Doxycycline Sclerotherapy of Aneurysmal and Unicameral Bone Cysts in the Appendicular Skeleton and Pelvis: Single-Center 14-Year Experience.

PURPOSE: To evaluate the safety, effectiveness, and patient satisfaction of doxycycline sclerotherapy for aneurysmal bone cysts (ABCs) and unicameral bone cysts (UBCs). MATERIALS AND METHODS: This was an institutional review board (IRB)-approved single-center retrospective review of all ABCs and UBCs of the appendicular skeleton and pelvis completing doxycycline sclerotherapy and having at least 2 years of follow-up from 2007 to 2021. Radiographic outcomes in a patient cohort were assessed with a modified Neer score. Patient-reported outcome (PRO) surveys were completed by a subgroup of the cohort assessing pain after treatment (Likert scale), functional outcomes (Patient-Reported Outcomes Measurement Information System), and overall patient satisfaction (adapted from the Musculoskeletal Tumor Society). RESULTS: Seventy-seven lesions met the inclusion criteria, with 55 (71%) receiving bone void filler in addition to doxycycline. Of the 77 lesions, 76 (99%) were successfully treated. Twelve lesions (16%) recurred but resolved with additional doxycycline treatment. One lesion failed sclerotherapy, requiring surgical excision. Of the 383 total treatments performed, 17 resulted in Society of Interventional Radiology (SIR)-classified adverse events (9 with Grade 1, 7 with Grade 2, and 1 with Grade 3). Twenty-five (32%) of the 77 cases completed PRO surveys, with 20 (80%) having little to no pain and 15 (60%) having no functional impairment after completing treatment. The PRO surveys documented high levels of satisfaction, with all patients agreeing that they would undergo doxycycline sclerotherapy again if given the option. CONCLUSIONS: Doxycycline sclerotherapy (with or without bone void filler) is a safe, effective, and well-tolerated stand-alone treatment for ABCs and UBCs.

Doxycycline Sclerotherapy of Mandibular Aneurysmal Bone Cysts: A Brief Clinical Study.

Aneurysmal bone cysts (ABCs) are benign bone tumors typically affecting children. Mandibular ABCs can be difficult to treat surgically, given their sensitive anatomic location and functional and cosmetic impacts. This report presents 3 pediatric patients with mandibular ABCs successfully treated with image-guided percutaneous doxycycline sclerotherapy. The first 2 patients presented with pain and swelling, whereas the third was diagnosed incidentally. Sclerotherapy was the sole treatment for cases 1 and 2, whereas case 3 had sclerotherapy after recurrence following prior surgeries. In all 3 patients, clinical symptoms resolved, and stable bone healing was documented on long-term follow-up. There were no functional or cosmetic complications. Doxycycline sclerotherapy is a safe and viable treatment for primary and recurrent mandibular ABCs.

The stratification of positive lymph nodes into pN1 and pN2 for upper urinary tract carcinoma is not prognostically significant.

The 3rd-7th edition of the American Joint Committee on Cancer had 3 categories for positive lymph nodes (pN1-3) in upper urinary tract carcinomas. The 8th edition removed pN3, defining pN1 as one lymph node with a tumor deposit ≤2 cm and pN2 as a node with a tumor deposit >2 cm or metastases in multiple nodes. The aim of this study was to assess if the current pN categories impact survival in renal pelvic and ureteral carcinomas. Nephroureterectomies performed at our institution for primary upper urinary tract carcinomas between 2010 and 2019 were reviewed. Lymphadenectomy was performed in 73.3% of cases (151/206, median = 9 nodes). Eighty-one (53.6%) patients were deceased at the last review (pN0, 53 [44.5%]; pN1-2, 28 [87.5%]). There was no difference in overall or recurrence-free survival between pN1 and pN2 with 5-year overall survival (95% confidence interval) of pN0, 60.7% (52.0-70.8%); pN1, 15.4% (4.3-35.2%); and pN2, 21.1% (8.8-40.3%). The metastatic deposit size threshold of 2 cm, the number of positive lymph nodes, as well as extranodal extension did not correlate with overall or recurrence-free survival. As such, pN1 and pN2 were grouped together with a 5-year overall survival of 18.8% (9.12-28.6%). The current stratification of upper urinary tract carcinomas into pN1 and pN2 does not provide prognostic information, and both yield a stage IV classification, regardless of pT or pM category. Therefore, we recommend further simplification of pN classification into one category for regional lymph node metastasis, irrespective of the lymph node deposit size or number of positive lymph nodes.

Renal Pelvic Urothelial Carcinoma With Invasion Into Renal Medulla Can Be Redefined as pT2 to Improve Correlation With Survival.

According to the American Joint Cancer Committee, pT3 renal pelvic carcinoma is defined as tumor invading the renal parenchyma and/or peripelvic fat and is the largest pT category, with notable survival heterogeneity. Anatomical landmarks within the renal pelvis can be difficult to discern. Using glomeruli as a boundary to differentiate renal medulla invasion from renal cortex invasion, this study aimed to compare patient survival of pT3 renal pelvic urothelial carcinoma on the basis of the extent of renal parenchyma invasion and, thereafter, determine whether redefining pT2 and pT3 improves pT correlation with survival. Cases with primary renal pelvic urothelial carcinoma were identified through a review of pathology reports from nephroureterectomies completed at our institution from 2010 to 2019 (n = 145). Tumors were stratified by pT, pN, lymphovascular invasion, and invasion of the renal medulla versus invasion of the renal cortex and/or peripelvic fat. Overall survival between groups was compared using Kaplan-Meier survival models and Cox regression multivariate analysis. pT2 and pT3 tumors had similar 5-year overall survival, with multivariate analysis demonstrating an overlap between hazard ratios (HRs) for pT2 (HR, 2.20; 95% CI, 0.70-6.95) and pT3 (HR, 3.15; 95% CI, 1.63-6.09). pT3 tumors with peripelvic fat and/or renal cortex invasion had a 3.25-fold worse prognosis than pT3 tumors with renal medulla invasion alone. Furthermore, pT2 and pT3 tumors with only renal medulla invasion had similar overall survival, whereas pT3 tumors with peripelvic fat and/or renal cortex invasion had a worse prognosis (P = .00036). Reclassifying pT3 tumors with only renal medulla invasion as pT2 yielded greater separation between survival curves and HR. Thus, we recommend redefining pT2 renal pelvic carcinoma to include renal medulla invasion and restricting pT3 to peripelvic fat and/or renal cortex invasion to improve the prognostic accuracy of pT classification.

Doxycycline sclerotherapy of cervical spine aneurysmal bone cysts: single-institution 13-year experience.

BACKGROUND: Aneurysmal bone cysts (ABCs) are benign, locally aggressive neoplasms that typically affect patients during their first two decades of life. Curettage with or without bone grafting or adjuvants is the current standard treatment; however, other surgical and medical treatments, such as sclerotherapy, have been reported. Treatment options for cervical spine ABCs are more limited because the proximity of ABCs to critical structures leads to greater risk of spontaneous or treatment-related adverse events, including death. OBJECTIVE: To retrospectively review all children and young adults with cervical spine ABCs treated with doxycycline sclerotherapy at one referral center to assess its viability as a standalone treatment. MATERIALS AND METHODS: We retrospectively reviewed the clinical notes and imaging of 16 patients treated with doxycycline sclerotherapy for pathologically proven cervical spine ABCs at our institution between May 2008 and March 2021. All patients underwent image-guided percutaneous doxycycline sclerotherapy to ablate the ABC and stimulate bone formation. We assessed clinical outcomes through chart review and described post-treatment imaging outcomes using modified Neer scoring. RESULTS: Of the 16 total children and young adults treated, 2 were lost to follow-up, leaving 14 patients with a median age of 14.5 years. Twelve of these 14 patients were successfully treated with doxycycline sclerotherapy for a success rate of 86%. One patient experienced one treatment-related complication (Society of Interventional Radiology [SIR] adverse event classification D), before ultimately being successfully treated. Doxycycline treatment failed in two patients, who then underwent surgical management. Post-treatment imaging of successfully treated cases had a mean modified Neer score of 1.3, whereas post-treatment imaging in failed cases had a mean score of 3.5. CONCLUSION: Doxycycline sclerotherapy is a viable standalone treatment for cervical spine ABCs because it is safe and effective while avoiding the morbidity associated with open surgical treatments.

Image-Guided Percutaneous Management of Skull and Spine Giant Cell Tumors: Case Report of 2 Challenging Cases Successfully Treated with Doxycycline Sclerotherapy.

BACKGROUND: A giant cell tumor (GCT) of bone is a benign, locally aggressive tumor that is often challenging to treat. When complete resection is not possible, curettage with or without adjuvants is the most common treatment. The high frequency of local recurrence and risk of injury to adjacent structures can limit this surgical approach, especially with skull and spine lesions. CASE DESCRIPTION: We report 2 cases of axial skeleton GCTs, 1 in the skull of a 58-year-old woman in whom operative management failed, who experienced local recurrence, and 1 in the cervical spine of an 8-year-old girl that grew extracompartmentally to surround her brachial plexus. Both patients were referred to us because of the surgically challenging nature of their tumors. After completion of the same percutaneous doxycycline sclerotherapy protocol previously described for aneurysmal bone cysts (ABCs), both patients were considered cured and were able to return to normal activities without loss of pretreatment function. After 4 and 10 years of follow-up, respectively, there has been no tumor recurrence in either patient. CONCLUSIONS: We successfully treated 2 patients with very challenging axial skeleton GCTs using a percutaneous doxycycline sclerotherapy protocol previously shown to have success with ABCs. We believe that this minimally invasive procedure should be considered a potential alternative treatment for GCTs, especially axial skeleton lesions, which may not be easily approached with standard surgical techniques.