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Femoroplasty: a new option for femur metastasis

Ricardo Plancarte-Sanchez, MD, FIPP*; Jorge Guajardo-Rosas, MD†; Oscar Cerezo-Camacho, MSc‡; Faride Chejne-Gomez, MD†; Francisco Gomez-Garcia, MD§; Abelardo Meneses-Garcia, PhD¶; Cristopher Armas-Plancarte, MD†; Gustavo Saldan˜a-Ramirez, BSN†; Roberto Medina-Santillan, PhD** *Escuela Superior de Medicina, Postgraduate Division, Instituto Politecnico Nacional. Pain Clinic and Palliative Care Department, Instituto Nacional de Cancerologia, Mexico City; †Staff of Pain Clinic and Palliative Care, Instituto Nacional de Cancerologia, Mexico City; ‡Medical Sciences Researcher, Clinical Research Department, Instituto Nacional de Cancerolo- gia, Mexico City; §Orthopaedics and Trauma Department, Instituto Nacional de Cancer- ologı´a, Mexico City; ¶Escuela Superior de Medicina, Postgraduate Division, Instituto Politecnico Nacional, Mexico City; **Department of Research and Postgraduate studies, Escu- ela Superior de Medicina, Instituto Polite´cnico Nacional, Mexico City, Mexico n Abstract: Bone metastases are very frequent in patients the consolidation of the microfractures because of bone with cancer and usually are located in the patient’s long bones and spine. Various approaches to pain relief and sta-bility to the affected bone have been used. The aim of the study is to report our experience with a new minimally polymethylmethacrylate cement, bone metastases, femur, invasive percutaneous technique in patients with bone metastases located in the head, neck, and proximal femur.
The technique is performed under fluoroscopic guidancethrough the application of polymethylmethacrylate bone cement. Our descriptive, retrospective, longitudinal caseseries included 15 patients who underwent femoroplasty.
Bone metastasis is a frequent condition in patients with All patients reported pain reduction and improved mobil- cancer. Its incidence depends on the primary tumor ity, with no complications observed. The femoroplasty pro- type. It develops in up to 50% of patients with cancer, cedure caused pain relief by stabilizing the bone through most frequently breast, prostate, and lung cancers.
Approximately 1.5 million new cancer cases are Address correspondence and reprint requests to: Ricardo Plancarte- reported each year.1 The most frequent symptom is Sa´nchez, MD, FIPP, Av. San Fernando 22, Col. Seccio´n XVI, 14060 MexicoCity, Mexico. E-mail: pain, which is severe and as a result produces altera- Submitted: July 12, 2011; Revision accepted: June 27, 2012 tions in mobility. This has repercussions on the muscu- loskeletal system and therefore on quality of life.2–4The vast majority of cancer patients with bone metasta- ses are in advanced stages of their disease. Some of Pain Practice Ó 2012 World Institute of Pain, 1530-7085/12/$15.00Pain Practice, Volume ••, Issue •, 2012 ••–•• these metastatic bone lesions involve long bones such as the femur, but there are few studies examining mini- obturator artery is divided into 2 types as well, the mally invasive treatments for these areas. Therefore, anterior and posterior. In the second plane, the mus- our primary goal in this study was to examine whether cles passing nearby are the tensor of fascia lata and such a therapy would improve quality of life and reduce pain in individuals with metastatic cancer to the femur.
In the third plane, we find the medial and lateral Existing treatments for this kind of patient include region of the greater trochanter of femur, between the surgery, radiation therapy, chemotherapy, hormonal meeting point of the gluteus medius and vastus medial- therapy, and the use of bisphosphonates. Of these, radiation remains the treatment of choice. Commonly,pharmacological handling by itself does not control pain adequately in these patients5; for this reason, it isnecessary to use a multimodal therapy that can offer a The Ethics Committee of the Instituto Nacional de better option of integral palliation.
Cancerologia (IRB) approved this retrospective obser- To provide pain relief and offer stability to the vational case series. Informed consent was obtained affected bone, physicians have been looking for new prior to intervention. Fifteen patients with metastatic minimally invasive techniques to approach these bone disease of the femur were treated at the Instituto Nac- metastases, such as vertebroplasty. Vertebroplasty ional de Cancerologia, Mexico City, from November consists of the application of bone cement to a com- 2004 through December 2007. Inclusion criteria were pression fracture within the vertebral body, which as follows: (1) patients with primary malignancy of produces substantial pain relief in 80–90% of the lung, breast, and prostate and metastatic lesions in the cases, with low morbidity. 6–11 Likewise, patients head, neck, and proximal one-third of the femur and who were treated with the application of bone (2) Karnofsky score >60%. Exclusion criteria were as cement—under fluoroscopic or tomographic guid- follows: (1) impairment of coagulation and platelet ance—reported 90% of pain relief in different parts dysfunction; (2) local infection at the proposed proce- of the skeletal system such as tibia, pelvis, as well as dure site; and (3) cognitive dysfunction.
several support points in the acetabulum, ilium, and Outcome measures were visual analog scale (VAS) rat- sacrum. 12–19 At the femoral level, when the polym- ing, use of opioid and nonopioid pain medication, and ethylmethacrylate (PMMA) bone cement is used, it changes in function as measured by mobility. All patients solidifies and permits stabilization of the bone struc- were previously evaluated using the following studies: ture and coxofemoral articulation. A lytic activity is elevation of alkaline phosphatase, bone scanning, pelvis originated as a consequence of the thermal action and affected hip X-ray, and pelvis MRI in some cases.
produced by the cement, reducing the metastatic Depending on the progression of their disease, some activity, and it is suggested that this probably inhib- patients were receiving chemotherapy, radiotherapy, and its the regional nociceptors, thus alleviating pain, as both opioids and nonsteroidal anti-inflammatory drugs (NSAID) without satisfactory results.
The objective of this study was to investigate a new, minimally invasive, fluoroscopically guided, percutane- ous technique called ‘‘femoroplasty’’ in patients withmetastatic disease in the head, neck, and proximal The patients’ blood pressure, pulse oximetry, and ECG were monitored continuously during the procedure;conscious sedation was achieved with fentanyl, propo-fol, and midazolam. One gram of IV cephalosporin was administered for prophylaxis prior to starting the pro- When performing femoroplasty, it is necessary to cedure. Using fluoroscopy, the patients’ pelvis and have good knowledge of the anatomical planes involved hip were imaged in the anteroposterior posi- tion. The patient was then placed in the lateral decub- described: In the first plane, the skin is innervated by itus position with the affected side up and the hip the lateral femoral cutaneous nerve and vascularized slightly flexed. Using sterile technique, the area was by the superior gluteal artery. The superior gluteal then prepped, and the fluoroscopy machine was ori- artery is divided into 2 types, superior and deep. The ented so that the needle entry site could be lateral to the Figure 1. Lateral view of the femur with 22-gauge needles Figure 2. Correct position of the needle in AP view.
placed on both sides; bone biopsy needle located in the middleof the greater trochanter.
through the greater trochanter until its tip reached the femur with a craniocaudal angle varying from 20 to 30 junction of the anterior and medial third of the femoral degrees. The C-arm was rotated until the femoral neck head. Once the biopsy needle was properly placed by this and head could be visualized and the greater trochanter maneuver, the spinal needle was removed and the intro- appeared as an oval (tunnel view). The procedure site duction of the biopsy needle continued (Figure 3).
was infiltrated with 2% lidocaine, and two 22-gauge Once the biopsy needle was placed adequately in needles were placed for reference between the neck and the femoral head, its location was verified with 3 mL head of the femur. An 11-gauge bone biopsy needle was of nonionic contrast to evaluate the filling pattern and then placed in the middle and upper area of the greater identify leaks into the articular space, veins, or muscle.
trochanter between the 2 spinal needles directed toward If necessary, the needle was repositioned. Subse- the femoral head and a third needle in the center. These quently, we administrated the PMMA, using fluoro- needles are essential to locate the femur, depth, and tra- scopic guidance in the lateral view using real-time jectory of the biopsy needle (Figure 1). Once the biopsy needle touched bone, it was then advanced across the Polymethylmethacrylate preparation: the PMMA cortical region of the trochanter using both lateral and was mixed to a semiliquid consistency and drawn up tunnel views for guidance (Figure 2).
into 1-mL syringes. Administration of the PMMA was A 22-gauge long spinal needle was passed through the performed under fluoroscopic imaging in the AP and biopsy needle as a guide before advancing the biopsy lateral view. To achieve satisfactory filling of the needle toward the femoral head; this reduced the possi- affected bone, the needle should be withdrawn while bility of needle deviation. The advancement of the spinal delivering the cement, directing the bevel of the needle needle was sometimes complicated by bone hardening.
toward the site that requires more filling (Figures 5A In this circumstance, the biopsy needle was advanced and 5B). The quantity of PMMA varies depending on Figure 3. The biopsy needle advanced through the femoralhead with the tip between the anterior and medial thirds.
Figure 5. (A) AP VIEW: PMMA application; (B) view of the pro-cedure’s final step.
PMMA, polymethylmethacrylate; VAS, visual analog scale; Mets source, origin of themetastasis.
the extent of the metastatic lesion and patient size.
Filling should be stopped once the distribution of Figure 4. Lateral view to verify PMMA distribution.
cement in the metastatic area has been achieved.
to be multifactorial. The injection of bone cement mayaid in the stabilization of microfractures, reduce thermaldamage, and reduce cytotoxicity in bones. Furthermore,the antineoplastic effect of bone cement may play a sig-nificant role in treating osteolysis.22,23 The present studydemonstrated a sustained effect on pain relief (decreasedVAS score) at femoral level across PMMA use, withimprovement in function and pain (WOMAC score.) Our study did not find any serious complications, perhaps because of the femoral characteristics (longbone, size, easy approach) in our study population.
The literature mentions potential complications infemoroplasty, We performed 17 femoroplasties in 15 patients (2 cement leakage, nerve and vascular injury, persistent bilateral): 8 women (mean age 42.6 ± 12.6), 2 with pain, incident fracture after cementoplasty, rejection to lung cancer and 6 with breast cancer, and 7 men PMMA, and avascular necrosis of femoral head by (mean age 62.8 ± 13.8), 6 with prostate cancer and 1 cement leakage to the circumflex artery. Three previ- with lung cancer (Table 1). The distribution of affected ous case series had been reported without detailed sides was as follows: 10 right sides and 7 left sides of affected femur in 15 patients. The mean volume of One previous series reported 11 patients who pre- sented with osteolytic lesions and severe pain (none of whom were treated with previous radiotherapy), and 5 patients more than 50% compared with baseline levels patients presented with fracture at the femoral neck or and was maintained throughout follow-up (ANOVA trochanter. The author used a greater volume of injec- repeated measures P < 0.01). Moreover, 15 sides saw tion than our study of PMMA (up to 30 mL) and improvement according to Western Ontario and found a clinical improvement in pain relief without McMaster Universities Osteoarthritis Index (WO- any information regarding statistical significance.24 In MAC) score, while only 2 reached slight improvement our study, every patient was treated with radiotherapy (standard medical therapy for bone metastases) and Baseline mean VAS score for pain was 5.6 ± 1.1.
pharmacologic treatment. They presented with signifi- Pain was localized in the affected pelvic member. Post- cant pain and functional impairment. The technique procedure VAS was 1.2 ± 2.3, remaining at the same presented in our study seems easier than Kang’s tech- level throughout the follow-up of 2 months (t-test nique, in spite of the fact that we used only one bone [basal vs. following measures] and ANOVA repeated biopsy needle and we did not use special tools, for measures <0.001) (Figure 6). All patients reported pain reduction on the treated pelvic member and improved The other 2 case series reported one and 2 cases, mobility; however, analgesic intake was not modified respectively. The case report used cementoplasty at the because of patients’ pathology. There were no compli- femoral head with optimal pain relief. The author used cations observed, but 3 patients presented with tran- a double approach (neck and acetabulum) with the sient pain that improved 10 days after the procedure.
patient in prone position.25 We consider prone posi-tion a more difficult position than lateral decubitus.
The lateral decubitus position allowed us to visualizethe AP and lateral views of femur in a better way.
Polymethylmethacrylate use at sites of bone metastases It also allowed us to modify the angle to obtain a resulted in improved function, pain relief, and health- coaxial or tunnel vision view. The lateral decubitus related quality of life. The use of PMMA at sites other approach resides in the middle of greater trochanter, than the vertebrae is a novel, interventional approach consequently allowing us to use only one needle to that may be used to potentially reduce pain and improve patient function. The mechanisms of bone cement– The last report took into account 2 cases of femur induced analgesia and functional improvement are likely cementoplasty. In both patients, the author found improvement in pain relief; however, one had a pathologic 8. Galibert P, Deramond H, Rosat P, Le Gars D. Prelimin- fracture in the treated area, and in the other, the ary note on the treatment of vertebral angioma by percutane- patient did not improve in functionality.26 In contrast, ous acrylic vertebroplasty. Neurochirurgie 1987;33:166–168.
we did not have pathologic fracture postprocedures.
9. O’Brien J, Sims J, Evans A. Vertebroplasty in patients with severe vertebral compression fractures: a technical We observed improved WOMAC scores in every report. AJNR Am J Neuroradiol 2000;21:1555–1558.
10. Amar A, Larsen D, Esnaashari N, Albuquerque FC, Adequate pre-, intra-, and postprocedure evalua- Lavine SD, Teitelbaum GP. Percutaneous transpedicular tions of the patient are necessary. The venography PMMA vertebroplasty for the treatment of spinal compres- procedure is an important tool that allows us to ade- sion fractures. Neurosurgery 2001;49:1105–1115.
quately fill the lesion and detect potential leakage 11. Weill A, Chiras J, Simon JM, Rose M, Sola-Martinez into the vasculature. PMMA bone cement should be T, Enkaoua E. Spinal metastases: indications for and resultsof percutaneous injection of acrylic surgical cement. Radiol- confined to the area of bone defect. Because of the high temperature reached during the hardening pro- 12. Kelekis A, Lovblad K, Mehdizade A, et al. Pelvic cess, the cement can cause thermal necrosis and pro- osteoplasty in osteolytic metastases: technical approach duce a dysfunction in nociceptors. It can also achieve under fluoroscopic. Guidance and early clinical results.
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dation of the microfractures in the affected lower 13. Marcy PY, Palussie`re J, Descamps B, et al. Percutane- ous cementoplasty for pelvic bone metastasis. Support Care Drawbacks to this study include a retrospective and 14. Hokotate H, Baba Y, Churei H, Nakajo M, Ohkubo nonuniform case series format, which is inherently K, Hamada K. Pain palliation by percutaneous acetabular flawed and subject to reporting bias. Future study will osteoplasty for metastatic hepatocellular carcinoma. Cardio- clarify the exact indications and outcomes of this tech- vasc Intervent Radiol 2001;24:343–346.
nique. In spite of these problems, we suggest this pro- 15. Cotten A, Deprez X, Migaud H, Chabanne B, Du- cedure may be best for those patients presenting with quesnoy B, Chastanet P. Malignant acetabular osteolyses: Karnofsky performance scores over 60%, with pain on percutaneous injection of acrylic bone cement. Radiology the affected pelvic extremity, and whose physical activ- ities present risk of fractures of the femoral bone, a sit- 16. Kelly C, Wilkins R, Eckardt J, Ward W. Treatment of metastatic disease of the Tibia. Clin Orthop Relat Res uation that rapidly deteriorates their quality of life.
17. Harris K, Pugash R, David E, et al. Percutaneous cementoplasty of lytic metastasis in left acetabulum. Curr 1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 18. Mercy P, Palussiere J, Descamps B, et al. Percutane- 2007. Cancer CA Cancer J Clin 2007;57:43–66.
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3. Perrin RG, Laxton AW. Metastatic spine disease: epi- 20. Deramond H, Wright NT, Belkoff SM. Temperature demiology, pathophysiology, and evaluation of patients.
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4. Coleman RE. Clinical features of metastatic bone dis- 21. Netter FH. Lower Limb. En: Atlas of Human Anat- ease and risk of skeletal morbidity. Clin Cancer Res omy, 4th ed. Philadelphia: Saunders, Elsevier Inc; 2006.
22. Baroud G, Samara M, Steffen T. Influence of mixing 5. Fallon M, McConnell S. The principles of cancer pain method on the cement temperature-mixing time history and management. Clin Med 2006;6:136–139.
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6. Tschishart C, Finkelstein J, Whyne C. Optimization J Biomed Mater Res B Appl Biomater 2004;68:112–116.
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