2. Bone is one of the most frequent sites of spread for many common cancers (breast, prostate, lung, kidney, multiple myeloma, etc.). Painful Bone metastases affect patient’s quality of life and clinical conditions. Chemiotherapy, Radiotherapy, bisphosphonates and analgesic treatment leave approximately one third of cases with inadequate or undermanaged pain control. Roos DE, Fisher RJ. (2003) Radiotherapy for painful bone metastases: an overview of the overviews. Clin Oncol 15:342-344. de Wit R, van Dam F, Loonstra S et al. (2001) The Amsterdam Pain Management Index compared to eight frequently used outcome measures to evaluate the adequacy of pain treatment in cancer patients with chronic pain. Pain 91:339- 349.

3. Imaging guided Percutaneous Injection of Bone Cement within a Bone Lesion with untreatable pain or with impending fracture.

4. Painful Bone lesions not responding to conventional therapiesPainful Bone lesions not responding to conventional therapies Painful Bone lesions with impending fracturePainful Bone lesions with impending fracture Surgery not feasibleSurgery not feasible Pts Improving on Medical therapyPts Improving on Medical therapy Coagulation disordersCoagulation disorders

5. Combined CT-Fluoroscopy guidance Combined CT-Fluoroscopy guidance Local anesthesia and/or Sedation Local anesthesia and/or Sedation Beveled Needle (11-13 Gauges) Beveled Needle (11-13 Gauges) Injection system Injection system Bone Cement Bone Cement

6. ax sagcor Hybrid Fluoro and CT guidance (Philips Allura XPER CT)

7. 59 female - 22 male Age from 36 to 94 years avg. 66 years 74 Malignant (71 metastases - 3 myeloma) 7 Benign diseases (2 geodes in RA, 1 encondroma, 2 periprosthetic resorption, 1 bone cyst, 1 trauma)

8. Femur (24 lesions) Tibia (8 lesions) Fibula (1 lesion) Scapula (8 lesions) Rib (4 lesions) Calcaneus (4 lesions) Omerus (2 lesions) Knee (4 lesions) Sacrum and hip (54 lesions) Astragalus (1 lesion) Metacarpal bone (1 lesion) 81 patients / 111 lesions / 86 sessions* Pain was evaluated using a 11-point Visual Analogic Scale (VAS from 0 to 10) before and after the procedure. Reduction equal or more than 2 point represented a clinically important difference 1 1 Farrar JT et al. “Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale”, Pain 94 (2001) 149-158 * 5 pts were treated twice

9. VAS= 10 before - 0 after

10. VAS= 10 before - 5 after - 5 after Hip & Femur KidneyCa Mets (Follow-up 11 months)

11. VAS= 10 before - 3 after Lung Cancer mets Follow-up: 16 months

12. Bladder Ca Metastasis on Right Calcaneus VAS= 10 before - 0 after

13. Femur - Patient not amenable to surgery (high surgical risk) Astragalus and Calcaneus - Pain and function loss (after 2 surgical osteosintheses)

14. VAS= 7 before - 0 after

15. Painful peri-prosthetic bone resorption in total hip replacement for osteoarthritis

16. VAS Score Number of Cases Pre-proceduralWithin 24 hrs 10400 9141 8 2 762 631 524 422 304 2018 1026 0021 Average VAS ± SD 8.8 ± 1.4 1.8 ± 2.1* *P<0.0001 (Wilcoxon signed rank test - two tailed)

17. No significant VAS difference (p=0.81) in follow-up subgroups

18. Immediate pain relief Mean VAS score dropped from 8.8±1.4 to 1.8 ± 2.1 within 24 hours. Mean VAS difference was 7.0 ± 2.0 (P<0.0001 Wilcoxon signed rank test). In 5/81 (6.1%) pain was not improved. Long Term pain relief No significant difference of VAS (p=0.81) was found in follow-up subgroups Average follow-up was 11.2 ± 6.2 months (3 to 36 months). 64 out of 81 patients (79%) quitted narcotic drugs In 43/81 (53%) analgesic therapy was suspended

19. In 7/81 patients (8,6%) Occurred a small PMMA leakage in soft tissues (asymptomatic during all f.up) Both patients (out of 81 pts: 2,4%), undergone percutaneous osteoplasty on femural shaft for lytic metastases had a pathologic fracture on treatment site (at day 31th and 18th) Leakage sites: Needle insertion Cortical gaps No venous leakages No joint leakages No deaths nor major complications occurred during the procedure.

20. Percutaneous osteoplasty is safe and effective to obtain pain regression both in painful bone metastases and benign lytic lesions not responding to conventional analgesic therapy Bone consolidation cannot be safely obtained with PMMA in the femural diaphysis