a prerequisite and should include extensive local sterility and antibiotic prophylaxis. Indications include the presence of a symptomatic, small to medium sized contained intervertebral disc herniation non-responding to a 4-6 weeks course of conservative therapy. Contraindications include sequestration, infection, segmental instability (spondylolisthesis), uncorrected coagulopathy or a patient unwilling to provide informed consent. Decompression techniques are feasible and reproducible, efficient (75-94% success rate) and safe (>0.5% mean complications rate) therapies for the treatment of symptomatic intervertebral disc herniation. Percutaneous, imaging guided, intervertebral disc therapeutic techniques can be proposed either as an initial treatment or as an attractive alternative prior to surgery for the therapy of symptomatic herniation in both cervical and lumbar spine. This article will describe the mechanism of action for different therapeutic techniques applied to intervertebral discs of cervical and lumbar spine, summarize the data concerning safety and effectiveness of these treatments, and provide a rational approach for the therapy of symptomatic intervertebral disc herniation in cervical and lumbar spine.

Baastrup's disease (kissing spines syndrome): a pictorial review.

Excessive lordosis is a common finding and may produce mechanical pressure that causes repetitive strains of the interspinous ligament with subsequent degeneration and collapse. Baastrup’s disease (kissing spine syndrome) is a term referring to close approximation of adjacent spinous processes due to degenerative changes of the spine. Baastrup’s disease usually affects the lumbar spine, with L4-L5 being the most commonly affected level. There is higher occurrence at ages over 70 and no gender predilection. Symptoms include back pain with midline distribution that worsens during extension, is relieved during flexion and is exaggerated upon finger pressure at the level of interest. Diagnosis rests on clinical examination and imaging studies. The hallmark of imaging findings is the close approximation and contact of adjacent spinous processes, with all the subsequent findings including oedema, cystic lesions, sclerosis, flattening and enlargement of the articulating surfaces, bursitis and occasionally epidural cysts or midline epidural fibrotic masses. Proposed therapies include conservative treatment, percutaneous infiltrations or surgical therapies such as excision of the bursa or osteotomy. The purpose of this study is to illustrate the spectrum of imaging findings in Baastrup’s disease and to emphasise upon including the syndrome in the list of potential causes of low-back pain.Teaching Points• Baastrup’s disease refers to close approximation of adjacent spinous processes.• Diagnosis of Baastrup’s disease is verified with clinical examination and imaging studies.• Contact of adjacent spinous processes results in oedema, sclerosis, flattening and enlargement.• Proposed therapies include conservative treatment, percutaneous infiltrations or surgical therapies.

A review of percutaneous techniques for low back pain and neuralgia: current trends in epidural infiltrations, intervertebral disk and facet joint therapies

Low back pain and neuralgia due to spinal pathology are very common symptoms debilitating numerous patients with peak prevalence at ages between 45 and 60 years. Intervertebral discs and facet joints act as pain sources in the vast majority of the cases. Diagnosis is based on the combination of clinical examination and imaging studies. Therapeutic armamentarium for low back pain and neuralgia due to intervertebral discs and/or facet joints includes conservative therapy, injections, percutaneous therapeutic techniques and surgical options. Percutaneous, therapeutic techniques are imaging-guided, minimally invasive treatments which can be performed as outpatient procedures. In cases of facet joint syndrome, they include, apart from injections, neurolysis with radiofrequency/cryoablation, MR-guided high-intensity focused ultrasound and percutaneous fixation techniques. In case of discogenic pain, apart from infiltrations, therapeutic techniques can be classified in to two main categories: decompression (mechanical, thermal, chemical) techniques and biomaterials implantation/disc cell therapies. Strict sterility measures are a prerequisite and should include extensive local sterility and antibiotic prophylaxis. This article will report clinical and imaging findings for each pathology type and the association with treatment decision. In addition, we will describe in detail all possible treatment techniques for low back pain and neuralgia, and we will report recently published results of these techniques summarizing the data concerning safety and effectiveness as well as the level of evidence. Finally, we will try to provide a rational approach for the therapy of low back pain and neuralgia by means of minimally invasive imaging-guided percutaneous techniques.