Use of Intra-Arterial Chemotherapy and Embolization Before Limb Salvage Surgery for Osteosarcoma of the Lower Extremity

Abstract

We report our experience with the use of intra-arterial chemotherapy and embolization before limb salvage surgery in patients with osteosarcoma of the lower extremity. We evaluated the effect of this procedure on the degree of tumor necrosis and on the amount of blood loss during surgery. We reviewed the medical records of all patients who received intra-arterial chemotherapy and embolization before undergoing limb salvage surgery for osteosarcoma of the lower extremity at our institution between January 2003 and April 2008. Patient demographic, tumor characteristics, treatment details, postembolization complications, and surgical and pathological findings were recorded for each patient. We evaluated the operative time, estimated blood loss (EBL), and volume of blood transfusion during surgery and in the postoperative period in all patients in the study group. The same parameters were recorded for 65 other patients with lower extremity osteosarcoma who underwent limb salvage operation at our institution without undergoing preoperative intervention. The study included 47 patients (25 males and 22 females). Angiography showed that the tumors were hypervascular. Intra-arterial chemotherapy and embolization were performed successfully, resulting in a substantial reduction or complete disappearance of tumor stain in all patients. No major complications were encountered. At the time of surgery, performed 3-7 days after embolization, a fibrous edematous band around the tumor was observed in 43 of the 47 patients, facilitating surgery. The goal of limb salvage was achieved successfully in all cases. Percentage tumor necrosis induced by treatment ranged from 70.2% to 94.2% (average, 82.9%). EBL during surgery, EBL from drains in the postoperative period, total EBL, and transfusion volumes were significantly lower in the 47 study patients compared to the 65 patients who underwent surgery without preoperative treatment with intra-arterial chemotherapy and embolization. The mean operative time was also significantly less in the intervention group compared to the nonintervention group (73.2 vs. 88.5 min; p < 0.05). In conclusion, intra-arterial chemotherapy and embolization performed 3 to 7 days before limb salvage surgery in patients with lower extremity osteosarcomas can cause substantial tumor necrosis, reduce the EBL and transfusion requirements during surgery, and induce formation of a false capsule around the tumor, thus facilitating surgical excision of the tumors.

Preoperative embolization of primary bone tumors: A case control study

“…In another study done by Kobayashi et al [27] on spinal tumors; the requirement of intraoperative blood transfusion volume was noted in the range of 028 units with mean of 7 units. In study done by Zhang et al [32] , the volume of blood infusion was noted to be 689 ± 133.89 mL. The intraoperative blood transfusion in our study group was comparable to study done by Zhang et al [32] , while lower than the study done by Thiex et al [29] and Kobayashi et al [27] .…”

“…In study done by Zhang et al [32] , the volume of blood infusion was noted to be 689 ± 133.89 mL. The intraoperative blood transfusion in our study group was comparable to study done by Zhang et al [32] , while lower than the study done by Thiex et al [29] and Kobayashi et al [27] . In our study, mean requirement of intraoperative blood transfusion was 700 mL (range 01400 mL).…”

“…In another study done by Kobayashi et al [27] , the blood loss was found to be in the range of 25011000 mL with a mean of 2554 mL. In a study done by Zhang et al [32] , the blood loss was in the range of 60580 mL with a mean blood loss of 290 mL. The lower blood loss in this study can be attributed to the fact that this study was done on osteosarcomas which is not very vascular tumor except for the telengiactatic form.…”

“…18 Retrospective EBL = 1100-2600 mL MBL = 1400 mL BT = 0-8 units Kobayashi et al [27] 2012 62 Retrospective EBL = 250-11000 mL MBL = 2554 mL BT = 0-28 units Al-Hadithy et al [20] 2011 26 Retrospective EBL = 100-1800 mL BT = 0-3 units Zhang et al [32] 2009 47 Retrospective EBL = 705 ± 120 mL BT = 689 ± 133 mL Lee et al [13] 2008 6 Prospective EBL = 200-830 mL BT = Nil Our study 2012-2013 26 (study group) Case control study For study group EBL = 250-2900 mL BT = 0-1400 mL 28 (control group)…”

Imaging Osteosarcoma

“…Cullen JW et al evaluated serial arteriography to evaluate tumor response, predict necrosis, and titrate the duration of combined intravenous and intra-arterial neoadjuvant chemotherapy in patients with histologically proven high-grade OS or malignant fibrohistiocytoma of bone. Serial arteriography was highly sensitive and accurately predicted good responses and individualized and modified, dose-intensified neoadjuvant protocol with an excellent histologic response rate with minimal complications (Figure 32) [79]. Imaging remains the corner stone of diagnosis, treatment and predicting prognosis in OSs.…”