Percutaneous consolidation of bone metastases: strategies and techniques
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Patients with cancer can present with bone metastases (BM), which are frequently complicated by different types of fractures necessitating prompt management to avoid serious impairment in terms of quality of life and survival.
Percutaneous image-guided bone consolidation has rapidly emerged as an alternative to surgical fixation and is mainly reserved for patients who are deemed unfit for surgical management. Two percutaneous techniques, osteoplasty and osteosynthesis, are available and are selected based on the biomechanics of the target bones as well as the fracture types.
The aim of this narrative review is to present the different types of BM-related fractures and the interventional strategies and techniques underpinning their minimally invasive percutaneous fixation.
KeywordsBone Metastases Fractures Osteoplasty Osteosynthesis
“Spine Instability Neoplastic Score”
Skeletal related events
Bone metastases are frequently complicated by three different types of fractures.
Percutaneous image-guided osteoplasty and osteosynthesis can be used to fix cancer-related bone fractures.
Percutaneous osteoplasty and osteosynthesis should be mainly offered to “non-surgical” patients.
Bone metastases (BM) represent a common clinical condition in cancer patients as bone-metastasizing tumors such as prostate, breast, and lung cancer account for approximately 45% of cancers [1, 2]. Clinically, BM often result in pain, fractures, and hypercalcemia ; moreover, surgery or radiation therapy (RT) is frequently required to manage these presentations. These events are commonly known as skeletal-related events (SREs). Amongst SREs, fractures represent one of the most troublesome complications as they can cause significant pain, functional disability, and neurological sequelae, dramatically affecting quality of life and survival. Surgical fixation has traditionally been the treatment of choice due to its construct durability. However, it is frequently deemed unsuitable for frail oncology patients generally due to perioperative factors such as prolonged anesthetic time and prolonged recovery time, adding again to a risk of reduction in quality of life and survival . For this reason, the minimally invasive, percutaneous image-guided techniques which are associated with a shorter recovery time have been introduced with encouraging results [4, 5, 6, 7, 8, 9, 10, 11, 12, 13].
The aim of this narrative review is to present the different types of BM-related fractures and the interventional strategies and techniques underpinning their percutaneous fixation.
Type of fractures
Bone insufficiency fractures resulting from the bone necrosis secondary to percutaneous ablation or radiotherapy or resulting from the bone resorption as a result of tumor metabolism or certain treatments (e.g., chemotherapy, long-term steroid treatment) (Fig. 1).
Pathologic fractures resulting from bone replacement by infiltrating tumor (Fig. 2).
Impending fractures being consistent with painful and extensive metastatic tumor involvement of the weight-bearing bones, which are therefore at an increased risk of fracture; subsequently, preventive consolidation is highly advised (Fig. 3).
Percutaneous bone consolidation is strictly applied to “non-surgical” cancer patients. This includes those patients being unsuitable for surgical management due to the suboptimal physiological state, refusal of consent, or unacceptable delay to systemic therapy. These patients are treated, provided they have an acceptable estimated life expectancy (> 1 month) [9, 13].
Requiring focal treatment to achieve local tumor control due to their oligometastatic (< 3–5 metastases, each < 3 cm) or oligoprogressing (1 to 3 metastases evolving despite good systemic tumor control assured by systemic therapies) status [14, 15, 16, 17].
Demonstrating soft-tissue infiltration requiring tumor debulking to prevent the complications to the adjacent organs or to control pain .
Contraindications to percutaneous bone consolidation are as follows: severely displaced fractures, concurrent osteomyelitis or active systemic infection, severe uncorrectable coagulopathy, and allergy to the bone cement or osteosynthesis material.
Percutaneous techniques and their selection
Solid phase composition
• PMMA pre-polymer and/or copolymers of acrylic acid (AA)
• Activator of the polymerization: benzoyl peroxide
• Radiopacifiers: barium sulfate, zirconium dioxide, tantalum, and tungsten
Liquid phase composition
• Methyl methacrylate monomer
• Activator of the polymerization: N-N-dimethyl-p-toluidine (DMPT)
• Inhibitor of polymerization during storage: hydroquinone (HQ)
• 2600–3500 MPa
• 46–76 MPa
• 70–111 MPa
PMMA is injected through a dedicated gun-like device, under continuous fluoroscopic guidance to monitor PMMA distribution within the target bone and to detect as early as possible any potential PMMA leakage. To avoid irradiation to operators’ hands, leaded gloves should be used. The injection is commenced in the distal normal bone in order to anchor the PMMA in healthy bone; thereafter, the trocar tip is gently withdrawn and the injection is continued to fill the lytic cavity as much as possible (Fig. 3). In the case of any PMMA leakages outside the bone, the injection should be immediately stopped especially if vascular leakages are noted. Disruption of the normal cortical bone does not represent an absolute contraindication to osteoplasty [8, 20] even though there is a theoretical increased risk of PMMA leakage. In the end, it should be noted that although PMMA leakage is the most common adverse event, it rarely results into a clinically significant complication .
The screws are made of stainless steel or titanium, comprised of a head and a body, and are self-drilling/self-tapping to avoid the jamming of the cut bone whilst being advanced into the target bone.
Screws are manually advanced by means of a dedicated screwdriver over a 1.8–2-mm Kirschner wire, which is deployed in the target bone coaxially through a 10G bone trocar either directly into the bone by means of an electric drill.
Kirschner wire deployment represents the most critical phase of the procedure, thus often requiring expert operators and advanced imaging guidance such as combined CT/fluoroscopy (Fig. 7) or cone-beam CT.
The screws need to be anchored in proximal and distal healthy bone by perpendicularly bridging the fracture line. They also ought to bridge the lytic BM parallel to the long axis of the target bone, in order to allow maximal inter-fragmentary compression. In particular, the head of the screw should abut the external cortical bone of the proximal bone fragment, and the distal part of the body should be anchored in the distal healthy bone (Fig. 5). Before deploying the screws, a dedicated calliper is used coaxially over the Kirschner wire in order to select the most adapted screw length.
Screws with the partially threaded part located only at the distal aspect of the body allow the best inter-fragmentary compression and are therefore indicated for minimally displaced fractures. Screws with a fully threaded body are indicated for non-displaced fractures. PMMA-injectable screws (Fig. 6) provided with multiple holes at the distal part of the body are indicated whenever there is a need to increase the screw anchoring within the distal bone such as in severely osteoporotic patients.
Secondary fractures are unlikely following osteosynthesis unless massive local tumor progression occurs. Nevertheless, unfavorable local evolution consistent with poor consolidation of the treated site or screw loosening has been described in up to 12.5% cases at mean 8.7-month follow-up with up to 1/3 patients being symptomatic . Therefore, clinic/imaging follow-up is warranted following osteosynthesis.
Selection of the consolidative technique
Whilst making a choice between the osteoplasty and osteosynthesis, the predominant biomechanics of the target bone as well as the type of fracture should be taken into account.
In the spine, vertebroplasty is highly effective in consolidating the insufficiency fractures or the painful lytic BM involving the vertebral bodies. Tumor infiltrations into the posterior wall of the vertebral body or the anterior epidural space, without significant spinal cord compression, do not contraindicate vertebroplasty , provided that the operators are highly experienced with the procedure and high-quality fluoroscopy is available. In cases of vertebral instability (which has been shown to be accurately calculated by the means of the “Spine Instability Neoplastic Score” (SINS) ) resulting from extensive tumoral involvement of the posterior vertebral elements, vertebroplasty is contraindicated and surgical approach is warranted. Surgical referral for urgent decompressive laminectomy should also be considered in all cases presenting with the emerging neurological symptoms related to the severe neoplastic compression of the spinal cord.
Painful lytic supra-acetabular BM represent a suitable indication for percutaneous osteoplasty in this area of high compressive stress . Nevertheless, if the acetabular BM is complicated by a fracture, osteosynthesis should be considered [5, 13]. Osteosynthesis is also indicated in cases of minimally or non-displaced fractures of the iliac wing or the ilio/ischio-pubic ramus as well as the midline fractures of the sacrum [5, 13]. In the end, if sacral wings fractures are noted, osteoplasty is indicated .
Mirels’ score: A score ≥ 8 indicates prophylactic consolidation
Several different types of bone fractures are encountered in cancer patients. The percutaneous image-guided fixation approaches can be considered and offered to “non-surgical” patients after careful evaluation of the predominant biomechanics of the target bones as well as the type of fractures.
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