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Letters to the Editor |
Department of Radiology, Hôpital Jeanne d’Arc, B.P. 303, 54201 Toul, France, e-mail: jc.hoeffel@chu-nancy.fr
Editor:
I read with interest the article by Dr Sans and colleagues in the September 1999 issue of Radiology (1).
I want to make some comments. Computed tomographic (CT)–guided percutaneous resection cannot be used when bones are superficial, close to the skin, or small. Actually, we have been unable to use this technique in three cases of osteoid osteoma on carpal bones. It also cannot be performed in cases of osteoid osteoma that develops on the site of a fracture callus treated with surgery (2). Dr Sans and colleagues report a case in which osteoid osteoma of the femur was misdiagnosed as osteomyelitis, but the diagnosis of osteomyelitis was not proved since no bacillus was found.
If en bloc excision of an osteoid osteoma is performed, histologic diagnosis is easy. If a pathologist must make a diagnosis with fragments for curettage, as happens with CT-guided percutaneous resection, the diagnosis is difficult. Both osteoid osteoma and osteomyelitic lesions are characterized by a central focus, that is, a nidus in osteoid osteoma and a sequestrum or abscess in infection, with surrounding vascularity and new bone production. The nidus of osteoid osteoma may have a variable histologic appearance, depending on its maturity and location, but it is characterized by a central osteoid with or without mineralization. Sequestra and involucra of chronic osteomyelitis consist of central osteoid and are surrounded by inflammatory tissue. Microbiologic data are required to determine an accurate diagnosis.
With regard to the introduction, the technique of percutaneous excision with CT guidance was not described first in 1990 by Voto et al (3) and Kohler et al (4); Doyle and King (5) described it in 1989. Doyle was director of the radiology department at the University of Dunedin in New Zealand, and King was an orthopedic surgeon at the Royal Melbourne Hospital in Australia. They described the new method and treated two patients: a female adolescent, aged 15 years, with a lesion of the anterior midshaft of the tibia and a man, aged 22 years, with a lesion on the posteromedial aspect of the midshaft of the femur. Both patients were able to walk out of the hospital on the day of the procedure and were completely symptom free 3 months later. Pathologic evidence of osteoid osteoma was demonstrated in core specimens removed from both patients.
Among the references, Dr Sans and colleagues do not include an article about the technique proposed by a group from Aachen, Germany. In 1991, Klose et al (6) described a technique for percutaneous excision of the nidus with CT guidance. In 1995, Adam et al (7) described another technique that involves drill biopsy and subsequent injection of ethanol that does not require the use of new equipment. Therefore, the cost of this latter procedure is lower. Sanhaji et al (8) were not the first to use this technique.
Another technique mentioned is the treatment with laser coagulation proposed by Gangi et al (9). Percutaneous laser photocoagulation seems to be a more effective technique for percutaneous extraction of osteoid osteoma, but it does not allow pathologic examination since no adequate specimen is available; therefore, there is no histologic proof of osteoid osteoma.
REFERENCES
Service Central d’Imagerie Medicale, Centre Hospitalier Universitaire Purpan, Place du Docteur Baylac, 31059 Toulouse Cedex, France, e-mail: sans.n@chu-toulouse.fr
Concerning Dr Hoeffel’s comments, I would like to make the following remarks.
If Doyle and King (1) appear to be the precursors of CT-guided percutaneous resection, then Kohler et al (2) deserve credit for developing specific hardware. Indeed, Doyle and King describe biopsy (Craig cutting bone biopsy) with the use a trocar of 3 or 4 mm in diameter, a diameter generally insufficient for complete resection.
With regard to alternative methods, in particular percutaneous laser photocoagulation proposed by Gangi et al (3), these methods seem in our opinion to have an important future use because of their ease of performance. Percutaneous laser photocoagulation should be used for osteoid osteomas that have a classical clinical manifestation and appearance, because photocoagulation does not allow for subsequent pathologic examination of the tissue.
Finally, en bloc excision does not seem to be necessary in the majority of cases. We prefer the use of noninvasive techniques to make the diagnosis.
REFERENCES
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