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Vascular and Interventional Radiology |
1 From the Departments of Radiology (D.I.R., M.T.) and Orthopedics (F.J.H., M.C.G., H.J.M.), Massachusetts General Hospital, Harvard Medical School, 199 Cambridge St, Boston, MA 02114. Received August 20, 2002; revision requested October 18; revision received December 18; accepted January 20, 2003. Address correspondence to D.I.R. (e-mail: dirosenthal@partners.org).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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MATERIALS AND METHODS: After needle biopsy, computed tomography (CT)-guided percutaneous RF ablation was performed with general or spinal anesthesia. With an RF electrode, the lesion was heated to 90°C for 6 minutes. Patient age and sex, lesion size and location, biopsy results, and complications were recorded. Clinical success was assessed at a minimum of 2 years after the procedure. Significance of patient age and sex and lesion location and size as a predictor of biopsy result was tested by means of 
2 analysis. In addition, effects of patient age and sex, lesion location and size, and biopsy results on clinical success were tested with the Fisher exact test.
RESULTS: During an 11-year period, 263 patients who were suspected of having osteoid osteoma underwent 271 ablation procedures. All procedures were technically successful. There were two anesthesia-related complications (aspiration, cardiac arrest) and two minor procedure-related complications (cellulitis, sympathetic dystrophy). Results at biopsy were positive in 73% (197 of 271 biopsies). Two-year follow-up data were available for 126 procedures. The other procedures had been performed more recently or the patients could not be contacted. There was complete relief of symptoms after 112 of the 126 procedures (89%). For procedures performed as the initial treatment, the success rate was 91% (107 of 117 procedures). Procedures for recurrent lesions had a significantly lower success rate (six of 10 procedures [60%], P < .001). Clinical outcome was not dependent on biopsy result, patient age or sex, or lesion size or location.
CONCLUSION: CT-guided percutaneous RF ablation of osteoid osteoma is a safe and effective technique.
© RSNA, 2003
Index terms: Bone neoplasms, therapy, 30.3122, 40.3122 • Osteoma, 30.3122, 40.3122
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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There are three fundamentally different approaches to treatment: surgical, conservative (medical), and percutaneous. Until recently, surgery (resection or curettage) or conservative management with nonsteroidal antiinflammatory medication were the only options. Traditional surgical treatment can be surprisingly challenging for both patient and surgeon. The tumor can be difficult to identify, and incomplete removal may lead to recurrence (2). Resection of weight-bearing bone may necessitate a prolonged period of restricted activities.
Osteoid osteomas may undergo spontaneous regression after several years of observation (3). Although this outcome is uncertain and many years may be required (4), conservative (medical) treatment is often advocated (5). In our experience, many patients are unwilling to tolerate the tumor pain and wish to avoid long-term use of nonsteroidal antiinflammatory medications because of gastrointestinal side effects.
Minimally invasive therapies that have been developed for osteoid osteoma include percutaneous excision with relatively large-caliber hollow needles and drills (6,7), magnetic resonance imaging–guided cryotherapy (8), arthroscopic removal (9), computed tomography (CT)-guided drilling of the nidus followed by ethanol injection (10,11), interstitial laser photocoagulation (12,13), and percutaneous radiofrequency (RF) thermocoagulation (14–19).
Good initial results have been reported for each therapy. In comparison with surgical excision, however, few data have been published, and the duration of follow-up is variable. Although the surgery literature acknowledges that percutaneous methods can be competitive with surgical approaches (20,21), surgical treatment of patients with osteoid osteoma continues to be widespread.
The purpose of our study was to report our experience with technical success, complications, and long-term clinical success of RF ablation of osteoid osteoma.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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Patients
Between July 1990 and August 2001, 263 patients (184 male patients and 79 female patients; age range, 2–56 years; mean age, 19 years) underwent 271 CT-guided RF treatments for osteoid osteoma. The lesions were located in the lower extremity (n = 234), upper extremity (n = 17), pelvis (n = 9), and spine (n = 3). The mean lesion diameter was 6 mm ± 3 (SD).
Two hundred forty-nine procedures were performed for initial tumor treatment, 14 for recurrence after surgery, and eight for recurrence after previous RF treatment.
All patients who had been referred for RF treatment were included in this series if they had both clinical and radiologic features of osteoid osteoma. Patients were excluded retrospectively if another diagnosis was made at needle biopsy performed at the time of the RF procedure. For several reasons, patients were not excluded if biopsy results were nondiagnostic. Many authorities consider that clinical and imaging features are so accurate that biopsy may not be required (20). Nondiagnostic biopsy findings are common in osteoid osteoma (22) even after surgery; findings at needle biopsies of primary bone lesions are known to have a substantial false-negative rate. Inclusion of the nondiagnostic procedures permits calculation of the rate of positive findings at needle biopsy. Finally, patients without histologically proved lesions are appropriate for determination of complication rates.
Most patients with lesions located in the hand or in the posterior arch of the vertebrae are not good candidates for RF ablation because of risk to nerves. If the electrode cannot be positioned within the tumor at least 1 cm away from major nerves, RF treatment is declined. Lesions in all other anatomic sites are included.
Patient age, sex, and history of prior treatment were recorded. Transverse, sagittal, and coronal CT images were examined by one author (D.I.R.) to identify the location of the lesion and the maximal diameter.
Procedures
Patients were informed of alternative treatments, including the option of medical management. Informed consent was obtained in all cases. All procedures were performed by one author (D.I.R.), as previously described (23), with general or spinal anesthesia and CT guidance. General anesthesia is preferred in most cases. Although spinal anesthesia can provide adequate pain control for many of the lesions in the lower extremities, children find it frightening, and recovery may be slow, which delays discharge. The majority of anesthetics are administered with a laryngeal mask airway and do not necessitate use of an endotracheal tube.
In general, the shortest distance through the bone is selected for access. However, if such an approach is unsafe (because of neurovascular or other anatomic structures) or technically difficult (because of a steeply oblique approach to the bone surface that would risk the needle skidding off the cortex), the lesion may be approached by drilling from the opposite side of the bone. Such an approach may also be used to obviate turning the patient into a prone position, which can be difficult to do and hard to monitor, especially in large individuals.
In most cases, a Bonopty drill (Radi Medical Systems, Uppsala, Sweden) was used. The drill is valuable when it is necessary to penetrate dense bone. Otherwise, the cannula serves to introduce a biopsy needle (usually a 16-gauge 15-cm-long OstyCut needle [Bard/Angiomed, Karlsruhe, Germany]).
After needle biopsy, an RF electrode with a 5-mm exposed tip was introduced. The electrode was connected to the RF generator (RFG-3C; Radionics, Burlington, Mass), and the tip temperature was slowly (1° every 1–2 seconds) increased to 90° C and maintained at that temperature for 6 minutes. An average procedure typically required between 1
and 2 hours from the time the patient entered the CT scanner.
Procedures were considered technically successful if the electrode was placed so that no portion of the lesion was more than 5 mm away from the exposed tip and if the target temperature was reached and maintained. If the lesion was large or elongated, two adjacent levels were treated to ensure complete ablation of the tumor.
After the procedure, patients with lesions in weight-bearing bones were told to avoid strenuous sports for 3 months. Except for this restriction, all daily activities were resumed immediately. No cast, splint, or other external support was provided. Physical therapy was not used.
Outcome
Technical success.—Short-term outcome was evaluated to detect procedure-related problems. Each patient was examined in the recovery room (D.I.R.). The procedure site and the location of the grounding pads were evaluated for evidence of bleeding, swelling, and burns. Neurovascular integrity was assessed, and the patient was asked about pain. If necessary, a brief course (24 hours) of narcotics was prescribed. The senior author again interviewed the patients by telephone 1 week after the procedure to inquire about late complications (burns, infections, wound problems) and resolution of procedure-related pain and to report results of the biopsy. It was recommended that the referring clinician see the patient at 1 month and at 1 year after the procedure and report any complications.
Clinical success.—To determine long-term outcome (>24-month follow-up), a questionnaire regarding the current clinical status was sent to the last known address of each patient. If patients failed to answer the questionnaire or gave ambiguous answers, a telephone interview was performed (M.T.). The patients were asked about symptoms and medications in current use and about any subsequent procedures. If the patient was free of pain and was not taking medications, the outcome was regarded as clinically successful. If an additional procedure for tumor had been performed, or if subsequent imaging studies demonstrated tumor, the outcome was classified as unsuccessful. If patients reported diminished or less frequent pain that was insufficient to prompt either evaluation or additional intervention, these procedures were classified as indeterminate.
All patients were included in the analysis of short-term (1-week) outcome for purposes of detecting complications. Analysis of long-term outcome was limited to patients for whom more than 24 months of follow-up was available. For purposes of analysis, patients were stratified by age, sex, tumor location, tumor size, whether they had undergone surgical procedures before the RF ablation, and whether biopsy findings confirmed the diagnosis.
Statistical Analysis
Statistical analysis was performed with SAS software (SAS Institute, Cary, NC). Descriptive statistics (mean, SD, and confidence interval) were provided where appropriate. Differences with a P value of less than .05 were considered to be statistically significant. Parametric data (patient age, lesion size) were tested with the t test. Categoric data (lesion location, patient sex, biopsy result) were evaluated with the 2 test or with the Fisher exact test if the number per category was small.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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There were two anesthesia-related complications. Asymptomatic pulmonary aspiration occurred in one patient while awakening. Although pulmonary opacities were radiologically evident, fever, cough, or other symptoms were not present. The opacities resolved spontaneously. Cardiac arrest occurred during anesthesia in a previously healthy 22-year-old man. It was presumably a result of marked vagal stimulation because it followed a brief period during which his cardiac rate slowed progressively. A "chest thump" delivered promptly by the anesthesiologist resulted in return of normal rhythm, and the patient has been well since then.
Despite concerns about appropriate activity levels after the procedure, no fractures or other delayed complications have been reported. There were no instances of skin burns or hematomas and no cases of neurovascular compromise.
Biopsy Findings
Osteoid osteoma was diagnosed in 197 of the 271 biopsies (positive rate, 73%). The remaining 74 biopsies (27%) had nondiagnostic findings. The patients with nondiagnostic biopsy findings were slightly older (mean, 20.6 years ± 11.7) than those with positive results at biopsy (mean, 17.6 years ± 8.8). This difference was statistically significant (t test, P = .024). The nondiagnostic group also included a significantly higher percentage of female patients (39% [29 of 74 patients]) compared with 26% (52 of 197 patients [2 test, P = .035]). The mean size of the lesions was the same in both groups (nondiagnostic mean, 5.5 mm ± 4.1; diagnostic mean, 6.0 mm ± 2.6 [P = .26]), and there was no difference in lesion location.
Outcome
Clinical success.—In 175 patients, the RF procedure had been performed at least 24 months before the start of this study; therefore, they were eligible for long-term evaluation. Follow-up information was available for 126 (72%) of these patients. Forty-nine patients were lost to follow-up.
One hundred twelve of the 126 procedures were a complete clinical success, which corresponds to an overall clinical success rate of 89% (95% CI: 82%, 94%). The patients were pain free, did not take medication, and had not required additional procedures. Five procedures were performed after a failed prior RF ablation, and five were performed after an unsuccessful prior surgical procedure. The clinical success rate of these repeat treatments was 60% (six of 10 repeat treatments). The difference in success rates between initial and subsequent treatments was statistically significant (Fisher exact test, P < .001). When repeat treatments were eliminated, the clinical success rate of initial RF treatments was 91% (107 of 117 initial RF treatments [95% CI: 85%, 96%]).
Fourteen RF ablation procedures did not relieve symptoms permanently. Procedures in nine patients were classified as unsuccessful because the tumor recurred that had already undergone a repeat procedure. In five instances, the outcome was indeterminate. These patients reported that the pain they continued to experience was neither severe enough nor frequent enough to necessitate additional investigations or procedures.
Among the 126 patients with follow-up data, 89 had positive findings at biopsy. Eighty (90%) of the 89 patients underwent successful procedures. Thirty-two (86%) of 37 biopsies with nondiagnostic findings were clinically successful. These rates do not differ significantly (2 test, P = .55). Patient age and sex and lesion size and location did not appear to affect the probability of a clinically successful outcome (Table). There is no apparent relationship between either the lesion location or success of needle biopsy and a successful outcome. Although patients with successful results were somewhat younger and had slightly smaller lesions, neither difference was statistically significant. A prior failed surgical or radiofrequency procedure was a poor prognostic factor for the success of RF ablation.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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In the current study, a considerable number of patients were lost to follow-up. This is partly due to the referral nature of our practice. Many of the patients traveled considerable distances to undergo the procedure, in some instances even internationally, and we had no ongoing contact with them. In some cases, telephone numbers and addresses that were accurate at the time of the procedure were no longer valid. Asymptomatic individuals, particularly teenagers, may be reluctant to return for follow-up. Therefore, the success rate among the patients lost to follow-up may be even higher than that among those for whom data is available. This surmise is supported by the fact that, to our knowledge, all patients who required a second interventional procedure (either percutaneous or surgical) returned to our institution.
Analysis of data for patients who were followed up for a minimum of 24 months demonstrated a clinical success rate of 91% for the initial treatment with RF. If repeat treatment was required, either because of failed surgery or failed ablation, the success rate was 60%. Although rare recurrences have been documented as late as 10 years after surgery (28), the standard accepted in the orthopedics literature is a minimum of 2 years to establish cure. Among published results of percutaneous treatments, only our small series (21) met this standard.
In some studies (14,15), a higher recurrence rate is suggested for large lesions. In our series, the size difference between successfully treated tumors and those that recurred was not statistically significant. Perhaps the lack of effect of tumor size is explained by our liberal use of overlapping fields to encompass the entire tumor. Our success rate was better for tumors that had not been treated previously. This experience is consistent with reports in the surgery literature (22). One author (19) notes that the prognosis is better for recurrent lesions if the patient never got relief from the initial procedure, but it is poor if recurrence follows a pain-free interval.
We do not think that percutaneous RF treatment is advisable for most spinal lesions because of proximity to nerves within the spinal canal, the lateral recesses, or the neural foramina. Although cortical bone may offer some protection from heat transmission (29), we believe that it is not a reliable insulator. For safety, the electrode should be at least 1 cm away from major nerves; therefore, most spinal lesions should probably not be treated with this method. Similar considerations apply to the rare tumors of the hand. The small but important nerves of the hand cannot be seen on CT scans and tend to be close to bone. In addition, convalescence after hand surgery is shorter than that for lower extremity lesions. Therefore, for these lesions the risks of RF ablation are greater, and the benefits are less. Perhaps this cautious approach may account for the low rate of complications.
We initially recommended that patients with tumors in weight-bearing bones avoid all running sports for 3 months after the procedure. The absence of any fractures, however, has caused us to progressively relax this restriction. Our current recommendation is to avoid only strenuous training activities that require prolonged distance running.
We have treated many tumors that were on or immediately beneath joint surfaces. Although the articular cartilage is at risk for a thermal injury, if this occurs it appears to be well tolerated, as we have yet to encounter a patient with symptoms referable to articular damage after the procedure. Perhaps very long-term follow-up will reveal premature degenerative changes, but it will be difficult to prove that an intraarticular tumor may also result in joint damage.
RF ablation must be compared with other percutaneous procedures. Excision with use of hollow needles has been performed with CT guidance, especially in Europe. Although the procedure is less invasive than surgery, complications such as fractures and osteomyelitis are reported in a few cases (6). In addition, there may be a requirement for hospitalization (6,7) and a period of limited activity (6). Results of other CT-guided ablative methods, such as drilling of the nidus followed by ethanol injection (10,11) or interstitial laser photocoagulation through an optical fiber (12,13), are promising, but limited data are available.
Medical management may be appropriate when the alternative is traditional surgical resection. Findings in our study, however, show that RF ablation can be performed as an outpatient procedure in the majority of patients with osteoid osteoma. The success rate is high, the complication rate is gratifyingly low, and the recovery is brief. RF ablation can be considered the treatment of choice for most osteoid osteomas located in the appendicular skeleton and pelvis.
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FOOTNOTES |
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Author contributions: Guarantor of integrity of entire study, D.I.R.; study concepts, D.I.R.; study design, M.T., D.I.R.; literature research, D.I.R.; clinical studies, H.J.M., F.J.H., M.T., D.I.R.; data acquisition, M.T., D.I.R.; data analysis/interpretation, D.I.R.; statistical analysis, D.I.R.; manuscript preparation, D.I.R.; manuscript definition of intellectual content, all authors; manuscript editing, M.C.G., D.I.R., F.J.H.; manuscript revision/review and final version approval, D.I.R.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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