Orthopedics

CME Review Article 

Embolization of Bone Tumors

Andreas F. Mavrogenis, MD; Giuseppe Rossi, MD; Eugenio Rimondi, MD; Panayiotis J. Papagelopoulos, MD, DSc; Pietro Ruggieri, MD, PhD

Abstract

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 serial.3,4,6-16

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 substance.3,8-20

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 chemotherapy.3,8,21

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 surgery.8

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 relief.3,4,26,27

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,…

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 serial.3,4,6-16

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 substance.3,8-20

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 chemotherapy.3,8,21

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 surgery.8

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 relief.3,4,26,27

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 recanalization.3,5,6,8,10,11,29,30

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 necessary.26,31

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).

Figure 1A: Axial CT scan Figure 1B: Metastatic renal cell carcinoma of the pelvis. Figure 1C: Pathologic feeding vessels originating from the left internal iliac artery.
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.
Figure 1D: Axial CT scan of the pelvis at 6 months after intraarterial selective embolization show tumor size reduction and ossification of margins. Figure 1E: Axial CT scan of the pelvis at 12 months after intraarterial selective embolization show tumor size reduction and ossification of margins.
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 recanalization.

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 required.42

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

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.

Sarcomas

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.

Embolization Technique

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 effectiveness.

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.

Figure 2A: AP radiograph of the left elbow of a 70-year-old man with a metastatic renal cell carcinoma of the olecranon. Figure 2B: Pre-embolization angiography showed 3 feeding vessels originating from the median brachial and ulnar artery.
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).
Figure 2C: Selective embolization of the feeding vessels was done. Figure 2D: Ossification of the lesion 6 months after embolization.
Figures 2C-2D: Selective embolization of the pathologic feeding vessels was done (C). Ossification of the lesion 6 months after embolization (D).

Embolic Agents

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 clot.21

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 tumors.6,11,26,28

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

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 3A: Axial CT scan of the pelvis of a 60-year-old woman with a metastatic paraganglioma of the pelvis. Figure 3B: Pre-embolization angiography. Figure 3C: Selective embolization of the pathologic feeding vessels originating from the right internal iliac artery. Figure 3D: Skin necrosis and superficial necrosis 7 days post-embolization.
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 canceled.
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.

Conclusion

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.

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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.

The material presented in any Vindico Medical Education continuing education activity does not necessarily reflect the views and opinions of ORTHOPEDICS or Vindico Medical Education. Neither ORTHOPEDICS nor Vindico Medical Education nor the authors endorse or recommend any techniques, commercial products, or manufacturers. The authors may discuss the use of materials and/or products that have not yet been approved by the US Food and Drug Administration. All readers and continuing education participants should 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 (pietro.ruggieri@ior.it).

doi: 10.3928/01477447-20110228-20

10.3928/01477447-20110228-20

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