Case Report

Submitted by: Asher Philip MSIV, Alda Tam M.D.

Faculty reviewer: Sandra Oldham M.D.

Date accepted: 28 September 2011

Radiological Category: Principal Modality (1):

Principal Modality (2):

This presentation is part of a case report submitted for publication in the Journal of Vascular and Interventional Radiology, September 2011.

Interventional Radiology MRI

CT

Case History

HPI:

• 75 yo male presenting with worsening right groin pain• Pain became progressively worse and eventually excruciating • Radiated from his buttock to the right groin, quadriceps, hamstring, calf and bottom of

his feet, with associated numbness and tingling• Pt used NSAIDs, gabapentin, local lidocaine patches over the course of several

months, but none of these relieved his pain

Case History

Past Medical History:

1. Hypertension

2. Myocardial infarction (1992)

3. Hypothyroidism

Past Surgical History:

1. Coronary artery bypass graft

2. Cardiac stent placement in 2005

3. Tonsillectomy

Social History:• Denies alcohol or tobacco use

Allergies: • Plavix ,unable to take statins

Family History:• Three healthy children; no relevant

history

Review of Systems:• General: Denies fever, chills• Cardiac: Denies chest pain or

palpitations• Respiratory: Denies dyspnea or

orthopnea• GI: Denies nausea and vomiting• Musculoskeletal: Reports pain in the

right leg and buttock and currently reports minimal weight bearing

T1 Transverse Section

T1 Coronal Section

CT Pelvis with Contrast

CT Pelvis with Contrast

• Metastatic disease

• Osteosarcoma

• Chondrosarcoma

• Abscess

• Osteomyelitis

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Radiological Presentations

CT of the Chest With IV Contrast, 06/18/2009

CT Pelvis w/o contrast, 06/18/2009

CT Pelvis with contrast, 06/18/2009

Bone Scan 06/17/2009

CT Chest: Numerous pulmonary nodules are identified throughout both lungs that are too numerous to count, almost all of which are subcentimeter but the largest of which measure up to 9 mm; prominent mediastinal lymphadenopathy

CT Pelvis: 1. 8.3 x 7.9 x 4.8 cm hypervascular, enhancing, heterogeneous mass with calcifications is seen in the right kidney associated with stranding of the peri-nephretic fat, thickening of the peri-renal fascia

2. 7 x 2 x 4.3 cm hypervascular soft tissue mass is seen in the right iliac bone which is expansile, destructive of the cortex on both sides, and extends to the acetabulum and its cortex. There is involvement and invasion of the adjacent right iliacus and right gluteus minimus muscles

Bone Scan: increased tracer uptake through the right acetabulum; expansile destructive osseous metastatic lesion, which is infiltrating posteriorly into the right ilium and also into the right anterior iliac crest; no evidence of additional osseous metastases

MRI: lytic lesion in the right iliac wing extending into the roof of the acetabulum

Findings and Differentials

• Metastatic cancer to the bone:

• breast

• lung

• prostate

• kidney

• bladder

• thyroid

• Osteosarcoma

• Chondrosarcoma

Differentials:

Findings and Differentials

Differential for Renal Mass:• Simple cyst

–Most common renal mass; present in up to 50% of the population over the age of 50– sharply demarcated from adjacent parenchyma– homogenous in appearance– rounded with imperceptible walls–does not enhance with contrast

•Solid Masses–Angiomyolipoma: Associated with tuberous sclerosis; macroscopic fat by CT; predisposed to hemorrhage–Oncocytoma: originates from the epithelium of the distal tubules or collecting ducts; characteristic central stellate scar

•Renal Cell Carcinoma–Most common primary renal malignancy– Originates from the epithelium of the proximal tubule–Peak incidence in adults in their 50s; male predominance–Classic triad of flank pain, a flank mass, and hematuria (<10% of cases)–By CT, they tend to be rounded soft-tissue masses, enhancing after IV contrast– Often homogenous when small; more heterogeneous when larger, frequently with necrosis and often with calcifications (up to 30%)–Propensity to spread into the renal veins and beyond

Discussion

Treatment:•Patient was treated with EBR and pain medications, but continued to complain of severe right extremity discomfort.• Decision made to pursue cryoablation.

Percutaneous Cryoablation:• Useful tool in the palliative treatment of musculoskelatal metastases• Accomplished by inserting cryoprobes into malignant tissue under imaging guidance•Rapid cooling of the cryoprobes through the Joule-Thompson effect (i.e. adiabatic gas expansion changes the temperature of the gas inside the probes)•Freezing and thawing phases•Leads to the removal of heat from the tissue, cellular injury by the formation of ice crystals and creation of unfavorable microenvironment

Discussion

Freezing phase 1 @ 1min, cryoablation

Freezing phase 1 @ 10 mins, cryoablation

Thawing phase 1, cryoablation

Freezing phase 2 @ 1 min, cryoablation

Freezing phase 2 @ 10mins, cryoablation

Thawing phase 2, cryoablation

CT-guided cementoplasty of right acetabulum with injection of 9 mL of polymethylmethacrylate.

Metastatic Renal Cell Carcinoma to the Rt Iliac Wing treated with Cryoablation and Cementoplasty

Diagnosis

Complications

Pt experienced isolated dysfunction of the right hip flexor w/o sensory deficit

Tx with 24 hr course of steroids- resolved

 1. Nazario J, Tam AL. Ablation of Bone Metastases. Surg Oncol Clin N Am 2010; 20:355-68.2. Erinjeri JP, Clark TW. Cryoablation: Mechanism of Action and Devices. J Vasc Interv Radiol 2010; 21:187-191.3. Nazario J, Hernandez J, Tam AL. Thermal Ablation of Painful Bone Metastases. Tech Vasc Interv Radiol 2011; 143:150-159.4. Thacker PG, Callstrom MR, Curry TB et al. Palliation of painful metastatic disease involving bone with imaging-guided treatment: comparison of patients' immediate response to radiofrequency ablation and cryoablation. AJR Am J Roentgenol 2011;197:510-515. 5. Ullrick SR, Hebert JJ, Davis KW. Cryoablation in the musculoskeletal system. Curr Probl Diagn Radiol 2008; 37:39-48.6. Gash JR, Noe J. Chapter 9. Radiology of the Urinary Tract. In: Chen MY, Pope TL, Ott DJ, eds. Basic Radiology. 2nd ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=6670552. Accessed September 27, 2011.

References