Giuseppe Rossi

Percutaneous CT-guided biopsy of the spine: results of 430 biopsies

Biopsies of lesions in the spine are often challenging procedures with significant risk of complications. CT-guided needle biopsies could lower these risks but uncertainties still exist about the diagnostic accuracy. Aim of this retrospective study was to evaluate the diagnostic accuracy of CT-guided needle biopsies for bone lesions of the spine. We retrieved the results of 430 core needle biopsies carried out over the past fifteen years at the authors’ institute and examined the results obtained. Of the 430 biopsies performed, in 401 cases the right diagnosis was made with the first CT-guided needle biopsy (93.3% accuracy rate). Highest accuracy rates were obtained in primary and secondary malignant lesions. Most false negative results were found in cervical lesions and in benign, pseudotumoral, inflammatory, and systemic pathologies. There were only 9 complications (5 transient paresis, 4 haematomas that resolved spontaneously) that had no influence on the treatment strategy, nor on the patient’s outcome. In conclusion we can assert that this technique is reliable and safe and should be considered the gold standard in biopsies of the spine.

Efficacy of Ultrasound-guided Intra-articular Injections of Platelet-rich Plasma Versus Hyaluronic Acid for Hip Osteoarthritis

Intra-articular injections of platelet-rich plasma (PRP) and hyaluronic acid (HA) represent efficacious medical treatments for osteoarthritis (OA), although no comparative study on long-term efficacy in hip OA exists. The goals of the current study were to compare the clinical efficacy of PRP vs HA at 12 months of follow-up in patients with hip OA and evaluate the influence of the type of infiltration and patient age, sex, body mass index, and degree of OA on temporal clinical evolution. One hundred patients with chronic unilateral symptomatic hip OA were consecutively enrolled and randomly assigned to 1 of 2 groups: group A received PRP and group B received HA administered via intra-articular ultrasound-guided injections. Patients were evaluated at baseline and after 1, 3, 6, and 12 months using the Harris Hip Score (HHS) and visual analog scale (VAS). An overall improvement was detected in both groups between 1- and 3-month follow-up. Despite a slightly progressive worsening between 6- and 12-month follow-up, the final clinical scores remained higher compared with baseline (P<.0005), with no significant differences between PRP and HA. Regarding clinical temporal evolution, multivariate analysis showed that HHS was not influenced by the type of infiltration, patient age, sex, body mass index, or degree of OA, whereas a significant association was detected between OA grade IV and VAS evolution (P<.0005). Intra-articular injections of PRP are efficacious in terms of functional improvement and pain reduction but are not superior to HA in patients with symptomatic hip OA at 12-month follow-up.

Palliative therapy for osteosarcoma.

Despite advances in diagnostic imaging, the evolution of neoadjuvant chemotherapy and the refinements in limb-salvage surgery, the progression-free survival rate remains poor for patients with metastatic, recurrent or unresectable osteosaroma. Different therapeutic strategies for these subgroups of patients have been employed to control disease and prolong survival. Treatment options are limited and controversial, including systemic and localized therapies. Surgical resection, whenever feasible, is still the standard treatment in advanced osteosarcoma. The role of chemotherapy is unclear while the use of radiotherapy, embolization and thermal ablation is increasing. New therapeutic experimental approaches and novel target therapies are needed to improve the outcome of these subgroups of patients.

Selective embolization with N-butyl cyanoacrylate for metastatic bone disease.

PURPOSE To evaluate the clinical and imaging effect of selective embolization using N-butyl cyanoacrylate (NBCA) as palliation for bone metastases. MATERIALS AND METHODS The procedures and effect of 309 embolizations performed in 243 patients were retrospectively analyzed; 56 patients had repeat embolization at the same location at 1-3 months; 197 patients had embolization for progressive bone metastases after radiation therapy. The mean tumor diameter before embolization was 7.8 cm (range 5-30 cm). In all patients, embolizations were performed under local anesthesia through transfemoral catheterization using NBCA in 33% ethiodized oil. The technical success of embolization was evaluated by angiography after completion of the procedure. The clinical and imaging effect was evaluated at follow-up examinations with a pain score scale and use of analgesics, hypoattenuating areas, tumor size, and ossification. RESULTS In all 309 embolizations, postprocedural angiography showed complete occlusion of metastatic blood supply and greater than 80% devascularization of the lesions. Greater than 50% reduction of pain score and analgesic doses was achieved in 97% of procedures. The mean duration of pain relief was 8.1 months (range 1-12 months). The mean maximal tumor diameter after embolization was 5.5 cm (range 2-20 cm). Variable ossification appeared in 65 patients. Postembolization syndrome, ischemic pain at the site of embolization, paresthesias, skin breakdown, and subcutaneous necrosis were observed in 87 patients. CONCLUSIONS Selective embolization with NBCA is a safe and effective palliative treatment for metastatic bone lesions of various primary cancers; pain relief is temporary.

Selective arterial embolisation for bone tumours: experience of 454 cases

PurposeThe authors present the experience of a single institution with selective arterial embolisation for primary and metastatic bone tumours.Materials and methodsA total of 365 patients were treated with 454 embolisation procedures from December 2002 to April 2010. Embolisation was the primary treatment for benign bone tumours, adjuvant treatment to surgery for benign and malignant bone tumours and palliative treatment for bone sarcomas and metastases. Indications for repeat embolisation included pain or imaging evidence of progressive disease: 105 patients had repeat embolisation at the same location at an interval of 1–3 months; 260 patients had one embolisation, 78 had two and 29 had three or more. In all patients, N-2-butyl cyanoacrylate (NBCA) in 33% lipiodol was the embolic agent used.ResultsA total of 419 of the 454 embolisations (93%) were technically successful. In 35 cases, embolisation was not feasible because of poor lesion vascularisation (21 patients with bone metastases and two with aneurysmal bone cysts), origin of the Adamkiewicz artery in the embolisation field (four patients with bone metastases and one with aneurysmal bone cyst), atheromatosis and arteriosclerosis (five patients with bone metastases) and anatomical and technical problems such as small-calibre vessels, many branches and acute vessel angles (two patients with bone metastases). A clinical response was achieved in 406 of the 419 procedures (97%), and no response in 13 procedures in patients with pelvis and sacrum tumours. Complications included postembolisation syndrome in 81 patients (22%), transient paraesthesias in 41 (11%), skin breakdown and subcutaneous necrosis at the shoulder and pelvis in five (1.4%) and paresis of the sciatic nerve in one (0.3%).ConclusionsWe recommend embolisation as primary or palliative treatment or an adjunct to surgery for tumours of variable histology. Strict adherence to the principles of transcatheter embolisation is important. Arteries feeding the tumour and collaterals must be evaluated carefully and catheterised superselectively to protect the normal tissues. NBCA is considered the most appropriate embolic agent for small-vessel occlusion without major complications.RiassuntoObiettivoScopo del nostro lavoro è presentare l’esperienza di una singola istituzione nell’embolizzazione arteriosa selettiva dei tumori primitivi e delle metastasi dell’apparato muscolo-scheletrico.Materiali e metodiTrecentosessantacinque pazienti sono stati sottoposti a 454 embolizzazioni da dicembre 2002 a aprile 2010. L’embolizzazione è stata usata come trattamento primario per pseudo-tumori e tumori benigni, con significato adiuvante nel trattamento dei tumori maligni e nelle forme benigne e con significato palliativo nel trattamento dei sarcomi dell’osso e delle lesioni metastatiche. Il dolore e l’evidenza all’imaging di una progressione di malattia era l’indicazione per la ripetizione dell’embolizzazione; 105 hanno ripetuto l’embolizzazione nella stessa sede, ad intervallo di 1–3 mesi; 260 pazienti sono stati sottoposti ad una sola embolizzazione, 78 pazienti a due embolizzazioni e 29 pazienti a tre o più embolizzazioni. In tutti è stato usato come unico agente embolizzante l’N-2-butil-Cianoacrilato (NBCA) diluito con lipiodol al 33%.RisultatiQuattrocentodiccianove embolizzazioni (93%) sono state portate a termine con successo. Si è ottenuta risposta clinica in 406 procedure (97%) e nessuna risposta in 13 procedure in pazienti con tumori del bacino e del sacro. In 35 pazienti non è stata eseguita alcuna embolizzazione: in 21 pazienti con metastasi e in 2 con cisti aneurismatiche per scarsa vascolarizzazione; in 4 con metastasi ossea ed in 1 con cisti aneurismatica per la presenza di arteria di Adamkiewicz nella vascolarizzazione della lesione; in 5 pazienti con metastasi ossee per problemi steno-ostruttivi su base ateromasica; in 2 pazienti con metastasi per problemi tecnici legati al calibro dei vasi. Per quanto riguarda le complicazioni, in 81 pazienti (22%) è stata osservata una sindrome post-embolica, in 41 pazienti (11%) paresi transitoria, in cinque pazienti (1,4%) necrosi cutanea e sottocutanea di spala e pelvi, e in un paziente (0,3%) è stata riscontrata una paresi transitoria del nervo sciatico.ConclusioniRaccomandiamo l’embolizzazione per tumori ossei di varia istologia come trattamento primario, adiuvante o palliativo. È fondamentale un rigorosa adesione ai principi delle tecniche di embolizzazione. I vasi afferenti alla lesione vanno attentamente valutati e cateterizzati in maniera altamente selettiva al fine di proteggere i tessuti non lesionali. L’NBCA è, a nostro avviso, l’agente embolizzante più adatto per l’occlusione di piccoli vasi in assenza di complicanze maggiori, ma richiede buona esperienza da parte degli operatori.

Embolisation of bone metastases from renal cancer.

PurposeThis study was done to evaluate embolisation for palliative and/or adjuvant treatment of bone metastases from renal cell carcinoma and discuss the clinical and imaging results.Materials and methodsWe retrospectively studied 107 patients with bone metastases from renal cell carcinoma treated from December 2002 to January 2011 with 163 embolisations using N-2-butyl cyanoacrylate (NBCA). Mean tumour diameter before embolisation was 8.8 cm and mean follow-up 4 years. Clinical and imaging effects of treatment were evaluated at follow-up examinations with a pain score scale, analgesic use, hypoattenuating areas, tumour size and ossification.ResultsA clinical response was achieved in 157 (96%) and no response in six embolisations of sacroiliac metastases. Mean duration of clinical response was 10 (range 1–12) months. Hypoattenuating areas resembling tumour necrosis were observed in all patients. Variable ossification appeared in 41 patients. Mean maximal tumour diameter after embolisation was 4.0 cm. One patient had intraprocedural tear of the left L3 artery and iliopsoas haemorrhage and was treated with occlusion of the bleeding vessel with NBCA. All patients had variable ischaemic pain that recovered completely within 2–4 days. Postembolisation syndrome was diagnosed after 15 embolisations (9.2%). Transient paraesthesias in the lower extremities were observed after 25 embolisations (25%) of pelvis and sacrum metastatic lesions.ConclusionsEmbolisation with NBCA is recommended as primary or palliative treatment of bone metastases from renal cell carcinoma. Strict adherence to the principles of transcatheter embolisation is important to avoid complications.RiassuntoObiettivoScopo del presente lavoro è stato valutare l’embolizzazione come trattamento palliativo e/o adiuvante delle metastasi ossee da carcinoma a cellule renali e discuterne i risultati clinici e radiologici.Materiali e metodiAbbiamo studiato retrospettivamente 107 pazienti con metastasi da carcinoma renale trattati con 163 embolizzazioni con N-2-butil ciano-acrilato (NBCA) da dicembre 2002 a gennaio 2011. Il diametro medio tumorale prima dell’embolizzazione era di 8,8 cm. La media dei follow-up era di di 4 anni. Gli effetti clinici e radiologici sono stati valutati durante i successivi controlli con una scala di punteggio per il dolore, uso degli analgesici, aree di ipoattenuazione, dimensione del tumore ed ossificazione.RisultatiUna risposta clinica è stata ottenuta in 157 embolizzazioni (96%) mentre non è stata ottenuta alcuna risposta in 6 embolizzazioni di metastasi alla sacro-iliaca. La durata media della risposta clinica è stata di 10 mesi (da 1 a 12 mesi). Aree di ipoattenuazione associabili a necrosi tumorale sono state osservate in tutti i pazienti. Ossificazione variabile è stata osservata in 41 pazienti. La media dei diametri tumorali dopo l’embolizzazione è stata di 4,0 cm. Un paziente ha riportato, durante la procedura, una lesione dell’arteria sinistra di L3 ed emorragia nell’ileo-psoas, è stato trattato con occlusione del vaso sanguinante con NBCA. Tutti i pazienti hanno avuto un grado variabile di dolore ischemico che è completamente scomparso in un arco di 2–4 giorni. Dopo la procedura sono stati diagnosticati 15 casi (9,2%) di sindrome post-embolizzazione. Parestesie transitorie agli arti inferiori sono state osservate dopo 25 embolizzazioni (25%) di lesioni metastatiche al sacro ed alle pelvi.ConclusioniL’embolizzazione con NBCA è raccomandata come trattamento sia primario che palliativo delle metastasi ossee da carcinoma renale. Una rigorosa aderenza ai principi di embolizzazione attraverso catetere è importante per evitare complicazioni.

Incidental vertebral compression fractures in imaging studies: Lessons not learned by radiologists

AIM To assess radiologists reporting rates of incidental vertebral compression fractures in imaging studies. METHODS We performed a review of the current literature on the prevalence and reporting rates of incidental vertebral compression fractures in radiologic examinations. RESULTS The bibliographic search revealed 12 studies: 7 studies using conventional radiology and 5 using multidetector computed tomography (MDCT). The loss of height cut-off to define a vertebral fracture varied from 15% to 25%. Fracture prevalence was high (mean 21.1%; range 9.5%-35%) in both radiographic and MDCT studies (mean 21.6% and 20.2%, respectively). Reporting rates were low with a mean value of 27.4% (range 0%-66.3%) and were significantly lower in MDCT than in radiographic studies (mean 8.1% vs 41.1%). Notably, recent studies showed lower reporting rates than older studies. CONCLUSION Many scientific studies have confirmed a high prevalence of vertebral compression fractures as incidental findings on imaging studies. However, the underreporting of these fractures, as determined in our study, may negatively affect patient care.

Successful Treatment of Aggressive Aneurysmal Bone Cyst of the Pelvis With Serial Embolization

Intralesional surgery is most commonly used for aneurysmal bone cysts. Rarely is en bloc resection used for active, aggressive, recurrent lesions and those located in expendable bones. However, persistence or recurrence of aneurysmal bone cysts is common. The clinical behavior of aneurysmal bone cysts is more aggressive in younger patients. Selective embolization is used as the primary treatment for aneurysmal bone cysts in surgically difficult anatomical locations and as an adjuvant to surgical treatment to reduce intraoperative blood loss and facilitate curettage.This article describes a 3-year-old boy with an aggressive aneurysmal bone cyst of the pelvis involving the right ischiopubic rami that achieved curative treatment with 3 embolizations with N-2-butyl-cyanoacrylate. Biopsy was diagnostic; however, the clinical course was misleading. Twenty days after the first embolization, despite complete occlusion of the feeding vessels, the patient experienced severe pain, increased size of the lesion, and lateral subluxation of the right hip. Based on the imaging and histological diagnosis, intralesional hemorrhage was assumed, and repeat embolization was performed. After the second embolization, the patient experienced perineal skin necrosis from normal vessel embolization; it was treated with wound dressing changes and healed uneventfully. A third embolization was performed because of a persistent lesion. Six years after treatment, the patient was symptom free, and imaging showed complete ossification of the cyst.Selective catheterization and occlusion of the feeding arteries with the appropriate embolic agent provide tumor devascularization, size reduction, pain relief, and induction of new bone formation. Multiple procedures are often necessary, and complications may occur.

State-of-the-art approach for bone sarcomas

Abstract Bone sarcomas are a variety of non-epithelial, malignant neoplasms of bone. The most common bone sarcomas are osteosarcoma, Ewing’s sarcoma, and chondrosarcoma. The approach to a patient with a suspected bone sarcoma from initial examination to the histological diagnosis and classification is staging. Staging is of critical importance, in order to classify different treatment options and point out which combination of them is more suitable depending on the severity of the tumor in every individual patient. Staging should include medical history, physical and imaging examination, and biopsy. This article presents the current approach for staging, principles of biopsy, tumor classification, treatment, and follow-up of patients with bone sarcomas.

Validity of preoperative ultrasound-guided aspiration in the revision of hip prosthesis.

Preoperative diagnosis of septic loosening hip prosthesis is often challenging. Culture test on joint samples obtained during revision surgery is the diagnostic gold standard while the role of preoperative hip aspiration is still controversial. The aims of this prospective randomized study were to compare the sensitivity, specificity and accuracy of preoperative ultrasound-guided and fluoroscopic-guided aspiration, and to identify associated laboratory parameters or scintigraphy that could help in predicting septic loosing hip prosthesis. Sixty patients affected by persistent pain after hip prosthesis randomly received fluoroscopic-guided or ultrasound-guided hip aspiration before revision surgery. The results of culture tests of joint fluid presurgically and at surgery were compared. In addition, associated blood inflammatory markers and scintigraphy were evaluated. Ultrasound-guided aspiration showed a better sensitivity (69% vs. 27%), specificity (94% vs. 75%) and accuracy (83% vs. 40%) than fluoroscopic-guided aspiration. The combination of ultrasound-guided aspiration and C-reactive protein represents the best model to predict septic loosening hip prosthesis preoperatively.