- Email: [email protected]
Radiofrequency Ablation of an Unusual Vertebral Body Osteoid Osteoma Contiguous with the Intervertebral Disc
1756
’
Letters to the Editor
Mamlouk et al
’
JVIR
Figure 2. Histopathologic analysis of the biopsy specimen confirms the diagnosis of hibernoma. Chordoma shares with hibernoma the expression of S100 protein, but exhibits coexpression of cytokeratins, which could not be demonstrated in the present case. In addition, the characteristic MDM2 amplification of well differentiated liposarcoma could not be detected (not shown). The bone biopsy shows broad lamellar trabeculae with osteoblastic rimming and displacement of hematopoiesis by aggregates of pale tumor cells. (a) Higher magnification of hibernoma cells reveals large, multivacuolated lipocytes with centrally placed small, hyperchromatic nuclei. (Hematoxylin and eosin stain; original magnification, 100). (b) The hibernoma cells show a distinct nuclear and cytoplasmic expression of S100 stain. (Original magnification, 200). This antigen is typically expressed by lipocytes; however, it may be shared by activated macrophages or chordoma cells.
iatrogenic tissue damage that is disproportional to the relatively small benign tumor. RF ablation is not only the treatment of choice for osteoid osteoma, but also an effective treatment for pain caused by bone metastases. Experience regarding percutaneous ablation of other benign bone and soft-tissue tumors is very limited, based on single case reports and small patient series. Based on the present case, we are able to demonstrate that percutaneous RF ablation may be used successfully to treat intraosseous hibernoma. We therefore believe RF ablation may broaden the scope of treatment options for hibernoma by offering an effective and less invasive alternative to classic surgery in patients with therapy-refractory pain.
Radiofrequency Ablation of an Unusual Vertebral Body Osteoid Osteoma Contiguous with the Intervertebral Disc From: Mark D. Mamlouk, MD Eric vanSonnenberg, MD Frank Schraml, MD Nicholas Theodore, MD Department of Radiology (M.D.M.) University of California, San Francisco San Francisco, California Department of Radiology (E.v.) Kern/University of California, Los Angeles, Medical Center 1700 Mt. Vernon Ave. None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.05.029
REFERENCES 1. Merkel H. On a pseudolipoma of the breast (peculiar fat tumors). Beitr Pathol Anat 1906; 39:152–157. 2. Gery L. In discussion of MF Bonnel’s paper. Bull Mem Soc Anat (Paris) 1914; 89:111–112. 3. Thorns C, Schardt C, Katenkamp D, Kahler C, Merz H, Feller AC. Hibernoma-like brown fat in the bone marrow: report of a unique case. Virchows Arch 2008; 452:343–345. 4. Reyes A, Wilson J, Desai H. Intraosseous hibernoma of the femur: an unusual case with a review of the literature. In: Abstracts and Case Studies From the College of American Pathologists 2008 Annual Meeting (CAP ’08). Northfield, IL: College of American Pathologists, 2008;3. Poster 20. 5. Kumar R, Deaver MT, Czerniak BA, Madewell JE. Intraosseous hibernoma. Skeletal Radiol 2011; 40:641–645. 6. Bai S, Mies C, Stephenson J, Zhang PJ. Intraosseous hibernoma: a potential mimic of metastatic carcinoma. Ann Diagn Pathol 2012, 10.1016/ j.anndiagpath.2012.07.001.
Bakersfield, CA 93306 Department of Radiology (F.S.) St. Joseph’s Hospital and Medical Center Phoenix, Arizona Department of Neurosurgery (N.T.) Barrow Neurological Institute Phoenix, Arizona
Editor: Osteoid osteoma is a benign bone tumor that occurs most commonly in the appendicular skeleton. Of all osteoid osteomas, 10% occur in the spine, and, of those, only 10% affect the vertebral body (1,2). Treatment for osteoid osteomas includes medical therapy, surgical resection, or percutaneous thermal ablation. Although the latter, more specifically radiofrequency (RF) ablation, is routinely used in the appendicular skeleton and within the spinal posterior
Volume 24
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Number 11
’
November
’
2013
1757
Figure 1. Axial (a) and sagittal (b) CT images of the lumbar spine show a 1.4-cm lytic lesion with a 1.1-cm central sclerotic nidus in the L1 vertebral body (arrow) compatible with an osteoid osteoma. There is extensive reactive sclerosis in the remaining vertebral body (arrowheads). Note the contiguity of the nidus in the lesion with the T12–L1 intervertebral disc (b).
elements, little information exists in regard to its use with vertebral body osteoid osteomas (3). Herein we report a successful case of RF ablation in a vertebral body osteoid osteoma that was contiguous with the adjacent intervertebral disc. The various pre- and intraprocedural maneuvers that permitted the safe performance of biopsy and RF ablation are highlighted. Review of this study was granted through the institutional review board. A 21-year-old woman presented with a 3-year history of intermittent mid-back pain that occurred at night and was controlled initially with various nonsteroidal anti-inflammatory drugs and a back brace. After an episode of routine exercise, the patient developed sudden onset of excruciating back pain. She presented to our institution in a near-immobilized state with a back brace and requiring a walker to move, having taken various pain reliever medicines. A computed tomography (CT) scan was performed that showed a 1.4-cm lytic lesion with a central 1.1-cm sclerotic nidus within the superior anterior aspect of the L1 vertebral body. There was extensive peripheral reactive sclerosis of the remaining vertebral body (Fig 1). The imaging findings were compatible with an osteoid osteoma. Although the appearance of the lesion suggested the diagnosis, the superior aspect of the nidus was not covered with cortical bone and openly communicated with the T12– L1 intervertebral disc. Magnetic resonance (MR) imaging of the lesion showed hyperintense T1 and hypointense T2 signals, with mild peripheral enhancement after gadolinium administration. After neurosurgical and interventional radiology consultations were obtained, biopsy and RF ablation were recommended to the patient and her family. Under conscious sedation, the patient was positioned prone in the CT scanner. With CT fluoroscopic guidance, 22-gauge spinal needles were advanced to the posterior aspect of the lesion through a left posterolateral paravertebral approach
Figure 2. Prone axial CT image shows the 17-gauge RF electrode within the osteoid osteoma accessed by a left posterolateral paravertebral approach.
by using tandem technique. After lesion access was achieved, biopsy of the nidus was performed via a bone biopsy coaxial set with an outer 11-gauge cannula and a 14-gauge inner biopsy needle (Cook, Bloomington, Indiana). Attention was made not to extend too anteriorly to protect the aorta. After the biopsy that showed benign cells, a 17-gauge RF ablation probe (Covidien, Mansfield, Massachusetts) was inserted coaxially into the nidus via the 11-gauge cannula (Fig 2). Two applications of RF ablation were performed for 6 minutes each at 901C with a 10-minute hiatus in between.
1758
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Letters to the Editor
Postprocedural CT showed no complications. The patient was admitted to the hospital for observation and was discharged the following day, as her pain completely subsided and her full range of motion was restored. She no longer required a back brace or walker. At 3-month and 1-year clinic follow-up, the patient reported no pain or other symptoms, and was pursuing her career in physical fitness. This successful RF ablation of a vertebral body osteoid osteoma suggests that this may be a safe treatment option in this atypical site for an osteoid osteoma. In addition, despite the contiguity of the osteoid osteoma with an intervertebral disc, RF ablation still was performed safely. These two aspects make this case highly unusual, if not unique. Thermal ablation (including RF and laser ablation) to treat vertebral body osteoid osteomas has been performed to a much lesser extent than in the posterior elements—a total of nine patients has been reported (3). The lower number of ablations to all spinal osteoid osteomas compared with those in the appendicular skeleton relates to the perceived risk of thermal damage to neural elements (4). The present case is another example to illustrate that RF ablation (and biopsy) can safely be performed in a vertebral body osteoid osteoma. To date, the recommendation has been to perform thermal ablation to an osteoid osteoma only if there is a 1-cm margin from vital structures in view of the risk of unwanted thermal injury (4). Dupuy et al (5) performed in vivo and ex vivo thermal ablation experiments in pigs and found that preserved cancellous or cortical bone between the lesion and the osseous spine provided an insulative effect and thus a margin of safety. In the patient described here, there was more than a 1-cm margin between the lesion and the spinal canal and neural foramina; however, there was no preserved bone surrounding the superior aspect of the lesion—
Solitary Intercostal Arterial Trunk: Second Case Report From: Jamie Edwards, DO Greg Bowers, MD William Bates III, MD Scott Forseen, MD Georgia Regents University Medical College of Georgia Augusta, Georgia
Editor: The solitary intercostal arterial trunk was described by Chang and Rubin (1) as an anomalous branch arising dorsally from the descending thoracic aorta at the level
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.05.061
Edwards et al
’
JVIR
there was open communication with the T12–L1 intervertebral disc. There are two documented cases of surgical treatment for vertebral body osteoid osteomas spanning across the intervertebral discs and into the contiguous vertebral body (2,6). Our patient had a theoretical risk of injury to the adjacent intervertebral disc by RF ablation; however, the immediate and long-term pain relief suggests that no damage occurred or that it was clinically insignificant. Although immediate postprocedural CT revealed no complications, no postprocedural MR imaging was done to evaluate the intervertebral disc because the patient became asymptomatic the day after the RF ablation and has continued so. After RF ablation, the patient’s condition improved rapidly and remarkably, despite the combined unusual location of an osteoid osteoma in the vertebral body and the contiguity with an intervertebral disc. Although this is only a single case, it provides encouragement for future therapy in similar patients.
REFERENCES 1. Motamedi D, Learch TJ, Ishimitsu DN, et al. Thermal ablation of osteoid osteoma: overview and step-by-step guide. Radiographics 2009; 29: 2127–2141. 2. Heiman ML, Cooley CJ, Bradford DS. Osteoid osteoma of a vertebral body: report of a case with extension across the intervertebral disk. Clin Orthop Relat Res 1976:159–163. 3. Woertler K, Vestring T, Boettner F, Winkelmann W, Heindel W, Lindner N. Osteoid osteoma: CT-guided percutaneous radiofrequency ablation and follow-up in 47 patients. J Vasc Interv Radiol 2001; 12:717–722. 4. Rosenthal DI, Hornicek FJ, Torriani M, Gebhardt MC, Mankin HJ. Osteoid osteoma: percutaneous treatment with radiofrequency energy. Radiology 2003; 229:171–175. 5. Dupuy DE, Hong R, Oliver B, Goldberg SN. Radiofrequency ablation of spinal tumors: temperature distribution in the spinal canal. AJR Am J Roentgenol 2000; 175:1263–1266. 6. Hurtgen KL, Buehler M, Santolin SM. Osteoid osteoma of the vertebral body with extension across the intervertebral disc. J Manipulative Physiol Ther 1996; 19:118–123.
of the T12 vertebral level and ascending between the aorta and vertebral column to the T3 vertebral level, giving off the intercostal arterial branches between T3 and T12. Additional anomalous branches arose dorsally from the aorta to supply the first and second intercostal arteries and the L2/L3 lumbar arteries. These authors also described an isolated splenic artery arising from the aorta at T11 and a replaced common hepatic artery. Our case is from a computed tomographic (CT) angiogram of the abdomen and pelvis with bilateral lowerextremity runoff. This case demonstrates an anomalous artery arising dorsally from the thoracic aorta at the T12 level that coursed rostrally between the descending thoracic aorta and thoracic spine with aberrant ventral displacement of the aorta. The anomalous artery supplied the T7– T11 intercostal arteries (Figures 1, 2). This patient was born without a vagina and also had a low-lying right kidney with a single right renal artery that originated from the proximal right common iliac
’
Letters to the Editor
Mamlouk et al
’
JVIR
Figure 2. Histopathologic analysis of the biopsy specimen confirms the diagnosis of hibernoma. Chordoma shares with hibernoma the expression of S100 protein, but exhibits coexpression of cytokeratins, which could not be demonstrated in the present case. In addition, the characteristic MDM2 amplification of well differentiated liposarcoma could not be detected (not shown). The bone biopsy shows broad lamellar trabeculae with osteoblastic rimming and displacement of hematopoiesis by aggregates of pale tumor cells. (a) Higher magnification of hibernoma cells reveals large, multivacuolated lipocytes with centrally placed small, hyperchromatic nuclei. (Hematoxylin and eosin stain; original magnification, 100). (b) The hibernoma cells show a distinct nuclear and cytoplasmic expression of S100 stain. (Original magnification, 200). This antigen is typically expressed by lipocytes; however, it may be shared by activated macrophages or chordoma cells.
iatrogenic tissue damage that is disproportional to the relatively small benign tumor. RF ablation is not only the treatment of choice for osteoid osteoma, but also an effective treatment for pain caused by bone metastases. Experience regarding percutaneous ablation of other benign bone and soft-tissue tumors is very limited, based on single case reports and small patient series. Based on the present case, we are able to demonstrate that percutaneous RF ablation may be used successfully to treat intraosseous hibernoma. We therefore believe RF ablation may broaden the scope of treatment options for hibernoma by offering an effective and less invasive alternative to classic surgery in patients with therapy-refractory pain.
Radiofrequency Ablation of an Unusual Vertebral Body Osteoid Osteoma Contiguous with the Intervertebral Disc From: Mark D. Mamlouk, MD Eric vanSonnenberg, MD Frank Schraml, MD Nicholas Theodore, MD Department of Radiology (M.D.M.) University of California, San Francisco San Francisco, California Department of Radiology (E.v.) Kern/University of California, Los Angeles, Medical Center 1700 Mt. Vernon Ave. None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.05.029
REFERENCES 1. Merkel H. On a pseudolipoma of the breast (peculiar fat tumors). Beitr Pathol Anat 1906; 39:152–157. 2. Gery L. In discussion of MF Bonnel’s paper. Bull Mem Soc Anat (Paris) 1914; 89:111–112. 3. Thorns C, Schardt C, Katenkamp D, Kahler C, Merz H, Feller AC. Hibernoma-like brown fat in the bone marrow: report of a unique case. Virchows Arch 2008; 452:343–345. 4. Reyes A, Wilson J, Desai H. Intraosseous hibernoma of the femur: an unusual case with a review of the literature. In: Abstracts and Case Studies From the College of American Pathologists 2008 Annual Meeting (CAP ’08). Northfield, IL: College of American Pathologists, 2008;3. Poster 20. 5. Kumar R, Deaver MT, Czerniak BA, Madewell JE. Intraosseous hibernoma. Skeletal Radiol 2011; 40:641–645. 6. Bai S, Mies C, Stephenson J, Zhang PJ. Intraosseous hibernoma: a potential mimic of metastatic carcinoma. Ann Diagn Pathol 2012, 10.1016/ j.anndiagpath.2012.07.001.
Bakersfield, CA 93306 Department of Radiology (F.S.) St. Joseph’s Hospital and Medical Center Phoenix, Arizona Department of Neurosurgery (N.T.) Barrow Neurological Institute Phoenix, Arizona
Editor: Osteoid osteoma is a benign bone tumor that occurs most commonly in the appendicular skeleton. Of all osteoid osteomas, 10% occur in the spine, and, of those, only 10% affect the vertebral body (1,2). Treatment for osteoid osteomas includes medical therapy, surgical resection, or percutaneous thermal ablation. Although the latter, more specifically radiofrequency (RF) ablation, is routinely used in the appendicular skeleton and within the spinal posterior
Volume 24
’
Number 11
’
November
’
2013
1757
Figure 1. Axial (a) and sagittal (b) CT images of the lumbar spine show a 1.4-cm lytic lesion with a 1.1-cm central sclerotic nidus in the L1 vertebral body (arrow) compatible with an osteoid osteoma. There is extensive reactive sclerosis in the remaining vertebral body (arrowheads). Note the contiguity of the nidus in the lesion with the T12–L1 intervertebral disc (b).
elements, little information exists in regard to its use with vertebral body osteoid osteomas (3). Herein we report a successful case of RF ablation in a vertebral body osteoid osteoma that was contiguous with the adjacent intervertebral disc. The various pre- and intraprocedural maneuvers that permitted the safe performance of biopsy and RF ablation are highlighted. Review of this study was granted through the institutional review board. A 21-year-old woman presented with a 3-year history of intermittent mid-back pain that occurred at night and was controlled initially with various nonsteroidal anti-inflammatory drugs and a back brace. After an episode of routine exercise, the patient developed sudden onset of excruciating back pain. She presented to our institution in a near-immobilized state with a back brace and requiring a walker to move, having taken various pain reliever medicines. A computed tomography (CT) scan was performed that showed a 1.4-cm lytic lesion with a central 1.1-cm sclerotic nidus within the superior anterior aspect of the L1 vertebral body. There was extensive peripheral reactive sclerosis of the remaining vertebral body (Fig 1). The imaging findings were compatible with an osteoid osteoma. Although the appearance of the lesion suggested the diagnosis, the superior aspect of the nidus was not covered with cortical bone and openly communicated with the T12– L1 intervertebral disc. Magnetic resonance (MR) imaging of the lesion showed hyperintense T1 and hypointense T2 signals, with mild peripheral enhancement after gadolinium administration. After neurosurgical and interventional radiology consultations were obtained, biopsy and RF ablation were recommended to the patient and her family. Under conscious sedation, the patient was positioned prone in the CT scanner. With CT fluoroscopic guidance, 22-gauge spinal needles were advanced to the posterior aspect of the lesion through a left posterolateral paravertebral approach
Figure 2. Prone axial CT image shows the 17-gauge RF electrode within the osteoid osteoma accessed by a left posterolateral paravertebral approach.
by using tandem technique. After lesion access was achieved, biopsy of the nidus was performed via a bone biopsy coaxial set with an outer 11-gauge cannula and a 14-gauge inner biopsy needle (Cook, Bloomington, Indiana). Attention was made not to extend too anteriorly to protect the aorta. After the biopsy that showed benign cells, a 17-gauge RF ablation probe (Covidien, Mansfield, Massachusetts) was inserted coaxially into the nidus via the 11-gauge cannula (Fig 2). Two applications of RF ablation were performed for 6 minutes each at 901C with a 10-minute hiatus in between.
1758
’
Letters to the Editor
Postprocedural CT showed no complications. The patient was admitted to the hospital for observation and was discharged the following day, as her pain completely subsided and her full range of motion was restored. She no longer required a back brace or walker. At 3-month and 1-year clinic follow-up, the patient reported no pain or other symptoms, and was pursuing her career in physical fitness. This successful RF ablation of a vertebral body osteoid osteoma suggests that this may be a safe treatment option in this atypical site for an osteoid osteoma. In addition, despite the contiguity of the osteoid osteoma with an intervertebral disc, RF ablation still was performed safely. These two aspects make this case highly unusual, if not unique. Thermal ablation (including RF and laser ablation) to treat vertebral body osteoid osteomas has been performed to a much lesser extent than in the posterior elements—a total of nine patients has been reported (3). The lower number of ablations to all spinal osteoid osteomas compared with those in the appendicular skeleton relates to the perceived risk of thermal damage to neural elements (4). The present case is another example to illustrate that RF ablation (and biopsy) can safely be performed in a vertebral body osteoid osteoma. To date, the recommendation has been to perform thermal ablation to an osteoid osteoma only if there is a 1-cm margin from vital structures in view of the risk of unwanted thermal injury (4). Dupuy et al (5) performed in vivo and ex vivo thermal ablation experiments in pigs and found that preserved cancellous or cortical bone between the lesion and the osseous spine provided an insulative effect and thus a margin of safety. In the patient described here, there was more than a 1-cm margin between the lesion and the spinal canal and neural foramina; however, there was no preserved bone surrounding the superior aspect of the lesion—
Solitary Intercostal Arterial Trunk: Second Case Report From: Jamie Edwards, DO Greg Bowers, MD William Bates III, MD Scott Forseen, MD Georgia Regents University Medical College of Georgia Augusta, Georgia
Editor: The solitary intercostal arterial trunk was described by Chang and Rubin (1) as an anomalous branch arising dorsally from the descending thoracic aorta at the level
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.05.061
Edwards et al
’
JVIR
there was open communication with the T12–L1 intervertebral disc. There are two documented cases of surgical treatment for vertebral body osteoid osteomas spanning across the intervertebral discs and into the contiguous vertebral body (2,6). Our patient had a theoretical risk of injury to the adjacent intervertebral disc by RF ablation; however, the immediate and long-term pain relief suggests that no damage occurred or that it was clinically insignificant. Although immediate postprocedural CT revealed no complications, no postprocedural MR imaging was done to evaluate the intervertebral disc because the patient became asymptomatic the day after the RF ablation and has continued so. After RF ablation, the patient’s condition improved rapidly and remarkably, despite the combined unusual location of an osteoid osteoma in the vertebral body and the contiguity with an intervertebral disc. Although this is only a single case, it provides encouragement for future therapy in similar patients.
REFERENCES 1. Motamedi D, Learch TJ, Ishimitsu DN, et al. Thermal ablation of osteoid osteoma: overview and step-by-step guide. Radiographics 2009; 29: 2127–2141. 2. Heiman ML, Cooley CJ, Bradford DS. Osteoid osteoma of a vertebral body: report of a case with extension across the intervertebral disk. Clin Orthop Relat Res 1976:159–163. 3. Woertler K, Vestring T, Boettner F, Winkelmann W, Heindel W, Lindner N. Osteoid osteoma: CT-guided percutaneous radiofrequency ablation and follow-up in 47 patients. J Vasc Interv Radiol 2001; 12:717–722. 4. Rosenthal DI, Hornicek FJ, Torriani M, Gebhardt MC, Mankin HJ. Osteoid osteoma: percutaneous treatment with radiofrequency energy. Radiology 2003; 229:171–175. 5. Dupuy DE, Hong R, Oliver B, Goldberg SN. Radiofrequency ablation of spinal tumors: temperature distribution in the spinal canal. AJR Am J Roentgenol 2000; 175:1263–1266. 6. Hurtgen KL, Buehler M, Santolin SM. Osteoid osteoma of the vertebral body with extension across the intervertebral disc. J Manipulative Physiol Ther 1996; 19:118–123.
of the T12 vertebral level and ascending between the aorta and vertebral column to the T3 vertebral level, giving off the intercostal arterial branches between T3 and T12. Additional anomalous branches arose dorsally from the aorta to supply the first and second intercostal arteries and the L2/L3 lumbar arteries. These authors also described an isolated splenic artery arising from the aorta at T11 and a replaced common hepatic artery. Our case is from a computed tomographic (CT) angiogram of the abdomen and pelvis with bilateral lowerextremity runoff. This case demonstrates an anomalous artery arising dorsally from the thoracic aorta at the T12 level that coursed rostrally between the descending thoracic aorta and thoracic spine with aberrant ventral displacement of the aorta. The anomalous artery supplied the T7– T11 intercostal arteries (Figures 1, 2). This patient was born without a vagina and also had a low-lying right kidney with a single right renal artery that originated from the proximal right common iliac