1 © 2015, Elsevier Inc., Heymann, Bone Cancer, Second Edition Chapter 44 Interventional Radiologic Techniques and their Contribution of the Management of Bone Tumors

2 © 2015, Elsevier Inc., Heymann, Bone Cancer, Second Edition FIGURE 44.1 CT-guided bone biopsy technique. 23-year-old male with a lytic lesion in his proximal tibia. (A) An 18G needle, in its sheath, has been taped onto the patient’s skin where it was marked by the referring surgeon. (B) Local anesthetic has been infiltrated, and the needle position and angulation are checked with CT. (C) Minor correction to the trajectory has been made, the periosteum infiltrated with local anesthetic, the skin incised and a 11G guide cannula inserted as far as the cortex. (D) The 14G bone biopsy needle has been drilled through the cortex into the lesion. Biopsy revealed giant cell tumor of bone.

3 © 2015, Elsevier Inc., Heymann, Bone Cancer, Second Edition FIGURE 44.2 CT-guided biopsy of a lytic expansile lesion of the right 7th rib. After penetration of the cortex a Tru-cut soft tissue biopsy needle is used to obtain multiple samples.

4 © 2015, Elsevier Inc., Heymann, Bone Cancer, Second Edition FIGURE 44.3 (A) Transpedicular approach for CT-guided biopsy of a destructive lesion in the 5th cervical vertebra in a 47-year-old male. Biopsy revealed metastatic pancreatic adenocarcinoma. (B) Parapedicular approach CT-guided biopsy of a lytic lesion in the L3 vertebral body in a patient with known lung cancer. Histology showed no evidence of malignancy.

5 © 2015, Elsevier Inc., Heymann, Bone Cancer, Second Edition FIGURE 44.4 (A) CT-guided biopsy of a mixed sclerotic/lytic lesion in the distal diaphysis of the left femur in a 19-year-old female. Biopsy revealed liposclerosing myxofibrous tumor (LSMFT). (B) Two weeks later, the patient returned with a fracture through the biopsy site.

6 © 2015, Elsevier Inc., Heymann, Bone Cancer, Second Edition FIGURE 44.5 (A) Unsubtracted aortogram focusing on the arterial supply to the right hemi-pelvis in a 25-year-old female with known metastatic rhabdomyosarcoma to the right iliac bone. The angiogram demonstrates a large hypervascular tumor with multiple, hypertrophied feeding arteries from a variety of territories including lumbar arteries and branches of the internal iliac artery. (B) Selective Digital subtraction angiography (DSA) of a lumbar artery found to be contributing supply to the tumor. (C) After embolization with 355– 500 micron diameter PVA particles post-embolization DSA of the selected lumbar artery demonstrates lack of tumor hypervascularity and a satisfactory angiographic result. Embolization was carried out for symptomatic control.

7 © 2015, Elsevier Inc., Heymann, Bone Cancer, Second Edition FIGURE 44.6 (A) Selective DSA using a Mickelson catheter of a common L4 lumbar artery trunk supplying both left and right lumbar arteries at this level. The patient was a 50-year-old male with known renal cell carcinoma metastases to lumbar vertebra. Note an intense arterial blush within the hypervascular metastatic deposit. (B) Post-embolization unsubtracted angiogram demonstrating a satisfactory angiographic result. Embolization coils were placed in a deep muscular arterial branch (arrow head) and a median sacral branch (arrow) to prevent non-target embolization and redirect higher concentration of PVA particles towards the malignant target which is now devascularized (compare to A).

8 © 2015, Elsevier Inc., Heymann, Bone Cancer, Second Edition FIGURE 44.7 Oblique posteroanterior projection demonstrating a severe compression fracture of L4. A 22 gauge spinal needle (white arrow) is placed at the periosteum of the left pedicle, which is visualized en face with the patient prone. Note the IVC filter (black arrow).

9 © 2015, Elsevier Inc., Heymann, Bone Cancer, Second Edition FIGURE 44.8 (A) Schematic demonstrating the expected needle trajectory in a transpedicular puncture during percutaneous vertebroplasty. (B) Schematic demonstrating cement injection.

10 © 2015, Elsevier Inc., Heymann, Bone Cancer, Second Edition FIGURE 44.9 (A) Posteroanterior fluoroscopic image during vertebroplasty via a left transpedicular puncture with the needle in situ demonstrating an ideal cement distribution. (B) Lateral fluoroscopic image after vertebroplasty in the same patient.

11 © 2015, Elsevier Inc., Heymann, Bone Cancer, Second Edition FIGURE Axial computed tomography image demonstrating the ideal intravertebral cement distribution post-vertebroplasty with cement crossing the midline and no extravasation. The transpedicular needle tract is clearly visible (arrow).

12 © 2015, Elsevier Inc., Heymann, Bone Cancer, Second Edition FIGURE CT-guided cryoablation of an osteoid osteoma in the right tibia with the cryoprobe in place. The anterior cortex, opposite to the nidus (arrow) was penetrated to spare the soft tissues.