Rev. bras. ortop. vol.52 número3

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Original

article

Osteoid

osteoma

–

radiofrequency

ablation

treatment

guided

by

computed

tomography:

a

case

series

夽

Rosana

Raquel

Endo

_,

_Natalia

_Fabris

_Gama

_,

_Suely

_Akiko

_Nakagawa

_,

Chiang

Jeng

Tyng

_,

_Wu

_Tu

_Chung

_,

_Fábio

_Fernando

_Eloi

_Pinto

a_{HospitalServidorPúblicoMunicipaldeSãoPaulo,DepartamentodeOrtopediaeTraumatologia,SãoPaulo,SP,Brazil}

b_{HospitalACCamargoCancerCenter,NúcleodeOrtopedia,SãoPaulo,SP,Brazil}

c_{HospitalACCamargoCancerCenter,DepartamentodeRadiologiaIntervencionista,SãoPaulo,SP,Brazil}

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Articlehistory: Received2June2016 Accepted7July2016

Availableonline28April2017

Keywords: Osteoidosteoma Radiofrequency

Boneneoplasms

Ablationtechniques

Computedtomography

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b

s

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t

Theosteoidosteomaisabenignprimarybonetumorthataffectsmainlymalesinthesecond andthirddecadesoflife.Radiographicfindingsshowaradiolucentnidussurroundedby reactivescleroticbone,particularlyinthelongbonesofthelowerextremity.Clinically,it presentspersistentpain,whichisworseatnightandimproveswithsalicylates.Itcanbea self-limitinginjury,withanaveragedurationofthreeyears,butbecauseofpainintensity andintolerancetoprolongeduseofnonsteroidalanti-inflammatories,surgicaltreatment isanoption.Thediagnosisissuspectedaccordingtothehistoryandradiographicfindings, andtheconfirmationismadebyhistologicalanalysis.Thetraditionalsurgicaltreatmentis thecompleteexcisionofthenidus,butsomedisadvantageshavebeendescribed,suchas difficultiesinlocalizingthelesionandriskoffractureduringtheprocedure,hospitalstayfor paincontrol,andunfavorableestheticoutcome.Theauthorsreportaseriesofcasestreated withthermalradiofrequencyablationguidedbycomputedtomographyinthisservice.Itis asafeandaneffectivepercutaneousmethodthataimstocure,minimizingthetraumaand morbiditywhencomparedwiththeconventionalblock-resectionmethod.

©2017PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileiradeOrtopedia eTraumatologia.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

夽

StudyconductedattheHospitalACCamargoCancerCenter,SãoPaulo,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](R.R.Endo).

http://dx.doi.org/10.1016/j.rboe.2017.04.005

338

Osteoma

osteoide

–

Tratamento

com

radioablac¸ão

guiada

por

tomografia

computadorizada:

uma

série

de

casos

Palavras-chave: Osteomaosteoide Radiofrequência Neoplasiasósseas Técnicasdeablac¸ão

Tomografiacomputadorizada

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Oosteomaosteoideéumtumorósseoprimáriobenignoqueacometemaisosexo mas-culinonasegundaeterceiradécadasdavida.Radiograficamente,caracteriza-sepor um nichoradiolucentecercadoporossoescleróticoreativo,principalmenteemossoslongosda extremidadeinferior.Clinicamente,apresentaumadorpersistentedelongadurac¸ão,com piorianoturnaemelhoriacomsalicilatos.Emborapossaserumalesãoautolimitada,com durac¸ãomédiadetrêsanos,aressecc¸ãodalesãoéumaopc¸ãodetratamentodevidoà inten-sidadedadoreintolerânciaaousoprolongadodeanti-inflamatóriosnãohormonais.Sua suspeitadiagnósticabaseia-seprincipalmentenahistóriaclínicaenosachados radiográfi-cos,aconfirmac¸ãoéfeitapeloestudoanatomopatológico.Otratamentocirúrgicoclássicoé aexcisãocirúrgicacompletadonicho,porémsãodescritasdesvantagenscomoadificuldade paraalocalizac¸ãointraoperatóriadalesão,riscodefraturaduranteoprocedimento,tempo deinternac¸ãohospitalarparacontroleálgicoeresultadoestéticodesfavorável.Relatamos umasériedecasostratadoscomtermoablac¸ãoporradiofrequênciaguiadaportomografia computadorizadaemnossoservic¸o.Trata-sedeummétodopercutâneoseguroeeficazque temcomoobjetivoacura,minimizaotraumaeamorbidadedoprocedimento,quando comparadocomométodoconvencionalderessecc¸ãoembloco.

©2017PublicadoporElsevierEditoraLtda.emnomedeSociedadeBrasileirade OrtopediaeTraumatologia.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND

(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Osteoid osteoma is a benign primary bone tumorinitially

reported by Heine1_{; Bergstrand}2 _{described its histology. In}

1935,Jaffe3_{classifiedthisneoplasmasaclinicaland}

patho-logicalentity,differentiatingitfromothertumors.

Thisisabenignprimaryneoplasmwhosenidusisformed byhypervascularizedimmatureosteoidtissue,surroundedby reactivescleroticbone.Itaccountsfor10%ofthebenignbone tumors4–6_{;itmostlyaffectsmales,inaratiorangingfrom1.6:1}

to4:1.6,7_{Themostprevalentagegroupisthesecondtothird}

decadesoflife.8

Osteoid osteoma can be observed in almost any bone

region,but it hasa higherincidenceinlongbones,mainly inthediaphysealregionofthetibiaandfemur.1,6

Clinically,it presentswithapersistent, long-lastingand

vague pain, with nocturnal worsening, that is sometimes

relieved withthe useofsalicylates and non-steroidal anti-inflammatorydrugs(NSAIDs).7,9

Radiographically,itischaracterizedbythepresenceofa radiolucent nidus whose diameter rarely exceeds 2cm,1,4,9

oftensurroundedbyreactivescleroticbone.

Themain radiographic differential diagnoses of osteoid

osteoma are bone infarction, chronic osteomyelitis, and

chondroblastoma.10 _{Sometimes, complementary imaging}

testssuchascomputedtomography (CT)ormagnetic

reso-nanceimagingcanprovideabettercharacterizationofthe niduse11,12_{;bonescanmay revealanintensenidusactivity}

andlowactivityofthesurroundingreactivearea.13_Thefinal

diagnosisismadethroughtheanatomopathologicalexam. Macroscopically, the nidus is well-delimited and

wine-colored. Normally, it does not exceed 2cm in diameter.

Microscopically,itiscomposedofarichlyvascularizedosteoid matrixandamatureintertwinedbonetrabeculae;itmayalso featureareasofcentralossification.

Classically, treatment consistsof block resection of the nidus.However,intraoperatively,itmaybedifficultto iden-tifytheexactlocationofthetumor.9_{Thus,minimallyinvasive}

approachessuchasthepercutaneousmethod,aidedby imag-ingmethods,overridethisdifficulty.

CT-guidedradiofrequencyablationisapercutaneous

tech-nique in which the use of electrodes connected to an

energysourceleadstoproteindenaturationandcoagulative necrosis.14_{However,adisadvantageofthemethodisthelack}

ofmaterialforanatomopathologicalexaminationand

diag-nosticconfirmation.

This study aimed to demonstrate the efficacy of the

adoptedtreatment,withsatisfactoryresultsinthecontrolof patientswithosteoidosteoma.

Material

and

methods

Theauthorsdescribethecasesoffivepatientswith

diagnos-ticsuspicionofosteoidosteomawhounderwentCT-guided

radiofrequencythermoablationbetweenSeptember2010and

March2013atthisservice.

Theneedforaninformedconsentwaswaived,asdatawas collectedthroughmedicalrecords.

Patients reported pain as main complaint; no patient

reportedapredilectionforthenightperiodandallpresented failuretorespondtodrugtreatmentwithsalicylates.

Fig.1–(1)AxialCTscanoftheleftfoot,indicatingosteolyticlesionwithsclerotichalo,locatedinthedomusofthetalus, compatiblewithosteoidosteoma;(2)introductionoftheJamshidineedlethroughthenidus;(3)positioningoftheablation needleinthepathcreatedbytheJamshidineedle;(4)controlCTaftertheprocedure.Case1:B.S.O.C.,16years,female.

340

Fig.3–(1)AxialCTscanoftherightarmshowinganosteolyticlesionwithsclerotichalo,locatedinthehumerus, associatedwithcorticalthickening,suggestiveofosteoidosteoma;(2)beginningofinsertionoftheJamshidineedle;(3) Jamshidineedleinsertedinsidethehumerus;(4)CToftherightarmshowingthecorrectpositioningoftheablationneedle insidethelesion.Case3:R.M.,38years,male.

Fig.5–(1)AxialCToftherightthighshowinganosteolyticimageinthefemoralcortex;(2)imageshowingtheJamshidi needleinsidethefemoralcortex;(3and4)CTcontrolofthepathmadebytheJamshidineedle;(5and6)CTcontrolshowing theablationneedlewithinthenidus.Case5:D.C.N.,20years,male.

PatientsincludedinthestudyarelistedinTable1;Figs.1–5

presenttheimagesacquiredduringtheprocedure.

Proceduretechnique

Patientis positionedon the CTframeunder general anes-thesia.Asepsis and antisepsismeasuresperformed forthe procedure.CTimagesaremade,identifyingtheexactlocation ofthenidus,itsrelationshipwithadjacentstructures,andthe bestpathtoitscenter.

AfterCT planning,an8-gaugeboneneedle (Jamshidi)is insertedintothenidus,thusmakingtheorificethroughwhich

Table1–Listofthepatientsincludedinthestudy.

Age Gender Location

Case1 16years Female Talus

Case2 21years Female Olecranon

Case3 38years Male Humerus

Case4 38years Male Tibia

342

thecool-tipsingleradiofrequencyneedle,witha1-cm bone-specificactiveprobe,ispassed.Aftertheneedleisintroduced anditspositioningisconfirmedthroughimagingexam, abla-tionisinitiated.Theclassicalinitialcyclelastsapproximately

12min,andthemaximumtemperatureoftheneedletothe

end ofthe procedure is60◦C_{. Coolingis providedby 0.9%} salineeveryminute,maintainingthetemperatureoftheactive probebelow10◦_{C.Afterthisfirstcycle,coldsalinecirculation}

isturnedoffandthesecondcyclestarts.Thecharringcycle isdonewithoutcooling;itlasts4–6minandthetemperature reaches80◦_Cto90◦_C.

Results

Follow-up consisted of clinical and radiographic

examina-tionsafterthe firstweekoftheprocedure, aswell asafter thefirst,sixthand12thmonthsoftheprocedure;afterthis period,patientswereconsideredtobeinremissionandtold toreturnyearly.Themostimportantperiodtoevaluatetumor recurrenceiswithinthefirst12months.9_{Intheablation}

treat-ment,nomaterialforanatomopathologicalexaminationwas retrieved.Nointercurrenceswereobservedduringtheablative procedure;patientsevolvedwithoutradiographicrecurrence ofthelesionuntilthepresent,andwithcompleteresolution ofthepain.

Discussion

Osteoidosteomaisabenignbonetumorthatusuallyaffects young individuals.Ithas a typicalclinical presentation; in mostcases,thepainisintermittent,withnocturnal worsen-ing,andasatisfactoryresponsetosalicylates.Itsdiagnostic suspicionisbasedmainlyonclinicalhistory,physical exami-nation,andradiographicfindings.9

Theclassictreatmentrequirescompletesurgicalexcision

ofthe nidus. The disadvantages ofthis procedure include

thedifficultyinlocatingtheintraoperativelesion,evenwith theuseofimage-guidedKirschnerwires;theneedforanew approachwhenresectionisincomplete;theriskofdamaging adjacentstructures;andtheriskofpostoperative complica-tionssuchasunsatisfactoryestheticresultsandvulnerability tofracturesduetothebonedefectcausedbyresection.For this reason,insome casesit isnecessary touse synthetic materialandbonegrafts,whichincreases themorbidityof theprocedure.15,16

TC-guidedradiofrequencythermoablationisaminimally

invasive percutaneous technique with low morbidity and

high accuracyinlocatingthe lesion.Itspossible complica-tions include cellulitis, bleeding, and infection at the site

of entry of the needle into the skin. Care must be taken

regarding the surrounding structures, such as the nerves; respectingthe1-cmdistancelimitfromthesestructurestothe activeprobeavoidsthermallesions.14_{Theoretically,themain}

disadvantageofthismethodistheabsenceof anatomopatho-logicalconfirmationofthediagnosis.However,someauthors defendthatthediagnosisispredominantlyclinicaland radio-graphic;histopathologicalconfirmationisnotnecessary,and itsabsencedoesnotinterfereintheclinicaloutcome.14,15,17,18

Thelimitations ofthis study were the small numberof patientsandtheshortfollow-uptimeelapsedfromthe treat-menttothedraftingofthepresentarticle.

The results obtained in the study are similar to those reportedbyotherauthors.14–16,19,20

Conclusion

CT-guidedradioablationisanappropriateoptionforthe treat-mentofosteoidosteoma,presentinggoodresults.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgement

ToCassiada Silvaforthehelpprovidedinconductingthis study.

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a

s

1.HeineJ.EinheilenderKnochensequesterundder

GrundphalanxdesRingfingers.ArchKlinChir.

1927;146:737–53.

2.BergstrandH.Übereineeigenartige,wahrscheinlichbisher

nichtbeschriebeneosteoblastischeKrankheitindenlangen

KnochenderHandunddesFusses.ActaRadiol.

1930;11(6):596–613.

3.JaffeHL.Osteoidosteoma.Abenignosteoblastictumor

composedofosteoidandatypicalbone.ArchSurg.

1935;31(5):709–28.

4.GreenspanA.Benignbone-forminglesions:osteoma,osteoid

osteoma,andosteoblastoma.SkeletalRadiol.

1993;22(7):485–500.

5.BusserWM,HoogeveenYL,VethRP,SchreuderHW,BalguidA,

RenemaWK,etal.Percutaneousradiofrequencyablationof

osteoidosteomaswithuseofreal-timeneedleguidancefor

accurateneedleplacement:apilotstudy.Cardiovasc

InterventRadiol.2011;34(1):180–3.

6.KransdorfMJ,StullMA,GilkeyFW,MoserRPJr.Osteoid

osteoma.Radiographics.1991;11(4):671–96.

7.BoscainosPJ,CousinsGR,KulshreshthaR,OliverTB,

PapagelopoulosPJ.Osteoidosteoma.Orthopedics.

2013;36(10):792–800.

8.AkhlaghpoorS,AzizAhariA,ArjmandShabestariA,

AlinaghizadehMR.Radiofrequencyablationofosteoid

osteomainatypicallocations:acaseserie.ClinOrthopRelat

Res.2010;468(7):1963–70.

9.CampanacciM,RuggieriP,GasbarriniA,FerraroA,

CampanacciL.Osteoidosteomadirectvisualidentification

andintralesionalexcisionoftheniduswithminimalremoval

ofbone.JBoneJointSurgBr.1999;81(5):814–20.

10.BecceF,TheumannN,RochetteA,LarousserieF,CampagnaR,

CherixS,etal.Osteoidosteomaandosteoid

osteoma-mimickinglesions:biopsyfindings,distinctive

MDCTfeaturesandtreatmentbyradiofrequencyablation.Eur

Radiol.2010;20(10):2439–46.

11.LiuPT,KujakJL,RobertsCC,deChadarevianJP.Thevascular

groovesign:anewCTfindingassociatedwithosteoid

12.YipPS,LamYL,ChanMK,ShuJS,LaiKC,SoYC.Computed

tomography-guidedpercutaneousradiofrequencyablationof

osteoidosteoma:localexperience.HongKongMedJ.

2006;12(4):305–9.

13.MotamediD,LearchTJ,IshimitsuDN,MotamediK,KatzMD,

BrienEW,etal.Thermalablationofosteoidosteoma:

overviewandstep-by-stepguide.Radiographics.

2009;29(7):2127–41.

14.RosenthalDI,HornicekFJ,TorrianiM,GebhardtMC,Mankin

HJ.Osteoidosteoma:percutaneoustreatmentwith

radiofrequencyenergy.Radiology.2003;229(1):171–5.

15.BareiDP,MoreauG,ScarboroughMT,NeelMD.Percutaneous

radiofrequencyablationofosteoidosteoma.ClinOrthopRelat

Res.2000;373:115–24.

16.CantwellCP,ObyrneJ,EustaceS.Currenttrendsintreatment

ofosteoidosteomawithanemphasisonradiofrequency

ablation.EurRadiol.2004;14(4):607–17.

17.WoertlerK,VestringT,BoettnerF,WinkelmannW,HeindelW,

LindnerN.Osteoidosteoma:CT-guidedpercutaneous

radiofrequencyablationandfollow-upin47patients.JVasc

IntervRadiol.2001;12(6):717–22.

18.RehnitzC,SprengelSD,LehnerB,LudwigK,OmlorG,MerleC,

etal.CT-guidedradiofrequencyablationofosteoidosteoma

andosteoblastoma:clinicalsuccessandlong-termfollowup

in77patients.EurJRadiol.2012;81(11):3426–34.

19.LindnerNJ,OzakiT,RoedlR,GoshegerG,WinkelmannW,

WörtlerK.Percutaneousradiofrequencyablationinosteoid

osteoma.JBoneJointSurgBr.2001;83(3):391–6.

20.CribbGL,GoudeWH,CoolP,TinsB,Cassar-PullicinoVN,

ManghamDC.Percutaneousradiofrequency

thermocoagulationofosteoidosteomas:factorsaffecting