Treatment Of Aneurysmal Bone Cysts Research Articles

Aneurysmal bone cyst: A 19-case series managed by percutaneous sclerotherapy

IntroductionSclerotherapy offers an alternative to surgery for the treatment of aneurysmal bone cyst (ABC). The main objective of the present study was to assess the radiological efficacy of sclerotherapy in terms of ossification on MRI. Secondary objectives were to assess clinical efficacy on pain evaluation and to analyze recurrence and complications according to type of sclerosing agent and intraoperative imaging technique. Materials and methodsBetween 2006 and 2014, 19 patients (7 females, 12 males, aged 3 to 17 years) with ABC treated by sclerotherapy were included. Six received Ethibloc®, 9 Aetoxisclerol®, 2 liquid absolute alcohol, and 2 absolute alcohol gel. Assessment used fluoroscopy in 17 cases and CT in 2. Ossification was assessed on MRI and pain on a visual analog scale and HEDEN score. ResultsOssification was complete in 11 cases (84.6%) and partial in 2 (15.4%). Eighteen patients (94.7%) were pain-free at 3 months. There was no recurrence, at a minimum 2 years’ follow-up. One case of skin necrosis was observed, associated with use of liquid absolute alcohol; there was 1 case of arterial reflux of Ethibloc® under CT control. DiscussionSclerotherapy enables minimally invasive treatment of lesions that are deep, difficult of access to surgery and potentially damaging. Use of absolute alcohol gel and fluoroscopic control seems to improve the risk/benefit ratio, limiting complications by vascular extravasation of the sclerosing agent, thanks to real-time visualization of diffusion. Its clinical and radiological efficacy makes sclerotherapy and alternative primary treatment choice in ABC. Level of evidenceIV, retrospective study.

Treatment of aneurysmal bone cyst by curettage and hydrogen peroxide as an adjuvant without refilling of the resultant cavity

Background Aneurysmal bone cyst (ABC) is a rare tumor-like lesion with wide controversy as regards the perfect means of treatment and the way to manage the resulting bony cyst after curettage. Patients and methods The study included 24 patients: 13 were male and the mean age was 12.6 years (range: 6–26 years). Six cases were diagnosed as solid ABC, nine (37.5%) cases were in the proximal femur. All cases were treated by thorough curettage followed by washing the cyst with hydrogen peroxide for 5 min. No bone graft or substitute was used as a filler of the cysts, except strut fibular graft, which was used to stabilize weak cysts in nine cases. Plaster cast was used in 11 cases for external fixation. Follow-up ranged from 12 to 46 months (mean: 25 months). Results All cysts healed without pathological fracture. There was no local recurrence until the end of follow-up. All patients returned back to normal life. Conclusion Thorough curettage with lavage of the cyst with hydrogen peroxide could be an acceptable method of treatment of ABC without the need of refilling of the resulting cavity.

Bone marrow injection for the treatment of aneurysmal bone cyst

Bone marrow injection for the treatment of aneurysmal bone cyst

Fibular graft for reconstruction of proximal femoral aneurysmal bone cysts

Background The treatment options of aneurysmal bone cyst might change according to patient’s age, location, and type of lesion. Curettage and insertion of bone graft or polymethyl methacrylate are the principal techniques used. Patients and methods Eight patients (five male and three female; aged 8–14 years, with a mean age of 11 years) were treated with fibular autograft and iliac graft for the treatment of aneurysmal bone cyst in the proximal femur. Plain radiography and clinical assessment were performed through the whole follow-up period between 20 and 48 months (with a mean of 36 months). The musculoskeletal tumor society scoring system for limb salvage for the lower limb was used for clinical evaluation. Results Clinically, seven out of eight patients had excellent results according to the musculoskeletal tumor society scoring system for limb salvage for the lower limb. One case had postoperative pathological fracture after beginning weight bearing. Fibular grafts were fully incorporated into the recipient site within 12–16 months, with a mean incorporation time of 13 months. The graft donor site showed some minor problems such as leg discomfort and heel pain. Conclusion Curettage and an autogenous nonvascularized fibular graft is a good technique to treat benign cystic lesions of the proximal femur in relatively young patients. It is recommended to externally protect the limb with plaster of Paris. Hydrogen peroxide lavage was used to control local recurrence.

Current Strategies for the Treatment of Aneurysmal Bone Cysts.

Aneurysmal bone cysts are benign bone tumors that usually present in childhood and early adulthood. They usually manifest as expansile osteolytic lesions with a varying potential to be locally aggressive. Since their first description in 1942, a variety of treatment methods has been proposed. Traditionally, these tumors were treated with open surgery. Either intralesional surgical procedures or en bloc excisions have been described. Furthermore, a variety of chemical or physical adjuvants has been utilized in order to reduce the risk for local recurrence after excision. Currently, there is a shift to more minimally invasive procedures in order to avoid the complications of open surgical excision. Good results have been reported during percutaneous surgery, or the use of embolization. Recently, sclerotherapy has emerged as a promising treatment, showing effective consolidation of the lesions and functional results that appear to be superior to the ones of open surgery. Lastly, non-invasive treatment, such as pharmaceutical intervention with denosumab or bisphosphonates has been reported to be effective in the management of the disease. Radiotherapy has also been shown to confer good local control, either alone or in conjunction to other treatment modalities, but is associated with serious adverse effects. Here, we review the current literature on the methods of treatment of aneurysmal bone cysts. The indication for each type of treatment along reported outcome of the intervention, as well as potential complications are systematically presented. Our review aims to increase awareness of the different treatment modalities and facilitate decision-making regarding each individual patient.

Paediatric musculoskeletal interventional radiology.

Interventional radiology technique is now well established and widely used in the adult population. Through minimally invasive procedures, it increasingly replaces surgical interventions that involve higher percentages of invasiveness and, consequently, of morbidity and mortality. For these advantageous reasons, interventional radiology in recent years has spread to the paediatric age as well. The aim of this study was to review the literature on the development, use and perspectives of these procedures in the paediatric musculoskeletal field. Several topics are covered: osteomuscle neoplastic malignant and benign pathologies treated with invasive diagnostic and/or therapeutic procedures such as radiofrequency ablation in the osteoid osteoma; invasive and non-invasive procedures in vascular malformations; treatment of aneurysmal bone cysts; and role of interventional radiology in paediatric inflammatory and rheumatic inflammations. The positive results that have been generated with interventional radiology procedures in the paediatric field highly encourage both the development of new ad hoc materials, obviously adapted to young patients, as well as the improvement of such techniques, in consideration of the fact that childrens' pathologies do not always correspond to those of adults. In conclusion, as these interventional procedures have proven to be less invasive, with lower morbidity and mortality rates as well, they are becoming a viable and valid alternative to surgery in the paediatric population.

Surgical treatment of active or aggressive aneurysmal bone cysts in children.

The aim of this study was to evaluate functional and radiological results, tumor control, and complications of the surgical treatment of aneurysmal bone cysts (ABCs) in children by extended curettage using a mechanical burr and cauterization, grafting, and internal fixation in specific locations. Sixty-four children [38 males, 26 females, median age=10 years (range, 5-18 years)] with active or aggressive ABCs of long and flat bones were subjected to a median follow-up of 66 months (range, 28-130 months) following surgical treatment. The pathological fracture rate was 72%. Surgical procedures included intralesional extended curettage (92%) or en-bloc resection (8%). Internal fixation was required in 53%. The pathological fractures healed successfully in 8-12 weeks. The median Musculoskeletal Tumor Society (MSTS) score at the last follow-up was 95% (range, 55-100%). Treatment failure (partial healing/recurrence) and complication rates following extended curettage were 7 and 5.2%, respectively. Statistically, the only parameter affecting partial healing and local recurrence was proximity of the lesion to the growth plate (P=0.011). Extended curettage using a mechanical burr and cauterization, grafting, and internal fixation in specific locations can promote healing in most cases of ABC, with low recurrence and complication rates.

Aneurysmal bone cyst of the patella- A case report

Primary tumours of the patella account for less than 0.06% of bone tumours and metastatic lesions are even rarer. Aneurysmal bone cyst (ABC) accounts for 1% among primary bone lesions, and its occurrence in the patella is very rare. Twenty one year old male presented to orthopaedic OPD with complaints of swelling and pain in left knee since one year with increased pain and episodic fever since 3months. There was a history of minor trauma of left knee a year back which healed without any complications there was no other revelant past history. On radiological examination which included x-ray, CT and MRI revealed a osteolytic cystic lesion of patella and provisional diagnosis of aneurismal bone cyst of Patella made and bone curettage was done. On clinic-radiological and histopathological correlation diagnosis of primary ABC of patella was made. The mainstay of treatment of ABCs is intralesional curettage with locally applied adjuvants such as liquid nitrogen or phenol. Other options include enbloc dissection or selective arterial embolization. Young age and open physes are associated with an increased risk of local recurrence. Hence close follow up of patient has to be made.

Abstract No. 456 - Image-guided percutaneous treatment of aneurysmal bone cyst of the jaw with bone allograft and autologous bone marrow: a case report with five-year follow-up

No. 456 Image-guided percutaneous treatment of aneurysmal bone cyst of the jaw with bone allograft and autologous bone marrow: a case report with five-year follow-up R. Freitas, K. Fonseca, R. Procopio, L. Lehman; Radiology, Universidade de Sao Paulo Medical School, Sao Paulo, Brazil; Oncology pediatrics, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Interventional Radiology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Buco-maxillo Surgery, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil Purpose: A six-year old boy with an aneurysmal bone cyst of the jaw was treated by percutaneous injection of bone allograft particles mixed with autogenous bone marrow under computed tomography (CT) guidance and general anesthesia. Materials and Methods: A six-year old boy presented with a mass at the left angle of mandible, self-limited recurrent oral bleeding, pallor and severe pain partially controlled with opioids. Open surgical biopsy revealed a fibrous bone lesion with giant cells. A thin-walled 7 x 6 x 6 cm diameter (132 cc) expansible bone lesion at the left angle of mandible containing fluid-fluid levels was detected by X-ray plain film, CT scan, ultrasound, and magnetic resonance imaging. A diagnosis of an aneurysmal bone cyst was stated. A minimally invasive percutaneous approach was proposed after multidisciplinary review and an informed consent was obtained. Frozen dried bone allograft particles obtained from tissue bank were crushed, mixed with fresh autogenous bone marrow and injected into the lesion by a percutenous 11-gauge needle under CT and fluoroscopy guidance. No complications were observed. Results: The patient was discharged from the hospital the next day without symptoms. After two weeks he returned at consultation without bleeding or pain complaints. Normal serum hemoglobin was observed three months later. CT scans performed during five years of follow up showed progressive healing, ossification of the left branch of the jaw, tumor shrinking and remodeling. No pain or bleeding was reported since the percutaneous treatment. Conclusion: This case report shows excellent healing of a locally aggressive aneurysmal bone cyst after image-guided percutaneous injection of autogenous bone marrow mixed with elements of allograft bone matrix. Five years of follow-up showed excellent functional and cosmetic results. Further research is required to clarify the exact mechanisms of this potential treatment. Educational Exhibit Abstract No. 457 Ultrasound guided percutaneous tenotomy/ fasciotomy: indications, technique, and initial experience A.S. Johar, M.C. Switzer, A. Braun; Radiology, Maricopa Medical Center, Phoenix, AZ Learning Objectives: The objective of this poster is to 1) Discuss the pathophysiology of tendinosis and the common clinical presentations. 2) Review the US findings of chronic tendinopathy. 3) Describe the percutaneous tenotomy technique and its advantages over traditional tendinopathy treatments. 4) Outline our initial experience with outpatient ultrasound tenotomy. Background: Tendinopathy is a common and underdiagnosed pathology which often impairs daily and recreational activities. Given its debilitating nature, a range of treatment options exist, many of which are conservative and few of which provide durable complete symptom relief. Ultrasound guided percutaneous tenotomy is a relatively new and promising technique with the ability to remove pain causing diseased tendon tissue without damaging the adjacent healthy tendon tissue. This technique is gaining traction due to its minimally invasive nature, quick recovery time, low cost, low morbidity and durable positive outcomes. Clinical Findings/Procedure Details: We will demonstrate the findings of tendinopathy by presenting supporting US images from multiple cases. We will detail the percutaneous ultrasonic tendon cutting and debriding technique while describing pertinent pearls and pitfalls. Finally, we will discuss the outcomes from our cases. Conclusion and/or Teaching Points: After reviewing the poster, viewers will be familiar with the pathology, presentation and imaging findings of chronic tendinopathy. Viewers should appreciate US guided percutaneous tenotomy as a minimally invasive, fast and effective treatment option for tendinopathy pain. Educational Exhibit Abstract No. 458 Lymphangiography: not gone, not forgotten E. Lindgren, J. Friese, C.E. Bender; Radiology, Mayo Clinic, Rochester, MN JVIR ’ Posters and Exhibits S199

Une nouvelle alternative pour le traitement du kyste osseux anevrysmal – résultats préliminaires du Surgiflo percutané

Aneurysmal bone cysts (ABC) are benign bone lesions that can be locally aggressive causing bone destruction and pathological fracture. Traditional treatments consist of surgery (curettage or excision), and or intralesional sclerotherapy. Ethibloc was one of the most effective fibrosing agents but was withdrawn because of reported local and general complications. The purpose of this preliminary study was to evaluate the results of a percutaneous haemostatic agent Sugiflo (Ethicon) in the treatment of active and aggressive ABC. Thirteen consecutive patients with ABC were treated in our institution between December 2009 and June 2013, at an average age of 10.1 years (3.2–17.4) by percutaneous intracystic administration of a mixture of a haemostatic agent Surgiflo and pure alcohol. The cysts were located in the proximal humerus (5), proximal tibia (3), distal femur (2), iliac bone (1), L3 (1), and C4 (1). Six patients were previously treated with surgical curettage (3), internal fixation (2) or surgical excision (1). The mixture was administered under fluoroscopic and or computed tomographic guidance under local, regional or general anesthesia. Patients were assessed clinically and radiologically at an average follow-up of 16 months (6–42). The number of required procedures per patient, the improvement of pain, rate of pathologic fracture if any, tumor volume, distance to the physis, as well as improvement in cortical thickness were assessed. Complications and recurrences were recorded. The procedure was performed once in 12 patients, and twice in 1 patient. At last follow-up, 12 patients were pain free. One patient with a very aggressive ABC of C4 developed neurologic symptoms 2 months following the procedure due to vertebral collapse and cord compression and required surgical resection and cervical fusion. There was a decrease in mean tumor volume by 13%, an increase in mean distance between physis and tumor of 7.9 mm, and in mean cortical bone thickness of 2.5 mm. The complications were minor and included postoperative pain for 3 weeks (1 case) and slight limb shortening (3 cases). Percutaneous administration of Surgiflo for active and aggressive ABCs seems to be effective and safe and shows promising results. It is an easier alternative to surgery mainly in some specific locations for which surgery may be associated with a high morbidity.

ANEURYSMAL BONE CYST OF THE CLAVICLE IN CHILDREN (CLINICAL CASES AND TREATMENT)

The purpose. To examine the results of the treatment of children with aneurysmal cyst of the clavicle. Material and methods. The results of examination and treatment of patients aged 16 and 17 years with a diagnosis of aneurysmal cyst of the clavicle. All patients underwent surgical treatment with the ABC stage delimitation. We used a surgical technique, which consists in open removement of the abnormal tissue with replacement of the bone defect with bone-plastic material or autogenous bone from the iliac crest. Conclusions. The method of treatment of aneurysmal bone cyst of the clavicle must be individualized depending on the location, aggressiveness and extent of the lesion. The use bone-plastic material or autogenous bone from the iliac crest restore the structural integrity of a compromised clavicle gives good results in the observation period of up to 2 years.

Is curettage and high-speed burring sufficient treatment for aneurysmal bone cysts?

To decrease the recurrence rate after intralesional curettage for aneurysmal bone cysts, different adjuvant treatments have been recommended. Liquid nitrogen spray and argon beam coagulation have provided the lowest recurrence rates, but unlike the high-speed burr, these adjuvants are not always available in operating rooms. We asked: (1) Is high-speed burring alone sufficient as an adjuvant to curettage with respect to recurrence rates? (2) What is the complication rate from this technique? (3) What are the risk factors for local recurrence? A retrospective review of the database of the University Musculoskeletal Tumor Unit and the private files of the senior author (EHW) for a period of 19years (1993-2011) was performed to identify all patients histologically diagnosed with primary aneurysmal bone cyst. During that period, patients with aneurysmal bone cysts were treated with intralesional curettage, burring, and bone grafting if the lesions showed an adequate cortical wall or a wall with thinned out portions which could be reconstructed with bone grafting. Based on those indications, we treated 54 patients for this condition. Of those, 18 were treated using approaches other than burring because they did not meet the defined indications, and an additional five patients were lost to followup before 2years, leaving 31 patients for analysis, all of whom were followed up for at least 2years (mean, 7years; range, 2-18years). Of these 31 patients, one had a recurrence (3.2%). Complications using this approach occurred in three patients (9.7%), and included growth plate deformity (1) and genu varus (2) secondary to collapse of the reconstructed condyle. With only one recurrence, we cannot answer what the risk factors might be for recurrence; however, the one patient with recurrence presented with a large lesion and a pathologic fracture. Curettage, burring, and bone grafting compare favorably in the literature with other approaches for aneurysmal bone cysts, such as cryotherapy and argon-beam coagulation. We conclude that high-speed burring alone as an adjuvant to intralesional curettage is a reasonable approach to achieving a low recurrence rate for aneurysmal bone cysts. Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Functional outcomes and quality of life following surgical treatment of aneurysmal bone cysts of the pelvis in children.

BackgroundAneurysmal bone cysts (ABCs) are a benign aggressive tumor that occurs rarely in the pelvis in the pediatric population. Pelvic ABCs may involve the triradiate cartilage and/or the acetabulum, which increases the technical difficulty of surgical treatment and has potential implications on the growth and development of the hip joint. This study examines the clinical presentation, rate of surgical complications, and recurrence rate, as well as, long-term clinical and functional outcomes of children with pelvic ABCs treated at a single institution by a single treatment modality.MethodsBetween 1988 and 2008, 142 children with histologically confirmed ABCs were treated at our institution. Seventeen (12 %) tumors were located in the pelvis. A total of 13 pelvic ABCs (5 ilium-periacetabular, 4 pubic, 3 ilium-iliac wing, and 1 ischium) were included in this study. There were eight male and five female patients with a mean age of 12.9 years (range 4.1–17.5 years) at the time of surgery. The Toronto Extremity Salvage Score (TESS), the Musculoskeletal Tumor Society 1993 (MSTS’93) score, and the Short Form Health Survey Sf-36 were obtained at a minimum 5-year follow-up in all patients (mean follow-up 11.5 years, range 5.5–19.8 years). The mean age at follow-up was 24.3 years (range 14.6–32.6 years).ResultsAll patients were treated surgically with intralesional curettage extended with a high-speed burr and bone grafting. Eight patients received adjunctive therapy with phenol. Five patients had preoperative selective arterial embolization. Of the 13 patients, 1 had a local recurrence diagnosed at 6 months after surgery. The only complication in the cohort was a superficial wound infection. At the latest follow-up, all patients were free of disease. The mean TESS score was 95 and the mean MSTS’93 score was 93 %. The mean self-rated general health score, according to the SF-36 was 87 % of total points possible.ConclusionsExtended curettage and bone grafting of pelvic ABCs in the pediatric population can yield high clinical and functional scores at an average of 11 years follow-up with a low rate of complications and recurrence.Level of evidenceIV, case series.

Assessment of 120 Maxillofacial Aneurysmal Bone Cysts: A Nationwide Quest to Understand This Enigma

Compared with other maxillofacial lesions, oral and maxillofacial (OM) aneurysmal bone cysts (ABCs) are rare, and most studies have been case reports. Because the features or radiographic findings of 1 case could not be representative of the whole, conclusions cannot be drawn and data analyses will not be feasible. Our aim was to assess and describe the clinical and histopathologic characteristics of a large sample of subjects with ABCs. To our knowledge, the present case series of OM ABCs is the largest ever reported. To address our research purpose, we designed and implemented a retrospective case series. A multicenter retrospective cohort study of patient charts dated from 1967 to 2013 (46 years) at 10 major universities in 8 cities was undertaken to assess OM ABCs nationwide. Subjects were included if they had documented chart data and definitive histopathologic slides confirming the diagnosis and treatment of ABC. They were excluded if their histopathologic slides did not confirm the diagnosis of an ABC. Data were collected, and special forms were completed. Variables such as age, gender, site (ie, maxilla, mandible, anterior, posterior), histologic type (ie, solid, mixed, vascular), signs, symptoms, radiographic features (ie, radiolucency, unicystic or multilocular), and outcomes (ie, treatment modal, recurrence, complications) of the lesion were evaluated and documented by OM surgeons and confirmed by OM pathologists for assurance. Data analyses were performed using Statistical Package for Social Sciences, version 20, software (SPSS, Chicago, IL) (P < .05). We assessed the medical records and histopathologic slides of 120 patients diagnosed and treated for OM ABCs nationwide. Of these patients, 69 were male (57.5%) and 51 were female (42.5%), with no predilection found. The key findings were as follows. The mean age of occurrence was 20.7 ± 2.5 years (range 4 to 78), and occurrence was significantly greater in the first 2 decades of life (P < .001). The incidence was 2.6 cases/year. ABCs were significantly more common in the mandible (P < .05) and posterior areas (P < .05). The most common histopathologic type was the mixed type (P < .05). Firm swelling was the most common clinical presentation (P < .05); all cases were radiolucent and commonly unilateral (P < .05). Most were treated by excision and curettage. Recurrence was reported in 11 patients (9.2%) during the follow-up period (1 to 45 years). The present retrospective cohort found ABCs with a variable presentation, disease course, and histopathologic type, with no gender predilection. ABCs were significantly more common in childhood and adolescence and in the mandible and posterior areas of the jaws. Of the cases reviewed, 90% were treated by excision and curettage. ABCs had a relatively low recurrence rate (<10%), precluding the need to perform aggressive surgery primarily.

Sclerotherapy with polidocanol for treatment of aneurysmal bone cysts

Background and purpose Recent data suggest that percutaneous sclerotherapy is a safe alternative to surgery for treatment of aneurysmal bone cysts (ABCs). We present our experience of this method.Methods We retrospectively analyzed data from 38 consecutive patients treated with repeated injections of polidocanol. Each injection consisted of 2–4 mg polidocanol per kg body weight. Radiological and clinical assessments were performed until healing.Results All cycts except 1 healed after a median of 4 (1–11) injections. A lesion failed to heal in 1 patient, who was operated. 3 patients experienced minor local inflammatory reactions.Interpretation Our results show that percutaneus sclerotherapy with polidocanol has high efficacy in the treatment of ABCs, with a low frequency of side effects. Our findings corroborate data presented in previous publications. We believe that the method will be especially valuable in ABCs of the pelvis and sacrum, where surgery is associated with considerable morbidity.

A comparison of cyst wall curettage and en bloc excision in the treatment of aneurysmal bone cysts

BackgroundThe recurrence rate after aneurysmal bone cyst (ABC) treatment is quite high despite its benign nature. In ABC therapy, curettage is the treatment of choice; en bloc excision results in a lower recurrence rate, but more extensive reconstructive surgery is needed with associated morbidity. The aim of the present study was to compare the outcomes of the two treatment options.MethodsA retrospective analysis was performed on 26 patients treated for ABCs: 16 by curettage and 10 by en bloc excision. Each lesion was classified according to Enneking and patients were followed up for a mean time of 9.2 years. On follow-up, radiological examination and functional assessment (range of motion, muscle strength) were performed. Recurrence was defined as the presence of an osteolytic lesion, especially one with a tendency to grow.ResultsOn follow-up, the following symptoms were more prevalent in the en bloc excision group compared to the curettage group: pain (en bloc 20% versus curettage 6.25%), limb length differences (en bloc 20% versus curettage 12.5%), reduced range of motion (en bloc 20% versus curettage 6.25%) and muscle strength impairment (en bloc 50% versus curettage 31.2%); however, the differences were not statistically significant (P >0.05). In the curettage group, two cases of postoperative complications and two cases of recurrence were seen, while in the en bloc excision group one case of complications was noted.ConclusionsCurettage is a standard procedure in ABC management. En bloc excision is another option, albeit more technically demanding, that may be considered in recurrent lesions with extensive bone destruction or for cysts in an expendable location.

Percutaneous doxycycline treatment of aneurysmal bone cysts with low recurrence rate: a preliminary report.

Aneurysmal bone cyst (ABC) has a recurrence rate of between 12% and 71% without en bloc resection or amputation. There is no percutaneous ABC treatment drug regimen demonstrating consistent evidence of bone healing with recurrence of < 12%. Doxycycline has properties that may make it appropriate for percutaneous treatment. We therefore asked: (1) Is there reduction in ABC lytic cyst volume with injectable doxycycline? (2) Is it associated with thickening of involved bony cortex? (3) Is the recurrence rate after percutaneous treatment < 12%? We retrospectively reviewed 20 patients who underwent percutaneous treatment of ABCs with doxycycline from 2006 to 2010. The mean age was 10 years (range, 3-18 years). There were 21 treatment locations: humerus (six), spine (five), clavicle (two), fibula (one), femur (two), ulna (two), tibia (two), and scapula (one). Twenty patients completed treatment involving 118 treatment sessions (two to 14 sessions per patient). Treatment response was evaluated radiographically by measuring the lytic component and thickness of involved cortex. Recurrence was indicated by new areas of lytic destruction after completion of treatment. The minimum followup was 24 months (mean, 38 months). Twenty of 20 patients demonstrated reduction in lytic destruction and bony healing. All patients demonstrated cortical thickening. One patient demonstrated recurrent minimal lytic destruction after 20 months of observation. In this series, patients undergoing percutaneous doxycycline treatment of ABCs demonstrated a healing response and a recurrence rate of 5% at more than 24 months.

3:30 PM Abstract No. 52 - Outcome of endovascular treatment for aneurysmal bone cysts

Purpose Surgical management of aneurysmal bone cysts (ABCs) is associated with perioperative morbidity, mortality and high recurrence. In addition, some ABCs are inoperable. We evaluated the presentation, morphology, technique and outcome of percutaneous image guided sclerotherapy for ABCs. Materials and Methods We retrospectively reviewed the medical records and imaging studies of patients with ABCs who underwent percutaneous sclerotherapy at our institution. Age, location, size, symptoms, image guidance, agents used and outcomes were documented. Symptomatic and radiological changes were evaluated and compared pre and post sclerotherapy. Results 27 pts (5-18 yrs; mean age, 11.5 yrs) including 20 nonspinal ABCs (5-18 yrs; mean age, 11.5 years) and 7 spinal ABCs (8-18 yrs; mean age, 13 yrs) underwent percutaneous sclerotherapy. Most common symptoms were pain, swelling and neurological. 21 pts had biopsy proven ABCs. Sonographic, fluoroscopic or C-arm flat-detector CT (dynaCT) as well as combinations of these modalities was used for guidance. The sclerosant agents were sodium tetradecyl sulfate (n=23), ethanol (n=12) and doxycycline (n=8); either singly or in combinations. In 7 pts (4 nonspinal, 3 spinal) sclerotherapy was combined with transarterial embolization.1-9 sclerotherapy sessions were performed (mean: 5). Range of follow-up was 2-69 (mean, 35.5) months. In 17 (85%) nonspinal and 4 (71%) spinal lesions, pain resolved, completely in 16 pts (14 nonspinal and 2 spinal) and partially in 10 pts (5 non-spinal and 5-spinal). Radiological regression was noted in 14 (70%) nonspinal and 3 (43%) spinal lesions. 3 other pts with spinal ABCs showed radiological progression and spinal instability. 6 pts (5 spinal, 1 nonspinal) required further operative interventions but with significantly lesser blood loss. There were no complications related to sclerotherapy. Conclusion Endovascular treatment is a safe and effective treatment for aneurysmal bone cysts. It can be used as definitive treatment or as a bridge to elective surgical operation. This approach provides symptomatic relief and regression of the size of most ABCs, with more favorable outcome in nonspinal lesions.

Denosumab: a potential new and innovative treatment option for aneurysmal bone cysts

Aneurysmal bone cysts (ABCs) are expansive and destructive lesions positive for osteoclast markers, resembling benign giant cell tumors (GCTs). Treatment options include surgical resection, curettage and cavity filling, embolization, injection of fibrosing agents, or radiotherapy. Particularly in children and adolescents with spinal ABCs, these options may be unsatisfactory, and innovative forms of treatment are needed. Denosumab is a human monoclonal antibody that inhibits osteoclast function by blocking the cytokine receptor activator of the nuclear factor-kappa B ligand. Satisfactory results with denosumab in treating GCTs and immunohistochemical similarities suggest that it may also have positive effects on ABCs. This report is the first description of the therapeutic use of denosumab in two patients with spinal ABCs. Two boys (aged 8 and 11) had recurrent ABCs at C5 after surgery with intralesional tumor resection. Treatment options were discussed by the interdisciplinary tumor board. Arterial embolization was attempted, but failed due to an absence of appropriate afferent arteries. After the families had received extensive information and provided written consent, denosumab therapy was initiated as an individualized treatment, despite the absence as yet of scientific evidence. After the start of denosumab therapy, both patients recovered from pain and neurologic symptoms significantly and are now in a healthy condition with no severe side effects. Magnetic resonance imaging check-ups after 2 or 4 months of denosumab treatment, respectively, showed tumor regression in both patients. Longer follow-up and clinical studies are warranted to establish the value of denosumab in the treatment of ABCs.

Expert’s comment concerning Grand Rounds case entitled “Solid variant of aneurysmal bone cyst on the cervical spine of a child: case report, differential diagnosis, and treatment rationale” (by Christos Karampalis, Robert Lenthall, and Bronek Boszczyk)

This article reports a case of solid variant aneurysmal bone cyst (S-ABC) in the cervical spine of a child [1]. Aneurysmal bone cyst (ABC) of the vertebral column occurs infrequently and, as the article points out, the solid variant is exceedingly rare in the spine. While MRI can be very helpful in formulating a differential diagnosis and differentiating S-ABC from more typical cystic ABC, imaging studies cannot always differentiate S-ABC from other benign bone lesions. Performing an incisional biopsy with intra-operative frozen section is an important first step in our approach to treatment of this and other forms of ABC. Traditional treatment of ABC with intralesional curettage and bone grafting produced recurrence rates of 10–60 % [2]. To limit recurrence, we recommend a four-step approach to treatment of ABC, including the solid variant form. This includes (1) intralesional curettage, (2) cauterization of the osseous cyst wall, (3) extended curettage with a high-speed diamond burr, and (4) dilute (5 %) phenol application [3]. Titanium instrumentation may be necessary after removal to reestablish spinal stability. As in this case, arterial embolization can be used as an adjunct to surgical excision.