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CASE REPORT
Year : 2020  |  Volume : 16  |  Issue : 7  |  Page : 1714-1717

Percutaneous microwave ablation with osteoplasty and interventional internal fixation for impending pathologic fracture of the proximal humerus


Department of Oncology, Tengzhou Central People's Hospital Affiliated with Xuzhou Medical University, Tengzhou, Shandong Province, China

Date of Submission07-Sep-2020
Date of Decision30-Sep-2020
Date of Acceptance25-Nov-2020
Date of Web Publication9-Feb-2021

Correspondence Address:
Kaixian Zhang
Department of Oncology, Tengzhou Central People's Hospital Affiliated with Xuzhou Medical University, Tengzhou 277500, Shandong Province
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_1315_20

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 > Abstract 


Humerus is the long bone second-most commonly affected by metastases. An impending pathologic humeral fracture requires rigid surgical stabilization to prevent it from fully fracturing. In the present study, we report a case of a 71-year-old male patient with a visual analog score of 10 (indicating extreme pain) and an impending pathologic fracture that allowed for combined treatment with percutaneous microwave ablation and simultaneous injection of bone cement during Kirschner wire insertion. The procedure was performed successfully with no complications. The patient reported pain relief and improved quality of life and functional status 1 day, 7 days, 1 month, and 2 months after his procedure.

Keywords: Interventional internal fixation, pathologic fracture, percutaneous osteoplasty


How to cite this article:
Yuan Q, Zhang K, Zhang X, Li P, Wu L, Man Q, Hu M, Wang B, Yang S. Percutaneous microwave ablation with osteoplasty and interventional internal fixation for impending pathologic fracture of the proximal humerus. J Can Res Ther 2020;16:1714-7

How to cite this URL:
Yuan Q, Zhang K, Zhang X, Li P, Wu L, Man Q, Hu M, Wang B, Yang S. Percutaneous microwave ablation with osteoplasty and interventional internal fixation for impending pathologic fracture of the proximal humerus. J Can Res Ther [serial online] 2020 [cited 2021 Mar 8];16:1714-7. Available from: https://www.cancerjournal.net/text.asp?2020/16/7/1714/308757




 > Introduction Top


Bone metastases are a major cause of morbidity related to progressing osteoclasia by severe pain, hypercalcemia, neurologic deficits, and pathologic fractures that these fractures cause immediate, severe pain and loss of motor function that reduces the quality of life (QOL).[1] Depending on the tumor biology, systemic chemotherapy and radiotherapy may fail to provide complete local control and pain relief and prevent future pathologic fractures.[2] Normal surgical fracture fixation may not be feasible in patients with weak bone strength or multiple comorbidities.[3] Therefore, minimally invasive therapies such as ablation, vertebral augmentation, and interventional internal fixation may be more suitable options for patients who are not eligible for conventional treatments.[4]


 > Case Report Top


The case was discussed in the multimodality cancer clinic and the ethics committee clearance was obtained. Informed consent from the patient was also obtained before treatment.

In December 2019, a 71-year-old male, previously diagnosed with gastric fundus cardia adenocarcinoma with mediastinal and abdominal lymph node metastases, underwent six cycles of chemotherapy (SOX: OXA 130 mg/m2 d1, S1 80 mg/m2 d1-14, q3w). In August 2020, he presented with subacute-onset, progressive left upper limb pain that worsened with activity. His pain visual analog scale (VAS) score was 10/10. Nonsteroidal anti-inflammatory drugs and opiate analgesics did not alleviate his pain. His Oswestry disability index was 40/50, and his Karnofsky performance scale rated as 60/100.[5]

Neurological examination revealed motor dysfunction, including limited flexion, extension, and abduction of the left shoulder joint. There were good movement in the left elbow, wrist, metacarpophalangeal joints, and fingers and normal feeling in his left upper arm, forearm, and hand. Grip strength of the left hand was at level 5. The pulse of the left radial artery was good with normal blood supply. There was no skin rupture or swelling. Magnetic resonance imaging revealed a soft-tissue mass shadow at the medial edge with heterogeneous signal intensity and a clear boundary extending from the head of the left humerus [Figure 1]. Three-dimensional (3D) computed tomography (CT) imaging and X-rays revealed left humeral proximal cortical discontinuity that suggested impending fracture.
Figure 1: The imaging of the 71-year-old male patient with osteolytic metastases in the left humerus. Axial and coronal computed tomography scans (a-c) and coronal magnetic resonance imaging (d) demonstrating osteolytic metastases at the head of the humerus extending to the upper humerus and cortical destruction in excess of ½

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According to the Mirels' scoring system[6] [Table 1], the patient's lesion was at the upper limb with a Mirels' score (MS) of 1, the nature of the lesion was lytic (MS 3), the size of the lesion was 1/3–2/3 (MS 2), and VAS was 10 (MS 3). His overall MS was 9.
Table 1: Mirels' scoring system

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For the procedure, the patient was maintained in a prone position and fixed with a vacuum negative pressure pad. A CT scan was conducted by 10-mm slices with a SOMATOM definition AS CT scanner (Siemens Healthineers, Germany). Sagittal and coronal 3D reconstruction of the left humerus was conducted to determine the exact location and depth of the lesion, design the simulated needle entry route, and select the predetermined puncture point. The area was sterilized using povidone-iodine, and sterile surgical drapes were applied. Ropivacaine was used for brachial plexus block anesthesia. A 10-cm 11-gauge bone needle was inserted into the predetermined puncture point and advanced within the central long axis of the humerus to its anterior edge under 3D CT scan guidance. A single 14-gauge microwave (MW) ablation antenna was coaxially inserted into the tumor, and the ablation zone was calculated 2 mm beyond the actual size of the target lesion to achieve adequate control. MW ablation was conducted with the ECO-100A1 MW ablation system (ECO Medical, Nanjing, China). Ablation power and time were selected depending on the lesion site, size, and adjacent tissues: first, 60 W for 5 min in the distal lesions; then, the antenna was retracted by 2 cm for 5 min before being removed. Using the coaxial technique, a 16-cm Kirschner wire (Zhejiang Guangci Medical Device Co., Ltd., China) was inserted into the humerus bone marrow cavity with a bone needle. The end of the Kirschner wire was 1.5 cm inside the humerus cortex. Another Kirschner wire was placed similarly [Figure 2].
Figure 2: Intraprocedural computed tomographic fluoroscopic images showing microwave antenna traversing tumor (a) and bone density in the lesion area decreasing after ablation (b). Two Kirschner wires being inserted into the bone marrow cavity of the humerus (c and d). 35 mL of bone cement being injected into the lesion (e). Bone cement uniformly distributing at the lesion location (f). No evidence of cement extravasation was observed

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Percutaneous osteoplasty was applied using polymethyl methacrylate (PMMA) (Heraeus Medical GmbH, Wehrheim, Germany). Several 1 mL syringes were used to extract paste cement and immediately placed in ice brine. A 10-cm 13-gauge bone needle was inserted into the proper position to select another puncture point. Bone cement (35 mL in total) was slowly injected into the ablative lesion in small batches through a bone puncture needle to ensure adequate filling of the superior humerus [Figure 2]. Several CT scans were conducted immediately after injection to monitor the filling and flow direction of the bone cement to detect any leakage. No complications occurred during the procedure. The patient's postprocedural pain was evaluated with VAS as 6/10, 3/10, 1/10, and 1/10 at 24 h, 7 days, 1 month, and 2 months, respectively. The postoperative morphine doses were 40 mg within 24 h and 10–20 mg daily for 7 days (no analgesia was required thereafter). His Oswestry disability index was 19/50, and his Karnofsky performance scale rated as 70/100 in 2 months after the procedure.


 > Discussion Top


Metastases of long bones often result in painful pathologic fractures, occurring in 10%–25% of patients.[7] Pathologic fractures occur mainly in the humerus (18.1%) and femur (72.5%).[8] Two-thirds of pathologic fractures occur in the proximal third of the humerus.[9] Preventing these fractures is an essential goal of therapy.

Traditional conservative treatments for bone metastases combine bisphosphonates with radiation therapy; however, these work slowly and decrease bone stability.[10] The National Comprehensive Cancer Network incorporated percutaneous thermal ablation into its guidelines for the management of osseous metastases in the axial and appendicular skeleton. Combined radiofrequency ablation (RFA) and cement injection may relieve pain and improve QOL.[11] In RFA, a high-frequency alternating current is run through an electrode needle into adjacent tissues, causing frictional heating and tissue necrosis. Performing RFA before cement injection may control cement distribution in posteriorly located lesions. A biomembrane formed at the tumor edge after RFA can prevent cement leakage into the spinal canal, thus preventing the spread of live tumor cells.[12]

MW ablation combined with percutaneous osteoplasty is an effective and safe treatment for extraspinal bone metastases.[13] MW ablation is less susceptible to heat sink effects and variable tumor tissue impedance, resulting in larger, more uniform ablation zones that allow for more PMMA to be administered with potentially greater analgesic effects.[14],[15]

PMMA osteoplasty consolidates weight-bearing bones subjected to axial compression forces, but it is less effective in locations subjected to torque stresses or where the tumor has invaded a joint or tendon insertion.[16],[17] The risk of a pathologic fracture remains high when percutaneous cementoplasty is conducted in a long bone without metal fixation. Cortical involvements of >30 mm have a significantly higher risk of fracture.[18] A bone lesion with an axial cortical involvement >30 mm and a circumferential cortical involvement >50% has a high risk of fracture and requires surgical stabilization.[19] Prophylactic fixation is recommended for lesions with an overall MS ≥9.[6] In the current case study, the patient's MS was 9, and the axial cortical involvement of bone metastases was >30 mm. In addition, considering the patient's age, and his health status, the attending physician of our department and multidisciplinary consultants recommended prophylactic fixation.

Treatment strategies are heavily based on the risk of fracture and expected survival of the patient. Intramedullary nailing (IN) has been the most accepted fixation method for symptomatic metastasis of the long bones, although adjuvant cement should be considered in patients with a long survival time, inadequate bone stock, and/or large lesions for better stabilization of impending pathologic fractures. IN effectively controls pain, perioperative bleeding, and local tumor progression by augmentation with bone cement around the nail. Multihole injection nails allow bone cement to be injected deeply during percutaneous fixation without additional bone cortex holes.[20]


 > Conclusion Top


Combining percutaneous MW ablation with osteoplasty and interventional internal fixation can provide superior local control and bone stability, while managing impending pathologic fractures in the proximal humerus. This microinvasive method causes little bleeding and injury in the adjacent tissues and has a low incidence of complications. In contrast to general anesthesia needed in surgical operations, brachial plexus block anesthesia reduces the physical damage of intoxication. Patients also require less bedrest and have a significantly reduced incidence of deep vein thrombosis. Patients are eligible for this treatment if they have unstable malignant bone lesions – either metastatic bone lesions with MS ≥8 or symptomatic and debilitating myelomatous lesions – and are unsuitable for standard surgery (for example, due to poor general health, interrupting chemotherapy, or refused surgery).[21]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

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Macedo F, Ladeira K, Pinho F, Saraiva N, Bonito N, Pinto L, et al. Bone metastases: An overview. Oncol Rev 2017;11:321.  Back to cited text no. 1
    
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Yevich S, Tselikas L, Kelekis A, Filippiadis D, de Baere T, Deschamps F. Percutaneous management of metastatic osseous disease. Chin Clin Oncol 2019;8:62.  Back to cited text no. 2
    
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Dey Hazra RO, Lill H, Ellwein A, Warnhoff M, Jensen G. Corrective osteosynthesis in failed proximal humeral fractures. Z Orthop Unfall 2020;158:524-31.  Back to cited text no. 3
    
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Kurup AN, Callstrom MR. Expanding role of percutaneous ablative and consolidative treatments for musculoskeletal tumours. Clin Radiol 2017;72:645-56.  Back to cited text no. 4
    
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Liu HF, Wu CG, Tian QH, Wang T, Yi F. Application of percutaneous osteoplasty in treating pelvic bone metastases: Efficacy and safety. Cardiovasc Intervent Radiol 2019;42:1738-44.  Back to cited text no. 5
    
6.
Jawad MU, Scully SP. In brief: Classifications in brief: Mirels' classification: Metastatic disease in long bones and impending pathologic fracture. Clin Orthop Relat Res 2010;468:2825-7.  Back to cited text no. 6
    
7.
Saad F, Lipton A, Cook R, Chen YM, Smith M, Coleman R. Pathologic fractures correlate with reduced survival in patients with malignant bone disease. Cancer 2007;110:1860-7.  Back to cited text no. 7
    
8.
Piccioli A, Spinelli MS, Maccauro G. Impending fracture: A difficult diagnosis. Injury 2014;45 Suppl 6:S138-41.  Back to cited text no. 8
    
9.
Toepfer A, Lenze U, Pohlig F, Eisenhart-Rothe RV, Gerdesmeyer L, Kirchhoff C, et al. Pathological fractures of the humerus: Experience with 76 cases in a musculoskeletal oncology centre. Z Orthop Unfall 2016;154:364-9.  Back to cited text no. 9
    
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Saito T, Toya R, Oya N. Pain response rates after conventional radiation therapy for bone metastases in prospective nonrandomized studies: A systematic review. Pract Radiat Oncol 2019;9:81-8.  Back to cited text no. 10
    
11.
Zhao W, Wang H, Hu JH, Peng ZH, Chen JZ, Huang JQ, et al. Palliative pain relief and safety of percutaneous radiofrequency ablation combined with cement injection for bone metastasis. Jpn J Clin Oncol 2018;48:753-9.  Back to cited text no. 11
    
12.
Yu Z, Tian S, Wang W, Li Y, Wang Y. Biomembrane formation after radiofrequency ablation prevents bone cement extravasation during percutaneous vertebroplasty for treating vertebral metastases with posterior margin destruction: An animal study. J Cancer Res Ther 2020;16:1082-7.  Back to cited text no. 12
    
13.
Qiu YY, Zhang KX, Ye X, Zhang XS, Xing C, Wu QS, et al. Combination of microwave ablation and percutaneous osteoplasty for treatment of painful extraspinal bone metastasis. J Vasc Interv Radiol 2019;30:1934-40.  Back to cited text no. 13
    
14.
Tomasian A, Jennings JW. Percutaneous minimally invasive thermal ablation of osseous metastases: Evidence-based practice guidelines. AJR Am J Roentgenol 2020;215:1-9.  Back to cited text no. 14
    
15.
Thompson SM, Schmitz JJ, Schmit GD, Callstrom MR, Kurup AN. Image-guided thermal ablative therapies in the treatment of sarcoma. Curr Treat Options Oncol 2017;18:25.  Back to cited text no. 15
    
16.
Wang Z, Zhen Y, Wu C, Li H, Yang Y, Shen Z, et al. CT fluoroscopy-guided percutaneous osteoplasty for the treatment of osteolytic lung cancer bone metastases to the spine and pelvis. J Vasc Interv Radiol 2012;23:1135-42.  Back to cited text no. 16
    
17.
Yevich S, Tselikas L, Gravel G, de Baère T, Deschamps F. Percutaneous cement injection for the palliative treatment of osseous metastases: A technical review. Semin Intervent Radiol 2018;35:268-80.  Back to cited text no. 17
    
18.
Deschamps F, Farouil G, Hakime A, Barah A, Guiu B, Teriitehau C, et al. Cementoplasty of metastases of the proximal femur: Is it a safe palliative option? J Vasc Interv Radiol 2012;23:1311-6.  Back to cited text no. 18
    
19.
Willeumier JJ, van der Linden YM, van de Sande MA, Dijkstra PD. Treatment of pathological fractures of the long bones. EFORT Open Rev 2016;1:136-45.  Back to cited text no. 19
    
20.
Park JW, Kim YI, Kang HG, Kim JH, Kim HS. Preliminary results: Use of multi-hole injection nails for intramedullary nailing with simultaneous bone cement injection in long-bone metastasis. Skeletal Radiol 2019;48:219-25.  Back to cited text no. 20
    
21.
Premat K, Clarençon F, Bonaccorsi R, Degos V, Cormier É, Chiras J. Reinforced cementoplasty using dedicated spindles in the management of unstable malignant lesions of the cervicotrochanteric region. Eur Radiol 2017;27:3973-82.  Back to cited text no. 21
    


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