Unicameral bone cyst: radiographic assessment of venous outflow by cystography as a prognostic index.

The aim of this study was to determine the benefits of cystography in the management of a simple bone cyst, its implication in the final result of the treatment after corticoid intracystic injections, and the presence of secondary effects. We retrospectively reviewed 42 patients diagnosed with a simple bone cyst. Cystography was performed before the corticoid injection. The presence or absence of loculation intracyst and the existence and number of venous outflows were determined. According to the venous drainage, cysts were classified as type 0 when a venous outflow did not exist and as type 1 when there was a rapid venous outflow (<3 min). The treatment protocol included a maximum of three corticoid injections at an interval of 6 months. Healing of the cyst was determined on the basis of Neer's criteria. Secondary effects and surgical complications were assessed. Cystography studies showed a unicameral bone cyst with absent loculation in 16 cases (37.3%), whereas the lesion showed multiloculation in 26 cases (62.7%). There was no statistical difference between loculation intracyst (present or absent) and the final outcomes of the 42 cysts treated with a steroid injection (P=0.9). Cystography showed a negative venogram in 10 cases (23.8%), whereas the cysts showed a rapid venous outflow in 32 cases (76.2%). On the basis of Neer's classification, all patients with a negative venogram achieved complete healing of the cyst. Patients with a rapid venous outflow achieved complete healing in 14 cases (Neer I). In two patients, the healing was incomplete at the end of the follow-up period (Neer IV). In most cases (21 cysts), healing was partial (Neer II). Five patients showed a recurrence after initial healing of the cyst (Neer III) (P<0.05). The number or the size of veins did not affect healing of a bone cyst (P=0.6). Two patients with a rapid venous outflow showed a generalized hypertrichosis after the first injection of corticosteroids. Sex and age at the initiation of the first injection were not significant factors of healing (P=0.4). The average follow-up time was 59 months (24-60 months). Cystography provides morphological and functional information of simple bone cyst. It is a useful test before the administration of percutaneous injections of sclerosing substances. It facilitates the differentiation of cysts that may achieve complete healing (negative venogram) from those that tend to show recurrence (rapid venous outflow). Therapeutic material should be introduced slowly and a second trocar should always be placed to decrease the risk of migration in cysts with communication with the venous system.

Precordial Doppler evaluation of simple bone cyst injection.

BACKGROUND: A randomized prospective trial of marrow-versus-steroids treatment of solitary bone cyst was ongoing. Protocol required contrast injection of the cyst. A subpopulation was noted to have large, rapid venous outflow of contrast material (omnipaque). Central embolization and resultant acute respiratory distress syndrome has been reported with bone marrow transplant. Particulate injection can result in bradycardia, low exhaled CO2, decreased SaO2 and voltage changes on electrocardiogram. METHODS: Precordial Doppler can measure flow and turbulence centrally after a peripheral cyst injection. Our cases were monitored with precordial Doppler as well as heart rate, ETCO2, blood pressure, electrocardiogram, and pulse oximetry. RESULTS: Five patients/7 injections were noted to have large and rapid outflow veins from solitary bone cyst. The Doppler showed increased signal in all 7 particulate injections (2 steroid injections, 5 bone marrow aspirates and cyst injections.) One marrow injection resulted in transient bradycardia and decreased blood pressure with no sequelae. One developed transient decrease in exhaled CO2. CONCLUSIONS: Rapid outflow has been reported in the past but precordial Doppler monitoring of injection into peripheral cysts is not reported. The potential for embolization with serious physiologic effects is a concern. Others have advocated injection of more particulate substances, such as calcium, sulfate, and demineralized bone matrix. This Doppler technique may be valuable for monitoring the potential harmful effects of these injections and lead to a better understanding of failure of cyst healing due to rapid outflow of material. LEVEL OF EVIDENCE: Level IV case series with poor reference standard.

Unusual finding after contrast injection of a solitary bone cyst. A case report.

Injection of radiopaque contrast into a solitary bone cyst (SBC) prior to methylprednisolone acetate (MPA) injection has been previously reported. We report an unusual finding during the injection of radiopaque contrast in the treatment of one case of SBC of the femur: a bicameral appearance of the cyst was observed; no filling of the proximal cavity occurred and immediate perfusion of the femoral vein with contrast was noted. In cases of SBC such as this one, percutaneous autologous marrow or corticosteroid injection may fail to be effective. Furthermore there exists the potential risk of fat embolus secondary to bone marrow injection. Based on these findings in the case reported, we suggest that contrast injection should be performed prior to bone marrow or corticosteroid injection in order to evaluate both the venous drainage of the cyst and its degree of loculation.

Intraosseous ganglion communicating with soft tissue counterpart.

We report the imaging and pathological findings of a rare case of intraosseous ganglion communicating with extraosseous counterpart. Both counterparts contain air and show rim-enhancement on T1-weighted images. Histopathologically, the enhanced-rim consists of reactive proliferation of capillary vessels due to degeneration.

An angiostatic agent in treatment of a recurrent aneurysmal bone cyst.

Healing of an aggressive recurrent aneurysmal bone cyst of the distal humerus was induced by oral dexamethasone, an angiostatic agent. The severe pain and tenderness resolved rapidly. The soft tissue swelling subsided, and a thick layer of bone formed around the cyst. Complete healing followed saucerization and curettage of the remaining vascular tissue in the center of the cyst. We suggest that angiostatic agents be included in the nonoperative methods of treatment of aggressive aneurysmal bone cysts.

Computerised tomography in the evaluation of expansile lesions arising from the skull vault in childhood--a report of 5 cases.

Expansile lesions of the skull vault are rare in childhood, and often present as relatively asymptomatic calvarial swellings. The cases of 5 children with expansile lesions of the skull vault due to both benign and malignant primary bone lesions are described. The value of computerised tomography in demonstrating that the "tumour" arises primarily from the skull vault as opposed to the underlying brain, and in demonstrating clinically unsuspected endocranial extension of the mass is described. The CT findings in 2 cases of aneurysmal bone cyst, including the significance of the presence of "fluid levels" in reaching a definitive diagnosis are discussed. The successful pre-operative embolisation in one case of aneurysmal bone cyst is reported.

Diagnosis of aneurysmal bone cyst of the mandible. A report of two cases with emphasis on scintigraphic approaches.

Aneurysmal bone cyst is rarely found in the mandible, and roentgenographic diagnosis of this condition is not easily made. In this report, the diagnostic value of bone scintigraphy and radionuclide angiography and CT imaging in two cases of aneurysmal bone cyst of the mandible are discussed. Bone scintigraphy with Tc-99m MDP demonstrated ring-like or doughnut-pattern accumulation of radioactivity, which corresponded to the expansile character of the bony lesion. The accumulation of radioactivity was intensive in the peripheral region despite the fact that the lesion was benign. Furthermore, the central rarefaction showed that the lesion was cystic. Radionuclide angiography with Tc-99m HSA, including blood pool scan, did not detect radioactive concentration. Thus bone scintigraphy and radionuclide angiography were found to be essential in the differential diagnosis of aneurysmal bone cyst from other forms of tumor, especially hypervascularized tumor and central hemangioma of the mandible.

[Evaluation of the treatment of the unicameral bone cyst in children (author's transl)]. / Bilan du traitement du kyste essentiel des os de l'engant.

Solitary bone cyst is characterized by its tenacity and the risk of recurrence. This fact led the authors to use a surgical procedure very different of the classic ways of treatment as they excluded any bone graft to the benefit of a muscle graft with wide resection. 35 cases have been operated on at several steps of childhood. The recurrence's rate decreased plainly and is no more than 9%. They concern only the wide humeral cysts which were active and close to the fertile plate of the humeral head. These recurrences have been very well tolerated and have not predisposed the child to some pathological fractures. Residual pseudo-cysts were seen in 20% of the cases; they related for us, to some gaps of rehabilitation. This procedure ay be considered as the complement of cortisone's local infection when this one is not able to heal the solitary bone cyst.

A clinical test to differentiate aneurysmal bone cyst from other benign osseous cystic lesions.

Intracystic pressures of benign osseous cysts recorded with a spinal manometer help to diagnose aneurysmal bone cysts. Sixteen benign osseous cystic lesions in various sites were subjected to manometer pressure readings. Twelve proved to be aneurysmal bone cysts. The results are recorded.

Adjuvant arterial embolization in the treatment of benign primary bone tumors in children.

This report presents an initial clinical experience with arterial embolization as adjuvent therapy in the surgical treatment of selected benign primary bone tumors in childhood. Embolization was dramatically effective in 4 children with spinal or pelvic vascular tumors. This technique facilitated local surgical resection and/or curettage. No child had evidence of local recurrence. Three of the 4 children had spinal cord or nerve root compression resulting in various degrees of paralysis prior to surgery. All treated patients had complete recovery from their paralysis. There were no complications of embolization or surgery. The treatment of benign primary bone tumors of the spine and pelvis is immeasurably improved by the adjuvant arterial embolization procedure. The immediate surgical treatment of these difficult tumors now becomes feasible with the greatly diminished blood flow resulting from embolization.

Ultrastructure of aneurysmal bone cyst.

The ultrastructure of 5 cases of primary aneurysmal bone cysts is described. The most frequent cells found are fibroblasts containing varying amounts of glycogen. Primitive mesenchymal cells in different stages of differentiation are seen. The foci of osteoid and bone originate through metaplastic changes of the spindle cell stroma. We feel that the fibroblastic proliferation and bone formation are manifestations of a reactive process. The giant cells are similar to those of other giant cell lesions of bone. A case of cystic chondroblastoma with secondary aneurysmal bone cyst features was studied. It shows, in addition to chondroblastoma cells, elongated cells similar to the reactive fibroblasts of primary aneurysmal bone cyst. We feel that aneurysmal bone cyst is a benign non-neoplastic condition that can develop in bone as a primary bone lesion; it may also be associated with a pre-neoplastic condition that can develop in bone as a primary bone lesion; it may also be associated with a pre-existing bone condition, and occasionally develops following trauma with subperiosteal hematoma.

Angiography in giant-cell tumours of bone.

The angiographic appearance of 9 cases of genuine giant-cell tumour of bone, 6 cases of aneurysmal bone cyst and one case of non-ossifying fibroma is described. Differential diagnosis would appear to be possible to a certain extent. The non-ossifying fibroma was poorly vascularized. The genuine giant-cell tumours were hypervascularized as well as some of the aneurysmal bone cysts making a differential diagnosis in these cases impossible. On the other hand, a poorly vascularized tumour devoid of soft tissue component and arteriovenous fistulas is probably an aneurysmal bone cyst. A hypervascular soft tissue component is of great prognostic value in cases of geniune giant-cell tumour.

[Intraosseous angiography in the elucidation of the pathogenesis of juvenile bone cysts (author's transl)]. / Beitrag der intraossären Angiographie zur Atiopathogenese der iuvenilen Knochenzyste

The results of intraosseous angiography in juvenile bone cysts suggest that their development is related to an anomaly of early metaphyseal vessels, although it is not established whether one is dealing with a primary ectasia or arteriovenous anastomoses. Juvenile bone cysts therefore belong to the category of congenital diseases. Intraosseous angiography also helps in distinguishing osteolytic processes from fibromas, myxomas, chondromas and osteoblastomas. None of the above-mentioned tumours consists of communicating chambers, such as have been demonstrated in cysts. The treatment consists of complete currettage followed by spongiosa tamponade.