Abstract
Background
Small case series suggest that preoperative transcatheter arterial embolization minimizes bleeding and facilitates surgery for hypervascular metastatic bone tumors. However, control groups would make our confidence in clinical recommendations stronger, but small patient numbers make prospective trials difficult to conduct on this topic.
Questions/purposes
In this case-control study, we asked whether (1) patients who undergo embolization have less estimated blood loss and/or shorter operative time than patients who do not have embolization; (2) larger tumor size, greater initial tumor vascularity, and longer interval from embolization to surgery are associated with greater estimated blood loss and packed red blood cell transfusion volume; and (3) embolization does not affect renal function in patients with normal preoperative renal function.
Methods
We retrospectively reviewed records of patients with hypervascular bone metastases treated at our institution between 1998 and 2008. Twenty-seven patients with renal cell carcinoma and 12 with thyroid carcinoma who underwent embolization before 41 surgical procedures were matched to 41 patients who did not have embolization with respect to age, diagnosis, tumor size and potential vascularity, and procedure type; matching was performed without knowledge of outcomes. In univariate and multivariate analyses, age, tumor size, use of embolization, surgery type and risk, embolization-to-surgery interval, and degree of devascularization were evaluated for correlations with estimated blood loss, packed red blood cell transfusion volume, operative time, and postembolization renal function.
Results
Overall, patients who had embolization had less mean estimated blood loss (0.90 versus 1.77 L; p = 0.002), packed red blood cell transfusion volume (2.15 versus 3.56 U; p = 0.020), and operative time (3.13 versus 3.91 hours; p < 0.001). Larger tumor size correlated with greater estimated blood loss (r = 0.451; p = 0.003), packed red blood cell transfusion volume (r = 0.50; p = 0.002), and operative time (r = 0.595; p < 0.001). Neither the interval for embolization to surgery nor the degree of devascularization correlated with estimated blood loss or transfusion volume. In open rodding with intralesional curettage, transcatheter arterial embolization was associated with reduced estimated blood loss, transfusion volume, and operative time. Packed red blood cell transfusion volume was not reduced by embolization in intramedullary nailing procedures with the patient numbers available. Among patients with normal preoperative renal function who had embolization, creatinine levels remained normal. Mild transient, reversible renal function change occurred in one patient with preoperatively abnormal renal function.
Conclusions
This study suggests that preoperative embolization probably reduces estimated blood loss, particularly for large tumors and during open femoral procedures.
Level of Evidence
Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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Acknowledgments
We thank Jesse Galle BA, CCRP (Department of Surgery, Memorial Sloan Kettering Cancer Center) for performing patient matching of cases and control subjects and for technical assistance in orthopaedic surgery patient database management.
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The institution of one of the authors (JHH) has received, during the study period, funding from the Rosalind Pearlman Research Fund at Memorial Sloan Kettering Cancer Center (charitable foundation) (New York, NY, USA).
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
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Each author certifies that his or her institution approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.
This work was performed at Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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Pazionis, T.J.C., Papanastassiou, I.D., Maybody, M. et al. Embolization of Hypervascular Bone Metastases Reduces Intraoperative Blood Loss: A Case-control Study. Clin Orthop Relat Res 472, 3179–3187 (2014). https://doi.org/10.1007/s11999-014-3734-3
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DOI: https://doi.org/10.1007/s11999-014-3734-3