Role of Image Guided Interventions in Orthopaedic Oncology

Transcription

1 Review Journl of Bone n Soft Tissue Tumors 2015 Sep-De;1(2) : Role of Imge Guie Interventions in Orthopei Onology Astrt Interventionl riology hs grown in leps n ouns speifilly in fiel of orthopei onology. The proeures hve vntge of eing minimlly invsive n hve muh etter postproeure rehilittion. These proeures n e roly lssifie s Non-vsulr n Vsulr interventions. Common non-vsulr proeures omprise of imge guie iopsies, riofrequeny ltions, verteroplsty n khyphoplsty. Vsulr proeures omprise of Emolotherpy n Slerotherpy. Isolte Lim Infusion (ILI), MR-HIFU (MRIguie High Intensity Fouse Ultrsoun), Cryoltion re few of the more reent vnes in the fiel of interventionl riology. Eh proeure hs its own initions, ontrinitions n sfety profile. The urrent rtile provies n overview of these proeures n there linil importne. Keywors: Interventionl riology, orthopei onology. Introution Imge guie interventions or otherwise populr s the fiel of interventionl riology omprise of proeures whih re performe with the help of n imging molity suh s fluorosopy, USG, CT or MRI. With the rising preferene for miniml invsive therpies, these proeures enjoy n inresing sope in the ptient mngement. Other thn eletive proeures, interventionl riology proves invlule for mnging meil n surgil emergenies. In reent yers, interventionl riology is plying vitl role in the fiel of orthopeis n orthopei onology. This rtile will give n outline of the ommon proeures performe y n interventionl riologist in orthopei onology. These proeures n e roly lssifie s Non-vsulr n Vsulr interventions. Non-Vsulr Interventions Common non-vsulr proeures omprise of imge guie iopsies, riofrequeny ltions, verteroplsty 1 Himnshu Pense *, Aniruh Kulkrni², Mnish Agrwl² 1 P.D Hinuj Hospitl Veer Svrkr Mrg, Mhim, Mumi, Ini Aress of Corresponene Dr. Himnshu Pense P.D Hinuj Hospitl Veer Svrkr Mrg, Mhim, Mumi, Ini. Emil: himnshu.pense@gmil.om n khyphoplsty. Imge guie iopsies n fine neele spirtion ytology (Figs. 1A n B, 2A n B, 3A n B n Fig. 4): This hs emerge s sfe, fster n urte tool for getting ignosis from musuloskeletl lesion. It is sfer n hs etter ptient tolerne s ompre to onventionl open iopsy [1]. Initions 1. Determine whether lesion is enign or mlignnt 2. Otin mteril for miroiologil exmintion in suspete infetive lesion 3. Determine sttus of lesion in ptient with known primry Contrinitions: Known ogulopthy, Pregnny (for CTguie proeures) Speil onsiertions It is impertive to etermine sfe route for iopsy, whih omes in the exision n/or rition fiel for treting the primry lesion. Clssi no-touh lesions like myositis ossifins in evolving stge; suhonrl geoes et shoul e ientifie Dr. Himnshu Pense Dr. Aniruh Kulkrni 2015 y Journl of Bone n Soft Tissue Tumors Aville on oi: /jst This is n Open Aess rtile istriute uner the terms of the Cretive Commons Attriution Non-Commeril Liense ( whih permits unrestrite non-ommeril use, istriution, n reproution in ny meium, provie the originl work is properly ite. on imging n prevente from eing iopsie. These lesions pper ggressive on histology, using riologil n pthologil isrepnies. Equipment n Tehniques Fluorosopy, USG, CT or MRI hve een use for imge guine for iopsy. CT sn is most often use for iopsy of one lesions [2]. The min vntge of CT eing preise visuliztion of trjetory of the neele. thus preventing mge to the importnt strutures like the neurovsulr unle. USG is preferre for superfiil one lesions with trgetle soft tissue omponent. It is preferre in ptients where rition exposure hs to e voie [3]. Fluorosopy is goo molity for iopsy of lrge lesions. In some ses, the lesion is visile only on MRI. In suh ses, MRIguie iopsy is inite. The proeure is generlly performe uner lol nesthesi with light setion when neessry. The ptient lies prone for verterl iopsy. For ny other one, the position epens on the site of the lesion. Comprtmentl ntomy gretly influenes the neele pproh, n suh knowlege is ritil for preventing unneessry surgery n loss of lim funtion. It is importnt to stress tht the iopsy Dr. Mnish Agrwl trjetory shoul e through the tissues tht woul e exise or omes in the rition fiel to prevent reurrene long 25 Journl of Bone n Soft Tissue Tumors Volume 1 Issue 2 Sep-De 2015 Pge 25-33

2 Figure 1 & 1: Destrutive L1 lesion is note with soft tissue omponent involving the left pr-verterl region. CT guie iopsy ws performe onfirming metstsis from renl primry Figure 2 & 2: A well-efine lesion is note in the region of the greter tuerosity of the left humerus, whih ws extening in the lower he. CT guie iopsy ws one with 11G one iopsy neele espeilly when enign isese is suspete. reurrene n one frture re the the iopsy trt. Severl stuies hve shown higher ury ommon omplitions. Instilling gelfom Generlly, n 11-15G Trephine Bone Biopsy of ore neele iopsy (89.7%-96%) to fine torpeos in the iopsy trt n rrest Neele is use to trget one lesions neele spirtion ytology (64%-88%) [4]. leeing from iopsy of hypervsulr without signifint soft tissue omponent. Biopsy of one lesions with soft-tissue metstsis. For FNAC, 22 G neele is generlly omponents (93%, 89%) hs higher Post-proeurl Cre: Ptient my e use. The yiel is etter for lrger neele. ignosti ury thn iopsy of lyti vise to tke pinkillers if pin is In se of verterl iopsy of the orsl lesions (85%, 71%) [5]. Also, in se of signifint Antiioti over is not neessry vertere, it is visle to use 13G neele inste of n 11G neele ue to the thinner peiles of the orsl vertere. In lesions with signifint soft tissue omponent, n 18G o-xil iopsy set with o-xil neele n semi-utomte or utomte gun woul e goo hoie. In irumsrie lyti lesion, it is pruent to use n 11/13G one iopsy neele s n nhor. Through this, the 18G iopsy neele is psse to otin soft tissue ores. MRI guie iopsies nee speil MRI omptile neeles. Smpling shoul e Figure 3 & 3: An ill-efine lyti lesion ws note in the left l of Figure 4: Fluorosopy guie iopsy of performe y fine-neele spirtion srum in known se of rinom of lung. CT guie iopsy of the lyti lesion in the shft of lower left (FNA) long with Core Neele Biopsy s the srl lesion ws performe using 11G one iopsy neele femur ws one. mny interventionl riologists feel tht oth the tehniques hve omplementry ysti lesions, iopsy from the wll of the post-iopsy. role. ysti lesion hs etter yiel thn spirting Biopsy Yiel n Outomes: This is n flui [6]. Infetions hve een reporte to importnt issue for one iopsies. It is Complitions hve high ignosti yiel of 80% to 90% importnt to tke enough smples, Pin, leeing, infetion, iopsy trt Figure 5, 5, 5 & 5: Known se of multiple myelom presente with severe low khe. Figure 5 n : Non-ontrst xil imge of the pelvis shows lyti re in oth the srl le (lk rrow). Sroplsty ws plnne. Figure 5 n shows one iopsy neele inserte uner fluorosopy guine in oth the srl le n high ensity one ement ws injete(lk rrow). Speil re hs to e tken to prevent lekge of ement long the srl nerves. Postsroplsty ptient h signifint pin relief. 26 Journl of Bone n Soft Tissue Tumors Volume 1 Issue 2 Sep-De 2015 Pge 25-33

3 Figure :6 shows prtilly ollpse D9 verterl oy. Figure 6 shows verteroplsty neeles inserte using ilterl trnspeiulr pproh. Figure 6 shows one ement eing injete in the verterl oy. Note the leking one ement in the interverterl is inferiorly, whih is generlly inonsequentil (lk rrow) on spirtion [7]. Dignosti yiel hs een ttriute to lrger lesion size n lrger speimen length [8]. Cementoplsty: This involves injeting one ement in the wekene weight-ering ones to relieve pin. The proeure is usully nme fter Contrinitions: Asolute ontrinitions re unorretle ogulopthy, spinl infetion, verterl infetion n llergy to one ement. Speil Consiertions: Few of the following situtions when present, shoul lert the interventionl riologist to tke extr re uring the proeure [11]- ssessment is very importnt. Pin sore efore the proeure shoul e reore. Point tenerness t the spinous proess shoul e eliite n orrelte with the ollpse verter on imging. A onventionl spinl riogrph woul e suffiient for this preliminry ssessment. A lower lim neurologil exm shoul lso e performe. Routine lortory investigtions like omplete loo ount n ogultion profile shoul e one. MRI is the test of hoie for pre-proeure evlution. It shows the ext site of mrrow eem, the size of the spinl nl, the ourse of the exiting nerve roots n llows evlution of epiurl extension of tumor. At the sme time, it will lso help to mke efinitive ignosis on the etiology of the lesion. CT proves useful to evlute the integrity of the posterior verterl ortex. Tehnique: Proeure is generlly one in prone or olique position. This position will f e Figure 7 : Ptient is known se of verterl oy hemngiom who, presente with khe. Figure 7 n shows ntero-posterior n lterl riogrphs of the hemngiom. Angioemoliztion using ynorylte ws one outsie. Cynorylte is mrke with lk rrow in figure 7A. Slerotherpy (with 2 soium tetreyl) n verteroplsty ws one lter. Figure 7 n shows verteroplsty neeles inserte vi ilterl trns-peiulr pproh. Figure 7e n f shows goo istriution of the one ement in the verterl oy. the one, whih is trete. For exmple, etuloplsty when etulr ementoplsty is one n sroplsty (Figs. 5A, B n C) when srum is trete. Verteroplsty n Khyphoplsty: Verteroplsty n khyphoplsty, lso know of verterl ugmenttion tehniques, involve injetion of one ement in the verterl oy to relieve pin n restore the height of the verterl oy [9]. Initions: Min inition of this proeure is to tret pinful verterl ompression frtures whih hve file onventionl meil therpy. Most ommon use is frture ue to primry osteoporoti isese. Others uses like steroi-inue osteoporosis (Fig. 6A- C), metstti isese, ompression ue to myelom, hemngiom (Fig. A-F) et re lso n inition for these proeures [10]. 1. Disruption of posterior ortex- inrese risk of ement leking into the spinl or 2. Verter pln or mrke loss in the height of the verterl oy 3. Epiurl extrusion of tumor 4. Nrrow entrl nl Pre-proeure ssessment n ImgingPre-proeure history n linil filitte extension of the frture segments [12]. Lol nesthesi with or without setion is require. Generl nesthesi shoul e voie s onsious ptient n lert the liniin out ny new symptoms uring the proeure. Routine pre-proeure ntiioti overge in form of 1gm Cefzolin is given. Figure 8, 8 & 8: Left mi-shft osteoi osteom with peri-lesionl ortil slerosis. CT guie riofrequeny ltion ws performe. Note the hr introuer neele with eletroe tip projeting in the entre of the lesion (lk rrow) 27 Journl of Bone n Soft Tissue Tumors Volume 1 Issue 2 Sep-De 2015 Pge 25-33

4 Figure 9 : Figure 9A shows right etulr gint ell tumor extening to the right ishium. Figure 9B n C shows hypervsulr tumor. Angioemoliztion ws performe using mirometer emospheres (prtiulte emoli gent). Signifint erese in tumor vsulrity ws seen post proeure. After 3 suh emoliztions, surgil resetion n stiliztion of the etulr omponent ws performe. Approh: Generlly, n 11 G neele is preferre for lower orsl n lumr vertere while 13 G neele my e use for upper orsl vertere. It is importnt to rememer the orienttion of the verterl peiles s one goes own the spine. Generlly, two pprohes re use to enter the verterl oy- the trnspeiulr pproh n the prpeiulr pproh. The trnspeiulr pproh hs n vntge of proteting the nerve roots n the prverterl tissue ue to the long introsseous ourse. The first step is to lign the ffete verterl oy in suh wy tht the spinous proess is in the miline, the verterl eges overlp n the peile is in the entre of tht hlf of the verterl oy. The entry point is mrke on the skin t out 10O'Clok position with respet to the peile tht will e trverse. Lignoine is infiltrte t tht site n smll skin nik given with n 11 No le. Neele is inserte from the plnne entry point. For trnspeiulr pproh, it is most importnt to keep the neele, lterl to the meil mrgin n superior to the inferior mrgin of the peile. This tkes re tht the neele is in the onfines of the peile. The neele position oul e heke on AP n lterl view on fluorosopy. One the neele rehes the posterior mrgin of the verterl oy, it shoul e further vne till the nterior thir of the verterl oy in lterl view n till the miline on AP view. Unipeiulr pproh woul suffie if the ement rosses to the opposite sie. Otherwise, ipeiulr pproh is require [13]. For prpeiulr pproh, the verterl oy is iretly entere n thus the neele is kept lterl to the lterl mrgin of the peile. Cement Injetion for Verteroplsty: The ement ommonly use is Polymethyl Methrylte (PMMA). It omes in power form with solvent. The power n solvent re mixe n left for few minutes. The ement is instille through the neele when it hs toothpste like onsisteny. It is importnt to losely monitor lekge of ement in the spinl nl or long the nerve roots. The enpoints for ement injetion inlue pssge of ement eyon the mrrow spe n ement rehing the posterior qurter of the verterl oy. Mthis n Wong hve reommene ement filling to perent of the resiul volume of the verterl oy [14]. Kyphoplsty: Before injeting ement, khyphoplsty involves n itionl step of inresing the size of the verterl oy. This is hieve with khyphoplsty lloon. Lter, eite Verteroplsty injetor system n e use to injet PMMA for khyphoplsty. It is reommene to tret up to 3 verterl levels t sitting to prevent the omplitions rising ue to mrrow ft emoliztions [15]. When frtures with Introsseous vuum phenomenon (Kummell isese) is note, it is importnt to ple the neele s lose s possile to the left in orer to llow the ement to fill the left. Complitions: Common omplitions re pin, hemtom, ement extrvstion long the nerve roots. Smll mount of extrosseous pssge of ement is seen in two-thirs of verteroplsty. As ginst this, khyphoplsty hs lower rte sine the vity fills first with susequent hrening of the ement. Other possile omplitions re prspinl sess, hypotension ue to ement n ft emoli, pneumothorx, spinl or mge ue to ement extrvstion n worsene pin [16]. The risk of omplition is more while treting mlignny-relte frtures. e Figure 10 : -Axil CT of the pelvis shows lrge multiysti neurysml one yst rising from the right srl l with thin rim of one. Figure 10 n : Angiogrphy shows lrge hypervsulr tumor, whih shows signifint erese in vsulrity post ngioemoliztion. Four sessions of ngioemoliztions were performe. Figure shows onsolition of the lesion with thikening of the ortil rim. Lter, surgil resetion of the lesion ws performe. Figure E shows post-opertive riogrph. 28 Journl of Bone n Soft Tissue Tumors Volume 1 Issue 2 Sep-De 2015 Pge 25-33

5 not lwys llow for uniform energy eposition insie the lesion. They n e ivie into single eletroe n multi-tine. Single eletroes hve the vntge of smll lier ut hve smller ltion rius. They n feture Figure 11 : 11 shows post-ontrst xil imge of the hest showing metstsis to the orsl verterl oy n right hot, oole-tip, n wterpeile from renl ell rinom. Ptient presente with right lower lim wekness. 11 -Mgnifie imge shows or perfuse. Multi- tine eletroes ompression (lk rrow). Pre-opertive ngioemoliztion ws performe. Figure 11 n shows hypervsulr inrese energy eposition y lesion with lmost omplete olitertion of the vsulrity post emoliztion. reting lrger zones of ltion genertor, n proue etter lesion Tle 1: Response to het of vrious tissues eletroe, estrution. ptient n 2. Bipolr evies o not require groun ps grouning p, euse the urrent psses (ting s through the sme or neighoring neeles. lrge ispersing Avntge is lesser errnt urrents. eletroe) in Applition of Riofrequeny Altion in series is Orthopei Onology: require. The A host of enign n mlignnt lesions n Post-proeure monitoring n Follow-up: eletroe n e trete with riofrequeny ltion. The ptient shoul lie supine for n hour the groun ps re tive. The RF This inlue- Benign tumors like Osteoi fter the proeure. Ielly, ptient's n e genertor genertes the RF urrent, whih Osteom, Chonrolstom, Aneurysml ishrge lter on the sme y. NSAID's enters the tissue to e lte through the Bone Cysts n Verterl hemngioms n e presrie for the proeure relte eletroe. This urrent les to rpi Mlignnt tumors like spinl metstsis, pin. Mny ptients hve signifint relief of osilltion of the moleules. The ptient ts ltion of soft tissue srom's to hieve symptoms immeitely fter the proeure. s resistor. The frition genertes het, lol ontrol. Ptient shoul e informe to report ny whih kills the ells. The mrke Other non-onology pplitions like suen onset khe s this my inite isrepny etween the surfe re of the riofrequeny neurotomy to tret khe new frture. 3-week follow-up postneele eletroe n the ispersive re lso prtie. proeure is generlly vise. At every eletroe uses the generte het to e Generl Contrinitions: follow-up, linil n pin sore ssessment tightly fouse n onentrte roun the Asolute ontrinitions to ltion is importnt. neele eletroe. The response of the tissue inlue ogulopthy isorers, skin Riofrequeny Altion: It involves to het epens on the temperture n the infetion, immunosuppression, n sene lting tissues y sening riofrequeny time for whih het ws pplie (Tle 1). of sfe pth to the lesion without hrming wves in the ptient. Bsi moe of killing Types of Eletroes: Mjor tegories vitl orgns or strutures. ells involves genertion of therml energy inlue monopolr evies, ipolr evies, Riofrequeny Altion for Benign roun the eletroe. n oltion evies. tumors: Among the enign tumors, osteoi Priniples [17,18]: The riofrequeny 1. Monopolr systems re most ommonly osteom is the ommonest enign one wve onsists of n lternting urrent t use. These require grouning p ple lesion trete with RFA. high frequeny (200 1,200 khz). on the ptient. Their min isvntge is RFA of Osteoi Osteom [18] (Fig. 8A n A lose loop iruit onsisting of the RF the formtion of errnt urrents, whih o B): It is enign lesion, ommoner in mles e Figure 12, 12, 12, 12 & 12e : Ptient with pin in lterl spet of right knee joint, ws ignose with Aneurysml one yst (ABC). Figure 12 n shows Jemshei one iopsy neele (lk rrow) with n 18G neele (re rrow) in the lesion. Slerotherpy ws one using 6 soium tetreyl. Seon session of slerotherpy ws plnne fter 3 months. Figure 12 shows goo onsolition of the lesion fter the first session. Figure 12 shows slerosent injetion in the seon session. Figure 12e shows lmost omplete resolution of the lesion. 29 Journl of Bone n Soft Tissue Tumors Volume 1 Issue 2 Sep-De 2015 Pge 25-33

6 (mle: femle = 4:1). It usully presents in the seon ee with noturnl pin, whih is relieve y spirin or other NSAID's. Imging fetures: CT is the molity of hoie. Typil lesion is seen in the ortex of long one with entrlly ple rioluent nius n surrouning sleroti rim. On ontrst enhne CT stuy, the nius shows enhnement. Generl tehnique: Perutneous riofrequeny ltion is relile n effetive tehnique tht provies fst, longlsting pin relief. Bourgult C et l reently pulishe pper treting 87 ptients with osteoi osteom. In this stuy, with men follow-up of 34 months, the suess rte for first-line tretment ws 89.6% n it ws 97.5% for seon-line tretment. The reurrene rte ws 10.4%. RFA is generlly one uner CT guine. Typilly, the skin entry is hieve with one iopsy neele, whih is vne till the ortex. In ses where there is signifint slerosis, this thik one is rille using one rill. One the lesion enters the lesion nius, iopsy of the lesion is tken. Further, the RF eletroe is inserte through the ore of the iopsy lesion into the lesion nius. Before, ltion is ommene; the iopsy neele is withrwn to prevent invertent heting of the surrouning tissues ue to het propgtion vi the neele. Otherwise, the iopsy neele n e exhnge for hr introuer with istl insulte tip over K-wire. The presene of intt ortex roun the lesion proues oven effet whih les to etter ltion of the lesion. RFA of other enign tumors: Conrolstom, n epiphysel tumor hs een trete with RFA s n lterntive to surgery. Ryk et l esries 17 ptients with honrolstom for whom RFA ws use s the primry tretment molity. On mein follow-up of 41.3 months, 12 out of 17 ptients showe omplete relief of pin [19]. Aneurysml one yst (ABC) hs een trete y RFA of the epithelil lining followe y ementoplsty nlogous to urettge n one grfting. There hve een reports where ltion of the ABC wll hs een hieve using riotive mteril [20]. There re some pulishe reports on the tretment of other enign one onitions suh s enhonrom, eosinophili grnulom, one hemngiom n gint ell tumors. RFA of Mlignnt tumors: This is usully one for pin relief with pllitive intent. In se of lrge tumors, ompressing nerves, RFA n e performe to eulk the tumors. As RFA estroys ells n theoretilly forms vity, ementoplsty n e performe long with the RFA to provie tensile strength [21, 22]. Emolotherpy for Musuloskeletl tumors Trnsrteril emoliztion hs een prtie for mny yers in oth enign n mlignnt musuloskeletl tumors. The min purpose of these proeures is to reue loo supply of the tumor, voiing non-trget emoliztion [23]. Emoliztion n e pre-opertive emoliztion, seril emoliztion or pllitive emoliztion. Pre-opertive emoliztion ims to olue s muh s possile, helping the surgeon to hve reltively looless fiel. Seril emoliztion ims to erese to size of the tumor. This n relieve the ptients of the symptoms like pin n in some, n mke the ptient fir for surgery. Pllitive, s the nme suggests ims to relive the ptients of the symptoms n to improve the qulity of life. Tehnique: Generlly, pre-proeure ross-setionl imging is helpful to see the extent n overll vsulrity of the neoplsm. A pre-proeure ssessment of pltelet ount, Interntionl Normlize Rtio (INR) n retinine levels is neessry. Initilly, ignosti ngiogrm is one to efine the supplying vessels following whih emoliztion is performe. Gelfom is the emoliztion mteril of hoie for pre-opertive emoliztion. In ses where seril emoliztion is require, prtiulte gents like polyvinyl lohol (PVA) or emospheres is use. Coils re use where prent vessel olusion is require or when protetion of istl vsulture is neessry. Emolotherpy in Benign Musuloskeletl Tumors: Emoliztion is generlly performe for enign tumors like Gint Cell Tumor, Aneurysml Bone Cyst, Verterl Hemngioms, Osteolstoms n rteriovenous mlformtions. Gint Cell Tumors (GCT's)(Fig. 9 A - D): GCT's riogrphilly pper s expnsile lyti lesions in the metphysel region rehing the enplte. These hve signifint vsulrity n re ssoite with signifint loo loss. Srl GCT's re espeilly ssoite with signifint peri-proeure loo loss n post-surgil moriity. In smll operle GCT's, emolotherpy ims to preopertively evsulrize the tumor while in ses lrge srl GCT's, it ims to reue the ulk of the lesion. It n lso erese the ssoite pin ue to ompression of the nerve roots [24]. Post-proeure inrese in ossifition of the lesion is sign of fvourle response to emoliztion. In series of 18 ptients of GCT's, mnge with emoliztion, follow of 26 yers showe urle response in 50% of ptients with lol reurrene rtes of 31% in 10 yers n 43% in yers [25]. Aneurysml Bone Cyst (ABC) (Fig. 10A n B): Though, urettge n resetion re the primry tretment molities of hoie, emoliztion hs een performe in reurrent ABC's n s pre-opertive mesure to reue loo loss [26]. Verterl Hemngioms: Surgery is the molity of hoie to tret verterl hemngioms using or ompression or ny neurogeni efiit. In these ses, preopertive emoliztion serves s n juvnt to surgery y reuing loo loss[27]. Arteriovenous Mlformtion of Bone: Trnrteril emoliztion n prove s useful tretment for AVM's of one. Diret punture of the hemngiom with perutneous emoliztion hs lso een ttempte to ontrol hemorrhge [28]. Other enign tumors like ervil spine osteolstoms hve een trete y emoliztion s juvnt to surgery. Emolotherpy in Mlignnt Musuloskeletl Tumors: Metstses: Hypervsulr metstses espeilly from thyroi n renl 30 Journl of Bone n Soft Tissue Tumors Volume 1 Issue 2 Sep-De 2015 Pge 25-33

7 rinoms re trete with emoliztion. The min intent is pllitive n ims to reue pin n other symptoms tht my rise ue to ompression of the surrouning strutures [7]. In 16 ses of renl ell rinom metstses leeing ws signifintly reue post emoliztion [29]. Metstti spinl tumors (Fig 11A, B n C): Hypervsulr spinl n pelvi tumors re trete with emoliztion s pre-opertive mesure to erese loo loss or s pllitive proeure to relieve symptoms. Slerotherpy of Bone Lesions: This involves instilling slerosent insie one tumor (espeilly ysti one tumor) to mge the lining enothelium, whih eventully results in thromosis. Slerotherpy using polionol hs een ttempte in treting Aneurysml one ysts (ABC) with enourging results. In pper written y Rstogi et l, the uthor hs trete 72 ses of ABC's with slerotherpy with stisftory result in more thn 97% [70] of ptients [31]. Signifint reution in size of the lesions hs een oumente. In hypervsulr ABC's, slerotherpy n e preee y emoliztion. Perutneous tretment of Vsulr Mlformtion: Though ongenitl vsulr nomlies re not one lesions, these ommonly present s swelling n re referre to n orthopei surgeon. Interntionl Soiety for the Stuy of Vsulr Anomlies (ISSVA) lssifies ongenitl vsulr nomlies into vsulr tumors n vsulr mlformtions. Tle 2: Review on the imging fetures of ommon vsulr nomlies Vsulr tumors re hemngioms, whih re seen in infny n hilhoo. They re further lssifie into infntile hemngiom, ongenitl hemngion, Kposiform hemngioenotheliom n tufte ngioms. Congenitl hemngioms re lssifie s Rpily Involuting Congenitl hemngioms (RICH) n Non- Involuting Congenitl hemngioms (NICH) [32]. Vsulr mlformtions n present nytime in life. They re lssifie s lowflow vsulr mlformtions n high-flow vsulr mlformtions. Low-flow vsulr mlformtions re nmely venous mlformtions, lymphti mlformtions or mixe while high flow vsulr mlformtions re rterio-venous mlformtions n rterio-venous fistuls. Dignosis: These onitions re ignose on the ge of presenttion, the hnges in the lesion over time (progression or regression) n some key imging fetures. Dynmi Contrst MR Angiogrphy (DCE_MRA) is the investigtion of hoie (33). Tle 2 provies review on the imging fetures of few of the ommon vsulr nomlies- Tretment of Vsulr tumors: Vsulr tumors generlly involute over time n eventully regress on follow-up. In ses of high flow lesions, enovsulr ngioemoliztion n e ttempte to relieve symptoms or to erese the vsulrity efore surgery. Tretment of Vsulr Mlformtions: Low-flow vsulr mlformtions re most ommonly trete y perutneous slerotherpy. Perutneous Slerotherpy (Fig 12A, B, C, D, E n F): This involves injeting slerosent in the mlformtion, whih les to nerosis of the enothelium n susequent thromosis. Contrinitions : Atril septl efets n pulmonry hypertension re solute ontrinitions [34]. Tehnique for venous mlformtion: The proeure is performe uner high qulity igitl sutrtion ngiogrphy imging with ro-mpping tehnique. The metho of slerotherpy epens on the ngiorhiteture of the lesion. Vsulr mlformtions re lssifie into sequestrte, non-sequestrte n mixe vrieties. Sequestrte lesions o not hve ny ommunition with the eep venous system, mking injeting slerosent in the lesion sfe. The non-sequestrte lesions hve ommunition with the eep venous system while mixe lesions hve oth the fetures [35]. Proeure is generlly performe uner lol nesthesi. Generl nesthesi with enotrhel intution is require for lesions involving the oro-nso-lryngel pthwy or when severe pin is expete uring slerosent injetion. Torniquent my e tie to erese the venous outflow for mlformtions involving the extremities. Goo hyrtion is neessry to ounter slerosent inue hemolysis. Proeure: The lesion is punture using 22G slp vein neele or 22G spinl neele. Contrst injetion is one to evlute the ngiorhiteture. In nonsequestrte lesions, slerosent is injete into the lesion. For non-sequestrte lesions, outflow trt is olue with lloon theter or glue or lte with N-YAG Lser [36,37]. The ommonest use sleorsent is soium tetreyl Sulphte (Setrol). It is injete s fom. For rioopity, it is mixe with oil-se solution like Lipiool or non-ioni ontrst. Not more thn 0.5ml/kg shoul e injete t time with mximum permissile ose of 20ml [38]. Other slerosents use re soium morrhute, leomyin, oxylyine, OKT- 432 n ethnol. Tretment for lymphti mlformtion: These re lssifie s ysti or hnnel type. Cysti type is further lssifie s mroysti, miroysti or mixe. These lesions present s lrge olletions of lymph, ommonly in the nek n the xillry lesions. Lymphti mlformtion is punture with neele uner ultrsoun (USG) 31 Journl of Bone n Soft Tissue Tumors Volume 1 Issue 2 Sep-De 2015 Pge 25-33

8 guine n flui is spirte with or without pigtil theter. Lter, the slerosent is instille in the lesion. Doxyyline is the slerosent of hoie s it n e injete in lrge quntities [39]. Post-proeure monitoring: Tight ressing n pinkillers re given post-proeure. The lesion tens to inrese in size for few ys ue to imflmmtion. This generlly settles with pinkillers. Complitions: Pin, infetion, hemtom n skin listering re the generl omplitions. Neuropthy my e seen fter ethnol injetion. Comprtment synrome is reful omplition seen when slerotherpy is one in lose spes like the orit. Hemolysis n hemogloinuri is seen when lrge mount of slerosent is use. Other rre omplitions re pulmonry eem n ute riovsulr ollpse [40]. Referenes Avnes in Interventionl Orthopei Onology Isolte Lim Infusion (ILI) for Mlignnt Extremity Bone Tumors: This is omprtively new pproh of elivering high ose of hemotherpeuti gent in the lim in whih the tumor is present. The min vntge is lrger quntity of ose of the hemotherpeuti gent n e ministere with less systemi sie-effets. ILB hs een ttempte for melnom using Atinomyin-D n for soft tissue srom's using melphln n tumor nerosis ftor [41]. MR-HIFU (MRI-guie High Intensity Fouse Ultrsoun) [42]: This involves fousing high intensity ultrsoun em in the esire tissue to e trete. The ultrsoun wves use het genertion in the tissue with ogultive nerosis. MRI is use to guie the tretment. In orthopei onology, MR- HIFU n e use for ltion of pinful one metstsis n lol tumor ontrol in infiltrtive tumors. Cryoltion [43]: Like riofrequey ltion estroys tissue y het, ryoltion mges tissue y extreme ooling to su-zero tempertures. It is inite for pinful one metstsis n for lol tumor ontrol. Use of thermoouples to mesure temperture is sometimes inite to prevent mge to surrouning nerves is some ses. Conlusion Interventionl Riology hs n ever inresing role in the ignosis n mngement of one n soft tissues tumors. Close o-opertion n isussions with the orthopei onologist n interventionl riologist is the ornerstone for seletion of orret tretment molity n optimizing response. 1. Mnkin HJ, Mnkin CJ, Simon MA. The hzr of iopsy revisite. J Bone Joint SurgAm 1996;78: Choi JJ, Dvis KW, Blnkenker DG. Perutneous musuloskeletl iopsy. Semin Roentgenol 2004;39: Ahrr K, Himmerih JH, Herzog CE, et l. Perutneous ultrsoun- guie iopsy in efinitive ignosis of osteosrom. J Vs Interv Riol 2004;15: Ksrein S, Allison DC, Ahlmnn E, et l. A omprison of fine- neele spirtion, ore iopsy, n surgil iopsy in the ignosis of extremity soft tissue msses. Clin Orthop Relt Res 2010;468: Logn PM, Connell DG, O'Connell JX, et l. Imge-guie perutne- ous iopsy of musuloskeletl tumor: n lgorithm for seletion of speifi iopsy tehniques. AJR Am J Roentgenol 1996;166: Jelinek JS, Murphey MD, Welker JA, et l. Dignosis of primry one tumors with imge-guie perutneous iopsy: experiene with 110 tumors. 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