Embolization was first reported by Dr Frieda Feldman in
1975 as a useful adjunct in the management of selective bone
tumors.1 Many authors have since reported on selective and
superselective intraarterial embolization for primary bone and soft tissue
tumors, and bone metastases from different primary neoplasms as an effective
treatment associated with rapid reduction in pain and tumor volume lasting from
1 to 9 months.2-18 However, clinical improvement was not always
concordant with tumor regression on imaging.8,10,13 Embolization
provides for devascularization, size reduction, calcification of margins and
pain relief; it can be palliative or adjunctive and primary or
The main indications for embolization are definitive
treatment of benign lesions such as hemangiomas or arteriovenous malformations,
reducing the risk of bleeding prior to biopsy or surgery, palliation of pain,
bleeding, fever, and hypercalcemia-like symptoms in inoperable tumors,
preventing further dissemination of a tumor, increasing the response to
chemotherapy and radiotherapy, and retention of selectively delivered
anti-mitotic agents or monoclonal antibodies deep into the tumor
The main purpose of embolization is to occlude as much
of the tumor supply as possible avoiding adjacent normal tissues. The outcome
ranges from complete tumor devascularization and necrosis to degrees of
ischemia and hypovascularity. Thus, the tumor will shrink, bleeding will be
reduced, borders between the tumor and the surrounding tissue will become
clear, and resection will be easier. Reduced bleeding is particularly
advantageous for patients with rare blood groups or those prone to transfusion
reactions.8,15,21 This is particularly important considering that
the resulting high transfusion requirements in tumor surgery are frequently
complicated by depletion of clotting factors and coagulopathy that cause
further variable intraoperative bleeding, while blood salvage techniques are
contraindicated because of the risk of further dissemination of tumor
cells.3,5,22 In addition, in large and unresectable tumors, reducing
the amount of live tissue, destroying the tumor tissue, or at least inhibiting
tumor growth will diminish the treatment dose before radiotherapy and
The usual contraindications to intravascular procedures
apply with attention to the presence of coagulopathy, thrombocytopenia, or
anemia.21 In the few cases in which wide or radical resection is
planned such as for renal or thyroid solitary bone metastases without
extraskeletal metastases, there is no indication for preoperative embolization
because it would lead to marked hypervascularity in the area surrounding the
tumor being resected and would therefore result in heavy bleeding during
Metastatic Bone Disease
Embolization is performed in primary bone tumors, as
well as metastatic lesions, in an ever-increasing number. Metastatic disease is
the most common malignancy of bone; prostate, breast, lung, kidney and thyroid
cancer account for 80% of skeletal metastases. The most common sites of bone
metastases are the spine, pelvis, ribs, skull, and proximal femur. The most
common manifestations are pain, pathological fractures and spinal cord
compression.23,24 Pain from bone metastases can be caused by tumor
biology, local chemical release of cytokines by tumor cells causing stimulation
of intraosseous nerves, pressure or mass effect of the tumor tissue within the
bone, and bone destruction causing mechanical instability and impending or
existing pathological fracture.2 Treatment options in these patients
are mostly aimed at palliation. However, all metastatic lesions are
progressive, causing bone failure. In addition, most, if not all metastatic
lesions are hypervascular. Some lesions such as renal and thyroid metastases
are highly hypervascular.6,25 This may cause technical difficulties
with respect to the extent of surgery and primary stability for pain
Embolization is useful for the treatment of metastatic
bone disease; preoperative or serial embolization techniques using different
embolic agents can be used as primary or adjuvant treatment to surgery,
radiation therapy, and/or chemotherapy.6,7,11,28 Serial embolization
provides for devascularization, size reduction, calcification of margins, and
pain relief. In patients who are not candidates for surgery it is typically
performed in 4- to 6-week intervals until symptomatic improvement occurs or the
tumor’s vascularity disappears as judged by angiography, magnetic
resonance imaging (MRI), or computed tomography (CT) scan.6,8,9,25
Preoperative embolization provides for tumor devascularization; typically,
surgery should be performed within 24 to 48 hours after embolization to prevent
Since all metastatic bone lesions are hypervascular, all
patients should be considered appropriate candidates for
embolization.6,25 In our clinical practice, we perform this
embolization procedure at the request of orthopedic surgeons. By hyperselective
catheterization and embolization of the pathological feeding arteries to the
lesion with the most appropriate embolic agent, embolization can be expected to
be successful in up to 90% of cases; multiple procedures are frequently
Occlusion of the vessels decrease the volume of a tumor; thus,
subsequent distention or destruction of the richly innervated periosteum is
reversed and that will provide pain relief. Pain-free periods may last between
1 and 9 months; at this time, re-embolization is safe and may be
necessary.32 Additional benefits result from decreased blood flow
and reduction of edema, which may cause direct pressure effects on adjacent
structures and nerves.6,10,13,30,33 Moreover, the success of
embolization of osseous metastases depends on the type and behavior of the
primary tumor; patients with renal or thyroid bone metastases have a good
chance of undergoing successful treatment with selective vascular occlusion, in
contrast to patients with lung metastases to bone.8 In our series
(unpublished data), clinical results were excellent; embolization had an
immediate palliative effect in 97% of the procedures. However, this palliative
effect was transient in patients with bone metastases; symptoms recurred after
approximately 8.1 months. Imaging showed evidence of tumor necrosis in all
cases and variable ossification (Figure 1).
|Figures 1A-1C: Axial CT scan of
the pelvis of a 63-year-old man with a metastatic renal cell carcinoma of the
pelvis (A). Pre-embolization angiography (B) and selective embolization (C) of
the pathologic feeding vessels originating from the left internal iliac artery.
|Figures 1D-1E: Axial CT scan of
the pelvis at 6 (D) and 12 (E) months after intraarterial selective
embolization show tumor size reduction and ossification of margins.
Giant Cell Tumors
Giant cell tumor of the sacrum can be difficult to
manage. Blood loss at surgery is typically high.34 Given the high
vascularity and morbidity associated with surgical resection and/or radiation
therapy, embolization has been reported to be a useful primary treatment
modality for sacral giant cell tumors; survival to local recurrence after
curettage, radiation, and embolization for sacral giant cell tumors has been
reported from 57% to 80%.9,34-38 Typically, surgery should be
performed within 24 to 48 hours after embolization to prevent
In our series, by using preoperative embolization and
adjuvants including radiation therapy and intraoperative phenol and nitrogen,
the overall survival to local recurrence was 90% at 60 and 120 months, and
local recurrence rate was 10%.39 Giant cell tumor may also occur in
the remaining areas of the spine, where embolization has also been used with
encouraging results alone or in conjunction with other
therapies.40,41 However, spinal embolization has significant risks,
particularly relating to long-term neurologic function. In the cervical spine,
angiography is important in identifying the vertebral arteries and in the lower
thoracic spine to identify the artery of Adamkiewicz. Where vertebral artery
sacrifice is to be considered a vertebral test balloon occlusion may be
Aneurysmal Bone Cysts
Curettage and resection are the treatments of choice for
aneurysmal bone cysts.43 Embolization has been used in combination
with surgery to reduce operative blood loss,44-46 or as primary
treatment for inaccessible or recurrent lesions and patients at high risk of
intraoperative bleeding.47-55 In our series, embolization was
effective in 94% of patients with aneurysmal bone cysts. Recurrence of the
lesion or no effect of the procedure was observed in 39% of the patients; these
patients underwent repeat embolization. More than half of the recurrences
occurred in patients with lesion size >5 cm.55
Vertebral hemangiomas associated with spinal pain or
cord compression with neurological deficits, radiation or decompression surgery
has been the treatment of choice. Vertebroplasty is generally reserved for
lesions without neurologic deficit. However, surgery is often associated with
massive hemorrhage from these highly vascular lesions and preoperative
embolization has been found to be a useful adjunctive step reducing
perioperative blood loss.56,57 Although embolization has been
advocated by some as primary treatment of vertebral hemangiomas, long-term data
are lacking.58-60 There are also a number of references to
transarterial or transvenous embolization of arteriovenous malformations
involving the bone as primary or adjunctive treatment.61-63 In our
practice, embolization of vertebral hemangiomas using N-2-butyl-cyanoacrylate
as embolic agent has been successful in all cases with no complications.
Embolization has been used for malignant bone tumors as
an adjunct to surgery, chemotherapy and radiation therapy, or as palliative
treatment.64-66 Chemoembolization in combination with limb salvage
surgery had encouraging results for ostoesarcomas.67 Embolization
for cervical spine osteoblastomas has been associated with favorable adjunctive
results with surgery, with no complications.68,69 Isolated cases of
preoperative embolization in hemangiopericytoma and postoperative embolization
in angiosarcoma have also been reported.70-72 In our practice, we
use embolization for sarcomas only for palliative treatment.
Pre-embolization planning with MRI, CT, and ultrasound
is generally advisable allowing identification of arterial blood supply, venous
drainage, extent into adjacent tissues, and proximity of vital structures
sharing potential blood supply. Computed tomography angiography is particularly
useful in complex lesions with multiple possible routes of arterial supply.
Vascular mapping of and the hemodynamic status of the tumor, as well as the
anatomic region must be determined using selective angiography before
embolization. Feeding arteries of the tumor and collaterals, the tumor’s
relationship with adjacent vascular processes, and possible arteriovenous
fistulas inside the tumor must be evaluated carefully.
Angiography and selective arterial embolization is
usually performed under local anesthesia using the Seldinger technique through
femoral artery transarterial catheterization. In patients with metastases in
the pelvis or lower extremities, the contralateral transfemoral access is
usually used. Once the diagnostic angiogram has been performed, the various
feeding vessels can be identified and catheterized superselectively with 4 or 5
French diagnostic catheters and microcatheters, and occluded using the most
suitable embolic agent, so as to protect the hemodynamics of normal bone
tissues as much as possible.8,15
Microcatheters offer several advantages. The embolic
agent can be delivered further from the parent vessel and potentially reduce
the chance of non-target embolization. The feeding vessels to these tumors are
often hypertrophied unnamed vessels and cannulation with the larger catheters
may be more difficult. Arterial spasm with larger-caliber catheters may lead to
false end points for embolization and reduce efficacy of these
procedures.8,21 Parameters pertaining to safe angiography including
coagulation times, International Normalized Ratio, prothrombin time or partial
thromboplastin time in patients on heparin, platelet count, and blood count
need correction if abnormal. Many of the particulate embolic agents,
embolization coils, and injectable thrombogenic agents require a functioning
intrinsic clotting system, and a normal coagulation profile assists in their
The technical success of embolization should be
evaluated by additional angiography after completion of the procedure.
Embolization should be considered technically complete when there was stasis of
intravascular contrast material and either complete elimination of the
tumor’s hypervascular staining, or >80% elimination of the tumor
pathological vasculature compared to the initial diagnostic
angiogram.8,21 If post-embolization angiography shows additional
feeding vessels, these should also be occluded (Figure 2). When the procedure
is followed by surgery, it is recommended that the surgery be performed within
24 to 48 hours to avoid revascularization; a delay is associated with increased
blood loss.8,21 The clinical and imaging effect of embolization
should be evaluated at routine follow-up examinations; the clinical effect can
be determined by pain relief and the imaging tumor response by hypoattenuating
areas within the tumor, tumor size, and ossification.
|Figures 2A-2B: AP radiograph of
the left elbow of a 70-year-old man with a metastatic renal cell carcinoma of
the olecranon (A). Pre-embolization angiography showed 3 feeding vessels
originating from the median (1) brachial, (2) and ulnar (3) artery (B).
|Figures 2C-2D: Selective
embolization of the pathologic feeding vessels was done (C). Ossification of
the lesion 6 months after embolization (D).
Embolic agents must be nontoxic, sterile, radiopaque and
easy to prepare or to obtain. Many factors determine the best choice of embolic
material, the most important of which is operator
experience.21,73,74 Major considerations for choosing an embolic
agent are speed and reliability of delivery, duration of occlusive effect, and
preservation of normal tissue. Currently available embolic agents include
gelatin sponge, polyvinyl alcohol (PVA) particles, liquid (absolute alcohol),
coils, tissue adhesives, ethanol, microfibrillar collagen, and autologous blood
For multiple lesions, distal location, or lesions
supplied by numerous collateral (accessory) vessels, particles can be used.
Polyvinyl alcohol particles are ground from blocks of foam and then separated
into different size groupings. Available sizes range from 50 to 1000 mm; the
most common size used is 300 to 500 mm. Polyvinyl alcohol has a number of
desirable characteristics. It is a particulate material capable of penetrating
the tumor blood supply and occluding it, it is relatively inexpensive, and it
is easy to deliver.21,75
Embosphere microspheres (Biosphere Medical, Rockland,
Maryland) are clear acrylic copolymer (trisacryl) microspheres that were
previously used as a microcarrier for cell culture, which helped confirm their
biocompatibility. Similar to PVA particles, they are available in sizes from 40
to 1200 mm. Their advantages include that they are compressible allowing easy
passage through a microcatheter with a luminal diameter smaller than that of
the spheres and more uniform in size than PVA, and the particle size does not
change in liquids.21 However, injection of particles is not precise
and may be difficult to deliver through small microcatheters or through
tortuous anatomy. In addition, the particles themselves are not radiopaque,
making exact documentation via radiography of their site of occlusion
impossible.12,15,32,76 Moreover, if particles are used, their size
has to be adjusted to the diameter of potential collateral vessels and shunts
because these entities often are present in hypervascular malignant bone
Gelatin sponge is a dissolvable sponge-like material
that comes in small flat rectangular blocks that can be cut with scissors into
elongated rectangles and rolled into pledgets, which can then be injected by
diagnostic catheters or microcatheters. Alternatively, the material can be cut
into small cubes and mixed vigorously in a syringe to form a slurry.
Gelatin sponge is considered a temporary occluding
agent, with the occluded vessel recannalizing in 2 to 4 weeks.77
Once stasis or near stasis has been achieved with gelatin sponge, many
interventional radiologists use coil embolization for final and complete vessel
occlusion.21 Stainless steel fibered and platinum coils are usually
reserved for single and large vessel occlusion. Prior to particulate or liquid
embolization, coils may be placed to protect the distal vasculature from these
agents. This situation may occur when the vessel is giving off several small
vessels to the tumor and continuing on to supply a distal structure that cannot
be sacrificed. Following particulate embolization, coils may be used to
permanently occlude the vessel and where either the expertise or time is
lacking for other forms of embolization.21 However, the use of coils
in the management of hypervascular bone tumors has been reported to be
ineffective because the rich vascularization of these lesions can open
collateral channels within hours.18,26,28
Liquid agents offer the advantages of low viscosity for
easy injection through small catheters or catheters with many bends through
tortuous blood vessels. Liquid embolic agents include absolute alcohol,
N-2-butyl-cyanoacrylate, Ethibloc (Ethicon), sodium tetradecyl sulfate and
Onyx. In a non-end organ, such as bone, with multiple arterial feeders, liquid
agents may increase the potential for non-target embolization.21
Alcoholic zein is a radiopaque alcoholic solution of
corn protein. It is a biodegradable agent that induces intravascular
thrombosis, marked local inflammation, and finally a fibrotic reaction.
Inflammation and subsequent fibrosis may trigger the reparative process of
mineralization by osteoblast stimulation. This reparative process, which
results in bone reconstruction and bone volume normalization, lasts several
months and even more than 1 year after embolization. Therefore, one should wait
at least 6 months to evaluate the efficacy of one procedure using this embolic
agent. The initial inflammation is short-lived and limited to the injection
site inducing local pain. However, the inflammation produced may be associated
with significant complications including transient aggressive bone destruction
suggestive of aseptic osteitis and dramatic bone remineralization. The high
viscosity of alcoholic zein allows excellent filling of the lesion with minimal
risk of distal embolization of the draining venous system. However,
fluoroscopic control is recommended for injection of alcoholic zein to minimize
the risk of migration. Moreover, manual venous compression is mandatory as soon
as cystograms show substantial venous drainage.78
N-2-butyl-cyanoacrylate or “liquid glue” is a liquid embolic agent
with distinct advantages as an embolic material. N-2-butyl-cyanoacrylate
spreads according to its polymerization time and the vascular flow. Although
N-2-butyl-cyanoacrylate can pass through bent catheters navigating tortuous
blood vessels, it does not permeate all the way to the capillary level, and
therefore does not cause tissue death. Another distinct advantage of
N-2-butyl-cyanoacrylate with lipiodol compared with particles is its dense
radiopacity. Thus, its exact site of occlusion can be observed and documented,
and non-target embolization can be identified immediately and corrected. In
addition, N-2-butyl-cyanoacrylate can successfully occlude the vessel in
patients with clotting pathologies.12,15,32,76 In our practice, we
consider N-2-butyl-cyanoacrylate the most appropriate embolic agent for
controlled embolization of the pathological tumor vasculature, permanent
occlusion of the target vessels and complete devascularization of the lesions.
Complications of embolization include dissection of the
femoral artery at the site of transarterial catheterization, pain due to
ischemic necrosis of the tumor, accidental embolization into non-tumor vessels,
infection, and post-embolization syndrome.3,5,6,8,10,15,26,30,79 The
post-embolization syndrome with symptoms such as fever, pain, and malaise has
been reported in 18% to 86% of cases.8,26 Embolization of adjacent
or distant non-targeted vessels can result in a large zone of tissue loss and
may be associated with risk of nerve palsy, skin breakdown, and subcutaneous or
muscle necrosis (Figure 3); tissue ischemia may lead to infection.
|Figure 3: Axial CT scan of the
pelvis of a 60-year-old woman with a metastatic paraganglioma of the pelvis
(A). Pre-embolization angiography (B) and selective embolization (C) of the
pathologic feeding vessels originating from the right internal iliac artery.
Skin necrosis and superficial necrosis 7 days post-embolization (D).
The risk of complications is higher in certain anatomic
regions, and thought should be given to the location and vascular supply of
at-risk vital structures on the pre-embolization angiography. Care should be
taken in the femoral region to avoid embolizing supply to the sciatic nerve, in
the humeral area to avoid circumflex femoral nerve, in the thigh to avoid the
lateral femoral cutaneous nerve, and in the spine to avoid the artery of
Adamkiewicz that originates between the T5 and L2 vertebra (Figure
4).6,11,17,26,80 During pelvic embolizations through the iliac
artery and its branches, the sciatic and femoral nerves may be damaged if
neural vessels were occluded, and cause ischemic neuropathies. To prevent these
complications, the posterior branch of the internal iliac artery and the
inferior gluteal artery must be spared at embolization.81,82 When
embolization is planned carefully and the vessel is occluded selectively via a
securely positioned catheter, complications rarely occur.
|Figure 4: Pre-embolization angiography of a
67-year-old man with a metastatic renal cell carcinoma of L3 vertebra shows the
Adamkiewicz artery originating from the second left lumbar artery (arrows). The
embolization was cancelled.
Preoperative and palliative transarterial selective
embolization is a safe and effective minimally invasive, interventional
treatment for pain relief and devascularization of primary and metastatic bone
tumors by various primary cancers. It can be combined with other treatment
modalities such as radiation therapy and chemotherapy. Aided by embolization,
inoperable lesions can also be included in the surgical treatment criteria. To
determine which cases are suitable for embolization, vascular mapping and the
hemodynamic status of the tumor must be determined using selective angiography
before the procedure. Arteries feeding the tumor and collaterals must be
evaluated carefully. For a sufficient result, feeding arteries must be
catheterized superselectively and the procedure must be undertaken with the
most appropriate embolic agent, protecting the normal tissues as possible.
- Feldman F, Casarella WJ, Dick HM, Hollander BA. Selective
intra-arterial embolization of bone tumors. A useful adjunct in the management
of selected lesions. Am J Roentgenol Radium Ther Nucl Med. 1975;
- Selvaggi G, Scagliotti GV. Management of bone metastases in cancer: a
review [published online ahead of print June 23, 2005]. Critical Rev Oncol
Hematol. 2005; 56(3):365-378.
- Wirbel RJ, Roth R, Schulte M, Kramann B, Mutschler W. Preoperative
embolization in spinal and pelvic metastases. J Orthop Sci. 2005;
- Olerud C, Jónsson H Jr, Löfberg AM, Lörelius LE,
Sjöström L. Embolization of spinal metastases reduces perioperative
blood loss: 21 patients operated on for renal cell carcinoma. Acta Orthop
Scand. 1993; 64(1):9-12.
- Chatziioannou AN, Johnson ME, Pneumaticos SG, Lawrence DD, Carrasco
CH. Preoperative embolization of bone metastases from renal cell carcinoma.
Eur Radiol. 2000; 10(4):593-596.
- Forauer AR, Kent E, Cwikiel WH, Esper P, Redman B. Selective
palliative transcatheter embolization of bony metastases from renal cell
carcinoma. Acta Oncologica. 2007; 46(7):1012-1018.
- Gottfried ON, Schmidt MH, Stevens EA. Embolization of sacral tumors.
Neurosurg Focus. 2003; 15(2):E4.
- Barton PP, Waneck RE, Karnel FJ, Ritschl P, Kramer J, Lechner GL.
Embolization of bone metastases. J Vasc Interv Radiol. 1996; 7(1):81-88.
- Hosalkar HS, Jones KJ, King JJ, Lackman RD. Serial arterial
embolization for large sacral giant-cell tumors: mid- to long-term results.
Spine. 2007; 32(10):1107-1115.
- Eustatia-Rutten CF, Romijn JA, Guijt MJ, et al. Outcome of palliative
embolization of bone metastases in differentiated thyroid carcinoma. J Clin
Endocrinol Metab. 2003; 88(7):3184-3189.
- Kickuth R, Waldherr C, Hoppe H, et al. Interventional management of
hypervascular osseous metastasis: role of embolotherapy before orthopedic tumor
resection and bone stabilization. AJR Am J Roentgenol. 2008;
- Breslau J, Eskridge JM. Preoperative embolization of spinal tumors.
J Vasc Interv Radiol. 1995; 6(6):871-875.
- Smit JW, Vielvoye GJ, Goslings BM. Embolization for vertebral
metastases of follicular thyroid carcinoma. J Clin Endocrinol Metab.
- Radeleff B, Eiers M, Lopez-Benitez R, et al. Transarterial
embolization of primary and secondary tumors of the skeletal system [published
online ahead of print January 18, 2006]. Eur J Radiol. 2006;
- Börüban S, Sancak T, Yildiz Y, Saglik Y. Embolization of
benign and malignant bone and soft tissue tumors of the extremities. Diagn
Interv Radiol. 2007; 13(3):164-171.
- Rossi C, Ricci S, Boriani S, et al. Percutaneous transcatheter
arterial embolization of bone and soft tissue tumors. Skeletal Radiol.
- Hemingway AP, Allison DJ. Complications of embolization: analysis of
410 procedures. Radiology. 1988; 166(3):669-672.
- Coldwell DM, Stokes KR, Yakes WF. Embolotherapy: agents, clinical
applications, and techniques. Radiographics. 1994; 14(3):623-643.
- Anne PH, David A. Angiography in bone tumour management. In: Coombs
R, Friedlaender G, ed. Bone Tumour Management. Kent: Butterworth;
- Keller FS, Rosch J, Bird CB. Percutaneous embolization of bony pelvic
neoplasms with tissue adhesive. Radiology. 1983; 147(1):21-27.
- Owen RJT. Embolization of musculoskeletal tumors. Radiol Clin
North Am. 2008; 46(3):535-543.
- Capdevila X, Calvet Y, Biboulet P, Biron C, Rubenovitch J,
d’Athis F. Aprotinin decreases blood loss and homologous transfusions in
patients undergoing major orthopedic surgery. Anesthesiology. 1998;
- Jacofsky DJ, Frassica DA, Frassica FJ. Metastatic disease to bone.
Hospital Physician. 2004; 39:21-28.
- Coleman RE. Metastatic bone disease: clinical features,
pathophysiology and treatment strategies. Cancer Treat Rev. 2001;
- Hansch A, Neumann R, Pfeil A, et al. Embolization of an unusual
metastatic site of hepatocellular carcinoma in the humerus. World J
Gastroenterol. 2009; 15(18):2280-2282.
- Sun S, Lang EV. Bone metastases from renal cell carcinoma:
preoperative embolization. J Vasc Interv Radiol. 1998; 9(2):263-269.
- Hess T, Kramann B, Schmidt E, Rupp S. Use of pre-operative vascular
embolization in spinal metastasis resection. Arch Orthop Trauma Surg.
- Manke C, Bretschneider T, Lenhart M, et al. Spinal metastases from
renal cell carcinoma: effect of preoperative particle embolization on
intraoperative blood loss. AJNR Am J Neuroradiol. 2001; 22(5):997-1003.
- Muresan MM, Olivier P, Leclère J, et al. Bone metastases from
differentiated thyroid carcinoma. Endocrine-Related Cancer. 2008;
- Van Tol KM, Hew JM, Jager PL, Vermey A, Dullaart RP, Links TP.
Embolization in combination with radioiodine therapy for bone metastases from
differentiated thyroid carcinoma. Clinical Endocrinol (Oxf). 2000;
- Layalle I, Flandroy P, Trotteur G, Dondelinger RF. Arterial
embolization of bone metastases: is it worthwhile? J Belge Radiol. 1998;
- Chuang VP, Wallace S, Swanson D, et al. Arterial occlusion in the
management of pain from metastatic renal carcinoma. Radiology. 1979;
133(3 Pt 1):611-614.
- De Vries MM, Persoon AC, Jager PL, et al. Embolization therapy of
bone metastases from epithelial thyroid carcinoma: effect on symptoms and serum
Thyroglobulin. Thyroid. 2008; 18(12):1277-1284.
- Turcotte RE, Sim FH, Unni KK. Giant cell tumor of the sacrum. Clin
Orthop Relat Res. 1993; (291):215-221.
- Eftekhari F, Wallace S, Chuang VP, et al. Intra-arterial management
of giant-cell tumors of the spine in children. Pediatr Radiol.
- Guo W, Ji T, Tang X, Yang Y. Outcome of conservative surgery for
giant cell tumor of the sacrum. Spine (Phila Pa 1976). 2009;
- Lackman RD, Khoury LD, Esmail A, Donthineni-Rao R. The treatment of
sacral giant cell tumours by serial arterial embolisation. J Bone Joint Surg
Br. 2002; 84(6):873-877.
- Leggon RE, Zlotecki R, Reith J, Scarborough MT. Giant cell tumor of
the pelvis and sacrum: 17 cases and analysis of the literature. Clin Orthop
Relat Res. 2004; (423):196-207.
- Ruggieri P, Mavrogenis AF, Ussia G, Angelini A, Papagelopoulos PJ,
Mercuri M. Recurrence after and complications associated with adjuvant
treatments for sacral giant cell tumor. Clin Orthop Relat Res. 2010;
- Luther N, Bilsky MH, Hartl R. Giant cell tumor of the spine.
Neurosurg Clin North Am. 2008; 19(1):49-55.
- Tsuchiya H, Kokubo Y, Sakurada K, et al. A case of giant cell tumor
in atlas [in Japannese]. No Shinkei Geka. 2005; 33(8):817-823.
- Finstein JL, Chin KR, Alvandi F, et al. Postembolization paralysis in
a man with a thoracolumbar giant cell tumor. Clin Orthop Relat Res.
- Guzey FK, Emel E, Aycan A, et al. Pediatric vertebral and spinal
epidural tumors: a retrospective review of twelve cases [published online ahead
of print December 14, 2007]. Pediatr Neurosurg. 2008; 44(1):14-21.
- Fraser RK, Coates CJ, Cole WG. An angiostatic agent in treatment of a
recurrent aneurismal bone cyst. J Pediatr Orthop. 1993; 13(5):668-671.
- Kónya A, Szendröi M. Aneurysmal bone cysts treated by
superselective embolization. Skeletal Radiol. 1992; 21(3):167-172.
- Han X, Dong Y, Sun K, Lu Y. A huge occipital osteoblastoma
accompanied with aneurismal bone cyst in the posterior cranial fossa [published
online ahead of print December 4, 2007]. Clin Neurol Neurosurg. 2008;
- De Cristofaro R, Biagini R, Boriani S, et al. Selective arterial
embolization in the treatment of aneurysmal bone cyst and angioma of bone.
Skeletal Radiol. 1992; 21(8):523-527.
- Papagelopoulos PJ, Choudhury SN, Frassica FJ, et al. Treatment of
aneurysmal bone cysts of the pelvis and sacrum. J Bone Joint Surg Am.
- Falappa P, Fassari FM, Fanelli A, et al. Aneurysmal bone cyst:
treatment with direct percutaneous ethibloc injection: long term results
[published online ahead of print May 20, 2002]. Cardiovasc Intervent
Radiol. 2002; 25(4):282-290.
- Meyer S, Reinhard H, Graf N, Kramann B, Schneider G. Arterial
embolization of a secondary aneurysmatic bone cyst of the thoracic spine prior
surgical excision in a 15-year-old girl. Eur J Radiol. 2002;
- Adamsbaum C, Mascard E, Guinebretière JM, Kalifa G, Dubousset
J. Intralesional ethibloc injection in primary aneurysmal bone cysts: an
efficient and safe treatment [published online ahead of print July 11, 2003].
Skeletal Radiol. 2003; 32(10):559-566.
- Pogoda P, Linhart W, Priemel M, Rueger JM, Amling M. Aneurysmal bone
cyst of the sacrum. Clinical report and review of the literature [published
online ahead of print April 12, 2003]. Arch Orthop Trauma Surg. 2003;
- Topouchian V, Mazda K, Hamze B, Laredo JD, Penneçot GF.
Aneurysmal bone cyst in children: complications of fibrosing agent injection
[published online ahead of print June 23, 2004]. Radiology. 2004;
- Marushima A, Matsumaru Y, Suzuki K, et al. Selective arterial
embolization with n-butyl cyanoacrylate in the treatment of aneursymal bone
cyst of the thoracic vertebra: a case report. Spine. 2009;
- Rossi G, Rimondi E, Bartalena T, et al. Selective arterial
embolization of 36 aneurysmal bone cysts of the skeleton with N-2-butyl
cyanoacrylate. Skeletal Radiol. 2010; 39(2):161-167.
- Bandiera S, Gasbarrini A, De lure F, et al. Symptomatic vertebral
hemangioma: the treatment of 23 cases and a review of the literature. Chir
Organi Mov. 2002; 87(1):1-15.
- Acosta FL Jr, Dowd CF, Chin C, et al. Current treatment strategies
and outcomes in the management of symptomatic vertebral hemangiomas.
Neurosurgery. 2006; 58(2):287-295.
- Jayakumar PN, Vasudev MK, Srikanth SG. Symptomatic vertebral
haemangiona: endovascular treatment of 12 cases. Spinal Cord. 1997;
- Syal R, Tyagi I, Goyal A, et al. Multiple intraosseous
hemangiomas-investigation and role of N-butylcyanoacrylate in management.
Head Neck. 2007; 29(5):512-517.
- Doppman JL, Oldfield EH, Heiss JD. Symptomatic vertebral hemangiomas:
treatment by means of direct intralesional injection of ethanol.
Radiology. 2000; 214(2):341-348.
- Katzen BT, Said S. Arteriovenous malformation of bone: an experience
with therapeutic embolization. AJR Am J Roentgenol. 1981;
- Beek FJ, Ten Broek FW, Van Schaik JP, et al. Transvenous embolization
of an arteriovenous malformation of the mandible via a femoral approach.
Pediatr Radiol. 1997; 27(11):855-857.
- Resnick SA, Russell EJ, Hanson DH, et al. Embolization of a life
threatening vascular malformation by direct percutaneous transmandibular
puncture. Head Neck. 1992; 14(5):372-379.
- Crews KR, Liu T, Rodriguez-Galindo C, et al. High dose methotrexate
pharmacokinetics and outcome of children and young adults with osteosarcoma.
Cancer. 2004; 100(8):1724-1733.
- Philip T, Iiescu C, Demaille MC, et al. High dose methotrexate and
HELP [holoxan (isofamide), eldesine (vindesine), platinum] doxorubicin in
nonmetastatic osteosarcoma of the extremity: a French multicentre pilot study.
Ann Oncol. 1999; 10(9):1065-1071.
- Wang MQ, Dake MD, Wang ZP, et al. Isolated lower extremity
chemotherapeutic infusion for treatment of osteogenic sarcoma: experimental
study and preliminary clinical report. J Vasc Interv Radiol. 2001;
- Chu JP, Chen W, Li JP, et al. Clinicopathologic features and results
of transcatheter arterial chemoembolization for osteosarcoma. Cardiovasc
Intervent Radiol. 2007; 30(2):201-206.
- Trübenbach J, Nägele T, Bauer T, Ernemann U. Preoperative
embolization of cervical spine osteoblastomas: report of three cases. AJNR
Am J Neuroradiol. 2006; 27(9):1910-1912.
- Denaro V, Denaro L, Papalia R, et al. Surgical management of cervical
spine osteoblastomas. Clin Orthop Relat Res. 2007; (455):190-195.
- Findik S, Akan H, Baris S, Atici AG, Uzun O, Erkan L. Preoperative
embolization in surgical treatment of a hemangiopericytoma of the rib: a case
report. J Korean Med Sci. 2005; 20(2):316-318.
- Deneuve S, Lezy JP, Cyna-Gorse F, et al. Mandibular
hemangiopericytoma, a malignant vascular tumor [in French] [published online
ahead of print February 1, 2007]. Rev Stomatol Chir Maxillofac. 2007;
- Sanchez-Mejia RO, Ojemann SG, Simko J, Chaudhary UB, Levy J, Lawton
MT. Sacral epitheliod angiosarcoma associated with a bleeding diathesis and
spinal epidural hematoma: case report. J Neurosurg Spine. 2006;
- Basile A, Rand T, Lomoschitz F, et al. Trisacryl gelatin microspheres
versus polyvinyl alcohol particles in the preoperative embolization of bone
neoplasms [published online ahead of print July 30, 2004]. Cardiovasc
Intervent Radiol. 2004; 27(5):495-502.
- Munk PL, Legiehn GM. Musculoskeletal interventional radiology:
applications to oncology. Semin Roentgenol. 2007; 42(3):164-174.
- Yamamoto A, Imai S, Kobatake M, Yamashita T, Tamada T, Umetani K.
Evaluation of tris-acryl gelatin microsphereembolization withmonochromatic x
rays: comparison with polyvinyl alcohol particles. J Vasc Interv Radiol.
2006; 17(11 Pt 1):1797-1802.
- Bowers TA, Murray JA, Charnsangavej C, Soo CS, Chuang VP, Wallace S.
Bone metastases from renal carcinoma. The preoperative use of transcatheter
arterial occlusion. J Bone Joint Surg Am. 1982; 64(5):749-754.
- Vlahos L, Benakis V, Dimakakos P, Dimopoulos C, Pontifex G.
Acomparative study of the degree of arterial recanalization in kidneys of dogs
following transcatheter embolization with eight different materials. Eur
Urol. 1980; 6(3):180-185.
- Guibaud L, Herbreteau D, Dubois J, et al. Aneurysmal bone cysts:
percutaneous embolization with an alcoholic solution of zein-series of 18
cases. Radiology. 1998; 208(2):369-373.
- Görich J, Solymosi L, Hasan I, Sittek H, Majdali R, Reiser M.
Embolization of bone metastases [in German}. Radiologe. 1995;
- Soo CS, Wallace S, Chuang VP, Carrasco CH, Phillies G. Lumbar artery
embolization in cancer patients. Radiology. 1982; 145(3):655-659.
- Pisco JM, Martins JM, Correia MG. Internal iliac artery: embolization
to control hemorrhage from pelvic neoplasms. Radiology. 1989;
- Hare W, Lond F, Holland C. Paresis following internal iliac artery
embolization. Radiology. 1983; 146(1):47-51.
Drs Mavrogenis and Ruggieri are from the Department of Orthopedics,
Dr Rossi is from the Department of Interventional Angiographic Radiology, and
Dr Rimondi is from the Department of Radiology, Istituto Ortopedico Rizzoli,
Bologna, Italy; and Dr Papagelopoulos is from the First Department of
Orthopedics, Athens University Medical School, Athens, Greece.
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verify all information before treating patients or using any product.
Correspondence should be addressed to: Pietro Ruggieri, MD, PhD,
Department of Orthopedics, Orthopaedic Oncology Service, Istituto Ortopedico
Rizzoli, University of Bologna, Via Di Barbiano 1/10, 40136, Bologna, Italy