Skull base chondroblastoma with aneurysmal bone cyst-like changes treated with percutaneous radiofrequency ablation and doxycycline sclerotherapy: illustrative case.

BACKGROUND: Chondroblastomas (CBs) are rare benign bone tumors that are often difficult to treat because of their locations. CBs can be even more challenging to successfully manage when they present alongside aneurysmal bone cyst (ABC)-like changes. To minimize operative morbidity, especially in hard-to-reach lesions, percutaneous approaches for both lesions have been individually described. We present a skull base CB with associated ABC-like changes treated by combining two different previously described percutaneous modalities. OBSERVATIONS: The authors report successful percutaneous treatment of a skull base CB with adjacent ABC-like changes in a 17-year-old male. The CB was treated with radiofrequency ablation (RFA) and the adjacent ABC area with doxycycline sclerotherapy. After 3 years of follow-up, there has been no clinical or radiological evidence of recurrence. LESSONS: CBs occur in the skull base and, as elsewhere in the body, can be associated with ABC-like changes. Successful percutaneous treatment of such a CB with ABC-like changes is possible by combining previously described techniques of RFA and doxycycline sclerotherapy.

Update on aneurysmal bone cyst: pathophysiology, histology, imaging and treatment.

Aneurysmal bone cyst (ABC) is a benign but locally aggressive lesion that predominantly affects children and young adults. ABC, which accounts for approximately 70% of the cases, is now recognized to be a true neoplasm, whereas ABC-like changes associated to other bone neoplasms (also referred in the literature as secondary ABC) accounts for the remaining 30%. The solid variant of ABC is also considered a true neoplasm but is rare. ABC can involve any bone in the body, and although it has a metaphyseal preference, it can involve any part of a bone and soft tissues. As with any bone tumor, the initial evaluation of ABCs should be done with radiographs followed by magnetic resonance imaging or less frequently computed tomography for further characterization. The imaging appearance of ABC is variable; however, a lytic and expansile lesion with fluid-fluid levels is the most common presentation. The main differential diagnosis of an ABC in the pediatric population is unicameral bone cyst (UBC) and telangiectatic osteosarcoma, therefore a biopsy is recommended before treatment. The therapeutic options of ABC range from curettage with or without adjuncts such as phenol, liquid nitrogen, argon laser and bone grafting or bone substitutes to more recently employed alternatives such as image-guided sclerotherapy with various sclerosing agents and monoclonal antibodies (e.g., Denosumab).

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.

Soft tissue foreign bodies: A training manual for sonographic diagnosis and guided removal.

Sonography provides excellent detection, localization, and characterization of soft-tissue foreign bodies. Ultrasound guided foreign body removal is a safe and highly successful minimally invasive procedure that facilitates effective treatment and avoidance of complications in patients with soft tissue foreign bodies. Focused laboratory training is critical to successful implementation of a sonographic foreign body management practice.

Salivary gland ablation: introducing an interventional radiology treatment alternative in the management of sialorrhea.

BACKGROUND: Sialorrhea is common in children with neurological disorders and leads to social isolation, aspiration pneumonia and increased caregiver burden. Sialorrhea management includes anticholinergic medications and a variety of surgeries, but these are limited by side effects, recurrence and risks. OBJECTIVE: We present our method of salivary gland ablation, an interventional radiology treatment for sialorrhea, and report safety and efficacy data from pediatric patients who underwent salivary gland ablation. MATERIALS AND METHODS: Salivary gland ablation uses image-guided sotradecol and ethanol dual-drug injection into the salivary glands. Submandibular and sublingual glands are injected percutaneously using ultrasound. Parotid glands are injected retrograde through Stensen ducts using fluoroscopy. We conducted a retrospective review of the medical records of patients who underwent salivary gland ablation at our institution between 2005 and 2019. Pre- and post-procedure Drooling Frequency and Drooling Severity (DFDS) scale scores were compared and caregiver satisfaction was assessed. We devised two cohorts, one to study patient safety and a subcohort to study clinical efficacy using DFDS scores. RESULTS: One hundred and seventy salivary gland ablation procedures were performed in the 99 patients comprising the safety cohort. Of the procedures, 88.8% resulted in no or minimal complications. Respiratory difficulty, temporary nerve palsy and infection represent the majority of the 11.2% of patients who experienced periprocedural complications. There were no complications resulting in permanent sequelae. Twenty-seven patients met our inclusion criteria for the efficacy subcohort with a mean follow-up time of 5.4 years. DFDS at follow-up decreased from a median score of nine to a seven post-procedure (P=0.000018). The proportion of caregivers who were satisfied with the procedure increased as more glands were ablated, which suggests a causal link between the number of glands ablated and the outcome. CONCLUSION: Salivary gland ablation is a safe and effective procedure with the potential for permanent decrease in symptoms related to sialorrhea.

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.

Minimally invasive treatment of pediatric head and neck dermoids: percutaneous drainage and radiofrequency coblation.

BACKGROUND: Dermoids are common benign head and neck cysts in children containing a variety of different skin elements. Current standard treatment is surgical removal that sometimes requires extensive dissection to ensure complete resection and often leaves unwanted facial scarring. A minimally invasive treatment alternative should offer a similar rate of success with a decrease in operative complexity, recovery time and postoperative scarring. OBJECTIVE: To assess the outcomes of our minimally invasive percutaneous treatment of head and neck dermoids, we reviewed our 9-year interventional radiology (IR) department experience. MATERIALS AND METHODS: The medical records, imaging and procedural details were reviewed from a cohort of pediatric patients with dermoids treated in our IR department from January 2009 through February 2018. Patients in the study underwent ultrasound (US)-guided cyst puncture, 3% Sotradecol (sodium tetradecyl sulfate [STS]) emulsification of the thick cyst contents allowing complete drainage, and radiofrequency coblation of the cyst wall. RESULTS: In this retrospective study, we report on 22 dermoids in 21 patients. The average patient age was 3 years. Twenty-one of the 22 dermoids were successfully treated for an overall success rate of 95%. Four intraosseous dermoids were successfully treated using computed tomography (CT) guidance instead of, or in addition to, US. Average follow-up time was 22 months. CONCLUSION: The combination of percutaneous cyst drainage using STS as an emulsifying agent followed by radiofrequency coblation is a safe, effective, minimally invasive treatment for pediatric patients with head and neck dermoids.

Percutaneous treatment of ranulas: ultrasound-guided drainage with salivary gland chemical ablation.

BACKGROUND: Ranulas are salivary pseudocysts in the floor of the mouth adjacent to damaged salivary glands. Current surgical management is drainage of the ranula with removal of the offending gland. An analogous percutaneous procedure could potentially offer similar treatment efficacy in a more minimally invasive way. OBJECTIVE: To evaluate the outcomes of a cohort of patients with ranulas treated with percutaneous ranula aspiration and chemical ablation of the source salivary gland to see whether this technique could be proposed as a minimally invasive treatment alternative. MATERIALS AND METHODS: This retrospective single-center study evaluated 24 patients treated percutaneously for ranulas between January 2004 and December 2014. All patients were treated with percutaneous ranula aspiration and chemical ablation of the offending salivary gland. Treatment success and any complications were recorded. RESULTS: Complete ranula eradication was successfully accomplished in 87.5% of the patients with no complications. CONCLUSION: Initial results suggest that our technique of percutaneous aspiration of ranulas and chemical ablation of the source salivary gland is safe and effective.

Image-guided percutaneous removal of ballistic foreign bodies secondary to air gun injuries.

BACKGROUND: Ballistic injuries with retained foreign bodies from air guns is a relatively common problem, particularly in children and adolescents. If not removed in a timely fashion, the foreign bodies can result in complications, including pain and infection. Diagnostic methods to identify the presence of the foreign body run the entire gamut of radiology, particularly radiography, ultrasound (US) and computed tomography (CT). Removal of the foreign bodies can be performed by primary care, emergency, surgical, and radiologic clinicians, with or without imaging guidance. OBJECTIVE: To evaluate the modalities of radiologic detection and the experience of image-guided ballistic foreign body removal related to air gun injuries within the interventional radiology department of a large pediatric hospital. MATERIALS AND METHODS: A database of more than 1,000 foreign bodies that were removed with imaging guidance by the interventional radiologists at our institution was searched for ballistic foreign bodies from air guns. The location, dimensions, diagnostic modality, duration, complications and imaging modality used for removal were recorded. In addition, the use of sedation and anesthesia required for the procedures was also recorded. RESULTS: Sixty-one patients with ballistic foreign bodies were identified. All foreign bodies were metallic BBs or pellets. The age of the patients ranged from 5 to 20 years. The initial diagnostic modality to detect the foreign bodies was primarily radiography. The primary modality to assist in removal was US, closely followed by fluoroscopy. For the procedure, 32.7% of the patients required some level of sedation. Only two patients had an active infection at the time of the removal. The foreign bodies were primarily in the soft tissues; however, successful removal was also performed from intraosseous, intraglandular and intratendinous locations. All cases resulted in successful removal without complications. CONCLUSION: Image-guided removal of ballistic foreign bodies secondary to air guns is a very effective procedure that can obviate the need for open surgical procedures in children.

Ultrasound-guided corticosteroid injection of the subtalar joint for treatment of juvenile idiopathic arthritis.

BACKGROUND: The subtalar joint is commonly affected in children with juvenile idiopathic arthritis and is challenging to treat percutaneously. OBJECTIVE: To describe the technique for treating the subtalar joint with US-guided corticosteroid injections in children and young adults with juvenile idiopathic arthritis and to evaluate the safety of the treatment. MATERIALS AND METHODS: We retrospectively analyzed 122 patients (age 15 months-29 years) with juvenile idiopathic arthritis who were referred by a pediatric rheumatologist for corticosteroid injection therapy for symptoms related to the hindfoot or ankle. In these patients the diseased subtalar joint was targeted for therapy, often in conjunction with adjacent affected joints or tendon sheaths of the ankle. We used a protocol based on age, weight and joint for triamcinolone hexacetonide or triamcinolone acetonide dose prescription. We describe the technique for successful treatment of the subtalar joint. RESULTS: A total of 241 subtalar joint corticosteroid injections were performed under US guidance, including 68 repeat injections for recurrent symptoms in 26 of the 122 children and young adults. The average time interval between repeat injections was 24.8 months (range 2.2-130.7 months, median 14.2 months). Subcutaneous tissue atrophy and skin hypopigmentation were the primary complications observed. These complications occurred in 3.9% of the injections. CONCLUSION: With appropriate training and practice, the subtalar joint can be reliably and safely targeted with US-guided corticosteroid injection to treat symptoms related to juvenile idiopathic arthritis.

Ultrasound-guided corticosteroid injection therapy for juvenile idiopathic arthritis: 12-year care experience.

BACKGROUND: Intra-articular corticosteroid injections are a safe and effective treatment for patients with juvenile idiopathic arthritis. The potential scope of care in ultrasound-guided corticosteroid therapy in children and a joint-based corticosteroid dose protocol designed to optimize interdisciplinary care are not found in the current literature. OBJECTIVE: The purpose of this study was to report the spectrum of care, technique and safety of ultrasound-guided corticosteroid injection therapy in patients with juvenile idiopathic arthritis and to propose an age-weight-joint-based corticosteroid dose protocol. MATERIALS AND METHODS: A retrospective analysis was performed of 198 patients (ages 21 months to 28 years) referred for treatment of juvenile idiopathic arthritis with corticosteroid therapy. Symptomatic joints and tendon sheaths were treated as prescribed by the referring rheumatologist. An age-weight-joint-based dose protocol was developed and utilized for corticosteroid dose prescription. RESULTS: A total of 1,444 corticosteroid injections (1,340 joints, 104 tendon sheaths) were performed under US guidance. Injection sites included small, medium and large appendicular skeletal joints (upper extremity 497, lower extremity 837) and six temporomandibular joints. For patients with recurrent symptoms, 414 repeat injections were performed, with an average time interval of 17.7 months (range, 0.5-101.5 months) between injections. Complications occurred in 2.6% of injections and included subcutaneous tissue atrophy, skin hypopigmentation, erythema and pruritis. CONCLUSION: US-guided corticosteroid injection therapy provides dynamic, precise and safe treatment of a broad spectrum of joints and tendon sheaths throughout the entire pediatric musculoskeletal system. An age-weight-joint-based corticosteroid dose protocol is effective and integral to interdisciplinary care of patients with juvenile idiopathic arthritis.

Self-embedding behavior: radiologic management of self-inserted soft-tissue foreign bodies.

PURPOSE: To report on a series of self-embedding behavior (SEB), demonstrate the effectiveness and clinical effect of image-guided foreign body removal (IGFBR) in the treatment of embedded soft-tissue foreign bodies (STFBs), and evaluate the role of the radiologist in the clinical management of SEB. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board. From a database of 600 patients treated with IGFBR with ultrasonographic (US) and/or fluoroscopic guidance, self-injury was identified in 11 (1.8%) mainly adolescent patients with a mean age of 16 years (age range, 14-18 years). Evaluated data included number of foreign bodies; number of repeat episodes of foreign body insertion; location, type, and size of foreign body; incision size; imaging modality; and success or failure of foreign body removal. RESULTS: Seventy-six foreign bodies were inserted into the arm (n = 69), neck (n = 4), ankle (n = 1), foot (n = 1), or hand (n = 1) in the 11 patients. The number of STFBs per case ranged from one to 15. Foreign body types included metal (n = 40), plastic (n = 15), graphite (n = 12), glass (n = 4), wood (n = 3), crayon (n = 1), and stone (n = 1). STFB dimensions were 2.5-160.0 mm in length by 0.25-3.0 mm in thickness. Sixty-eight of the 76 STFBs were removed in the interventional radiology section. Incision lengths ranged from 4 to 8 mm (mean, 6 mm). The STFBs were removed with US guidance (n = 43), fluoroscopic guidance (n = 15), or a combination of the two modalities (n = 10). IGFBR was successful in all 68 cases, without complications. CONCLUSION: Greater awareness of SEB may result in radiologists being the first physicians to identify SEB and rapidly mobilize an interdisciplinary team for early and effective intervention and treatment. Percutaneous radiologic treatment of self-imbedded STFBs is safe, precise, and effective for radiopaque and nonradiopaque foreign bodies.

Percutaneous treatment of lymphatic malformations.

OBJECTIVE: The aim of this study is to investigate a new treatment regimen for macrocystic and microcystic lymphatic malformations (LM) of the head and neck. STUDY DESIGN: The study represents a retrospective review of outcomes from new percutaneous treatments for lymphatic malformations. SUBJECTS AND METHODS: Thirty-one patients (age range, 2 days to 51 years of age) underwent percutaneous treatment for LM of the head and neck from 2001 to 2007. The LM involved the orbit, ear, parotid gland, face, and neck. Twenty-seven patients underwent primary treatment of LM; 4 were treated for recurrence after operative resection. Macrocysts (>or=1 cm) were treated with dual-drug chemoablation (sequential intracystic sodium tetradecyl sulfate and ethanol); doxycycline was used for microcysts. Macrocysts and microcysts were treated after complete cyst aspiration with sonographic guidance. Fifty-four macrocysts and 125 microcysts were treated. The goal of treatment was complete cyst ablation documented by sonography or MR imaging. RESULTS: Mean number of treatments was 1.7 per patient; mean number of treatments for macrocysts was 1.1; mean treatments for microcysts was 1.7. Ablation efficacy was 179 of 179 (100%) cysts. Effective cyst ablation achieved effective clinical control with resolution of the external mass appearance. Treatments included massive head and neck mixed LM and cysts surrounding the facial nerve and brachial plexus. Infection occurred in 2 (6%) of 31 patients. No patient experienced postprocedural pain, skin necrosis, neuropathy, skin retraction, or myoglobinuria. CONCLUSION: Percutaneous sclerotherapy provides effective treatment for macrocystic and microcystic LM as primary treatment or for recurrence after surgical resection.

Radiofrequency ablation of a cervical osteoid osteoma: a trans-thyroid approach.

We present a 16-year-old girl with an osteoid osteoma in the vertebral body of C5. Given the difficulty of surgically treating the lesion, radiofrequency ablation was used. Percutaneous needle access to this lesion in the anterior aspect of the cervical vertebral body was limited by the many critical adjacent structures. We present our successful treatment of this lesion utilizing a trans-thyroid needle approach.

Sonographically guided aspiration of cerebrospinal fluid pseudocysts in children and adolescents.

OBJECTIVE: Cerebrospinal fluid (CSF) pseudocyst formation is an uncommon cause of ventriculoperitoneal shunt malfunction in children. Traditional staged treatment consists of shunt externalization, antibiotics, and later shunt revision and internalization. We sought to evaluate whether sonographically guided pseudocyst aspiration to alleviate acute symptoms and to exclude CSF infection could obviate shunt externalization and expedite the care of these patients. CONCLUSION: Sonographically guided CSF pseudocyst aspiration is an effective technique, allowing exclusion or confirmation of infection and providing relief of abdominal symptoms. In patients with sterile collections, staged surgical revision with shunt externalization can be avoided, speeding and simplifying treatment.