Osteoid Osteoma: Contemporary Management

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2018

Osteoid osteoma: Contemporary management

Shahryar Noordin Aga Khan University, [email protected]

Salim Allana Emory University

Kiran Hilal Aga Khan University, [email protected]

Riaz Hussain Lukhadwala Aga Khan University, [email protected]

Anum Sadruddin Pidani Aga Khan University, [email protected]

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Recommended Citation Noordin, S., Allana, S., Hilal, K., Lukhadwala, R. H., Pidani, A. S., Ud Din, N. (2018). Osteoid osteoma: Contemporary management. Orthopedic Reviews, 10(3), 108-119. Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_orthop/92 Authors Shahryar Noordin, Salim Allana, Kiran Hilal, Riaz Hussain Lukhadwala, Anum Sadruddin Pidani, and Nasir Ud Din

This article is available at eCommons@AKU: https://ecommons.aku.edu/pakistan_fhs_mc_surg_orthop/92 Orthopedic Reviews 2018; volume 10:7496

Osteoid osteoma: Contemporary management Epidemiology Correspondence: Shahryar Noordin, Orthopaedic Surgery, Aga Khan University, Osteoid osteoma accounts for around Karachi, Pakistan. Shahryar Noordin,1 Salim Allana,2 5% of all bone tumors and 11% of benign Tel.: 021.3486.4384. 4 Kiran Hilal,3 Naila Nadeem,3 bone tumors. Osteoid osteoma is the third E-mail: [email protected] Riaz Lakdawala,1 Anum Sadruddin,4 most common biopsy analyzed benign bone 5 tumor after osteochondroma and nonossify- Key words: Osteoid osteoma; tumor; benign; Nasir Uddin imaging; pathogenesis; management. 1 ing fibroma. Two to 3% of excised primary Orthopaedic Surgery, Aga Khan bone tumors are osteoid osteomas.5 Males University, Karachi, Pakistan; Contributions: SN, SA, study design, data col- are more commonly affected with an lection, manuscript writing; KH, NU, data col- 2 5 Department of Epidemiology, Rollins approximate male/female ratio of 2 to 1. lection, manuscript writing; NN, RL, AS, School of Public Health, Emory Adolescents and young adults are usually study design, manuscript writing. University, Atlanta, GA, USA; affected in the second decade of life, with 3Department of Radiology, Aga Khan most patients being under the age of 20 Conflict of interest: the authors declare no University, Karachi, Pakistan; years. It is less likely to be seen in patients conflicts of interests. 4Department of Surgery, Aga Khan under 5 years of age or in adults greater than 4 Received for publication: 15 November 2017. University, Karachi, Pakistan; 40 years. Revision received: 6 March 20018. 5Department of Pathology and Accepted for publication: 18 March 2018. Laboratory Medicine, Aga Khan University, Karachi, Pakistan This work is licensed under a Creative Localisation Commons Attribution NonCommercial 4.0 License (CC BY-NC 4.0). Osteoid osteoma occurs predominantly ©Copyright S. Noordin et al., 2018 Abstract in the appendicular skeleton. Spine is involved in one tenth of the cases.6 Flat Licensee PAGEPress, Italy Orthopedic Reviews 2018;10:7496 Osteoid osteoma is a benign bone-form- bones with intramembraneous formation in doi:10.4081/or.2018.7496 ing tumor with hallmark of tumor cells direct- the body and skull are rarely affected. The ly forming mature bone. Osteoid osteoma lower extremity is more commonly affected accounts for around 5% of all bone tumors than the upper extremity as shown in Figure and 11% of benign bone tumors with a male 1. Commonly long bones particularly the predilection. It occurs predominantly in long femur and tibia are involved, followed far increasingly severe at night and usually bones of the appendicular skeleton. behind by bones of the feet, with a predilec- responds to salicyclates and non-steroidal According to Musculoskeletal Tumor Society tion for the talar neck. Common sites of anti-inflammatory medications. If osteoid staging system for benign tumors, osteoid femoral involvement are the juxta- or intra- osteoma involves a bone in a subcutaneous osteoma is a stage-2 lesion. It is classified articular regions of the femoral neck. In the location, then the patient usually presents based on location as cortical, cancellous, or upper extremity, phalanges of the hand are with swelling, erythema and tenderness. subperiosteal. Nocturnal pain is the most commonly affected.4 If the proximal femur or pelvis is common symptom that usually responds to involved, the patient can present with salicyclates and non-steroidal anti-inflamma- referred pain in the knee. Lesions that are tory medications. CT is the modality of within the joint or juxta-articular can pres- choice not only for diagnosis but also for Classification ent with synovitis. If this continues to specifying location of the lesion, i.e. cortical progress, the patient can present with joint vs sub periosteal or medullary. Non-operative In long bones, osteoid osteoma is more pain, flexion contracture, decreased range treatment can be considered as an option often situated in the cortico-diaphyseal or of motion, and a limp or antalgic gait. since the natural history of osteoid osteoma is metaphyseal regions, but other localizations Sometimes in children, a limp may be the that of spontaneous healing. Surgical treat- such as intramedullary, subperiosteal, epi- only presenting symptom. If the lesion ment is an option for patients with severe pain physeal or apophyseal have also been involves the open physis, it can result in and those not responding to NSAIDs. noted.6 It is very rare to have two osteoid limb length discrepancy with potential Available surgical procedures include osteomas in the same patient.4 coronal and/or sagittal malalignment. radiofrequency (RF) ablation, CT-guided per- According to Musculoskeletal Tumor Referred pain and muscle atrophy can cutaneous excision and en bloc resection. Society staging system for benign tumors, result in misdiagnosis of a neurological dis- osteoid osteoma is a stage-2 lesion. It is order commonly seen in axial skeleton classified as cortical, cancellous, or subpe- involvement with postural scoliosis due to riosteal. Cortical lesions are most common.4 paravertebral muscle spasm, which is Introduction reversible after treatment.7 Osteoid osteoma is a benign bone-forming tumor with hallmark of tumor cells 1 Clinical presentation directly forming mature bone. These are Pathogenesis small, distinctive, nonprogressive, benign Pain is the most common symptom. osteoblastic lesions. Bergstrand first Usually it is a dull ache, which is unremit- The exact pathogenesis of osteoid described osteoid osteoma in 1930 and Jaffe ting and starts off as mild and intermittent osteoma remains unknown. High levels of in 1935 characterized it as a benign that gradually increases in intensity and per- prostaglandin E2 and prostacyclin have osteoblastic tumor.2,3 sistence. The pain has a tendency to become been found within the nidus that is believed

[page 108] [Orthopedic Reviews 2018; 10:7496] Review to cause local inflammation and vasodilata- fresh, and brown to granular after formalin ally thin and short, but can be sclerotic and tion. A study by Mungo et al.8 revealed fixation. They are well demarcated from the broad and are rimmed by a single layer of increased levels of cyclooxygenase-2 surrounding white sclerotic cortical bone. osteoblasts. Scattered osteoclasts are also expression in nidus osteoblasts. The nidus color is related to vascularity of present on the surface of bony trabeculae Cyclooxygenase-2 inhibition is believed to intertrabecular areas. As osteoid osteomas (Figure 2). The osteoblasts are plump, uni- be a mechanism by which NSAIDs provide are now treated by radiofrequency ablation, form in size and shape and have eccentric symptomatic relief in osteoid osteomas. such intact specimens as described above nuclei with small nucleoli and open chro- 12 These inflammatory mediators may also are rarely received for histopathology. matin. Cytoplasm is usually amphophilic. contribute to perilesional sclerosis exhibited No nuclear pleomorphism or increased by most osteoid osteomas. In addition, high mitotic activity is seen. The intertrabecular concentrations of intralesional unmyelinat- stroma is loose and fibrovascular (Figure 3). ed nerve fibers have been implicated in the Microscopic features The reactive bone surrounding the nidus is pathogenesis of the exquisite nocturnal dense cortical or trabecular bone and when Histologically, the nidus is well circum- pain. These processes probably function in the tumor grows closer to the bone surface, scribed and composed of haphazardly inter- it becomes more pronounced. In medullary parallel to produce the characteristic 13 9,10 anastomosing trabeculae of variably miner- lesions, it is less pronounced. inflammatory symptoms. alized woven bone. The trabeculae are usu- Historically, there has been debate over The pathologic evaluation of osteoid the years about the precise nature of osteoid osteomas. Initially considered a neoplasm by Jaffe, other investigators proposed a reactive or reparative process citing its limited growth potential and its ability to spon- taneously regress in some cases.2 Currently, most pathologists agree about the neoplastic nature of osteoid osteomas. The tumour’s histological similarity to osteoblastoma supports the belief that it is a benign tumour derived from the osteoblasts. There have been few cytogenetic studies that reported clonal cytogenetic abnormalities, including alterations involving chromosome 22q, a region which contains genes involved in cell proliferation that is commonly affected in a variety of other neoplasms.11

Gross features When removed intact, osteoid osteomas are usually small, and round to oval in Figure 1. Pictorial representation of osteoid osteoma. shape. The cut surface is red to pink when

Figure 2. Histology of osteoid osteoma. The nidus is composed Figure 3. The bony trabeculae can be thin as seen in this image. of densely broad sclerotic bone trabecuale show osteoblastic rim- ming and fibrovascular connective tissue.

[Orthopedic Reviews 2018; 10:7496] [page 109] Review osteoma has been affected by the increasing cal features, imaging techniques such as CT, lesion is seen in these cases.6,21 A study done use of radiofrequency ablation (RFA) or bone and SPECT scans can assist in diag- by PARK et al showed 28.6% of osteoid other minimally invasive techniques. The nosing the lesion. osteoma cases in their study had no plain techniques now used include core biopsy or radiography abnormality despite very typi- biopsy obtained from a drill procedure. As cal clinical presentations. Radionuclide compared to specimens received by tradi- imaging was used to diagnose these cases. tional surgery, the yield of diagnostic tissue Imaging findings Therefore in cases where plain radiographs is lower and tissue findings are often are not conclusive but clinical suspicion is obscured by heat or crushing artifacts. high, further imaging workup should be Plain radiography 22 Consequently, pathologists may or may not Osteoid osteoma appears as an oval requested. be able to confirm the diagnosis on smaller, lytic lesion located within dense cortical CT usually fragmented, and frequently distort- bone in the diaphysis surrounded by ed fragments of tissue.14 CT is the modality of choice for diagno- fusiform cortical bone thickening and scle- sis and specifying location of lesion, i.e. rosis. The cortical based lucency is less than cortical vs sub periosteal or medullary. CT 20 2 cm. Underlying lytic nidus may not shows well-defined nidus as round or oval always be visualized due to significant scle- with low attenuation (Figure 5). Nidus can Immunohistochemical features rosis. The sclerotic reactive bone often is show mineralization which may be punc- S100 and neurofilament show nerve fibers seen distant from the lesion, in extra capsu- tate, amorphous or ring like. Surrounding involving tumor.15 Osteoid osteomas also lar location. reactive sclerosis can vary from mild scle- show strong nuclear expression for Runx2 and The tumor present at subperiosteal loca- rosis to extensive periosteal reaction and Osterix, which are regulatory transcription fac- tion is a rounded sclerotic focus that ele- new bone formation, which may obscure 6 tors. This suggests that osteoid osteomas share vates the periosteum with limited sclerotic the nidus. common genetic pathways with normal skele- reaction. In intramedullary location, these For cases where nonoperative manage- tal development.16 tumors are well-circumscribed with a com- ment is chosen as the treatment strategy, plete or partially calcified nidus. The sur- mineralization of the nidus is considered as rounding reactive sclerosis can be minimal a marker of age of the lesion. The mineral- or absent (Figure 4A). In posterior elements ization ratio of osteoid osteoma increases of the spine, osteoid osteomas are difficult Differential diagnosis significantly with pain duration. Touraine et to localize. The nidus is not visualized on al. showed that nidus mineralization ratio of Osteoid osteoma can be distinguished plain films but additional findings such as osteoid osteoma is positively related to pain from other bone forming tumors based on scoliosis with concavity at the side of the the difference in size, location, pathology, and clinical symptoms.17 A small Brodie abscess with a radiolucent center and surrounding reactive sclerosis can mimic osteoid osteoma. With intracortical Brodie abscess the sequestrum is irregular in shape and the inner margin of the lucency is not smooth, whereas in osteoid osteoma, the inner margins are usually smooth.18,19 Tumors can also mimic osteoid osteomas. Chondroblastomas in epiphyseal locations of children with osteolytic lesions and extensive bone marrow edema and periosteal reaction can resemble osteoid osteoma. However the epiphyseal and intramedullary location is more characteristic for chondroblastomas, whereas osteoid osteomas are usually diaphyseal and intracortical. In the pediatric age group cortical lesions in the tibia caused by osteofibrous dysplasia, adamantinoma and stress fractures produce cortical thickening and proliferation that can be mistaken for osteoid osteomas. In stress fractures, the reactive woven bone network is well oriented around trabeculae of fractured bone. It is not haphazard and lacks the small irregular Figure 4. A 10 years old boy with humeral osteoid osteoma. A) AP radiograph shows trabeculae seen in osteoid osteomas. Other radiolucent nidus arrow and surrounding sclerosis. B) Coronal STIR image shows lesions such as nonossifying fibromas, hypointense lesion long arrow (nidus) and perilesional edema (small arrow). C) Axial T1-weighted and corresponding post contrast T1-weighted Fat sat images show enchondromas, eosinophilic granulomas, hypointense nidus on pre contrast image with intense enhancement on pot contrast Perthes disease, tuberculosis, neuromuscu- images (long arrow). D) Technetium-99 bone scan, AP projection shows focal region of lar conditions and malignant bone tumors radiotracer uptake, corresponding to tumor nidus (Arrow). can also be considered. In addition to clini-

[page 110] [Orthopedic Reviews 2018; 10:7496] Review duration and may be a marker of tumor age to detecta case of osteoid osteoma. This abnormality on plain roentgenograms is (P=0.007, hazard ratio=0.193). They how- uptake was likely because of osteoblastic reported, MRI is done to investigate the ever reported no association of nidus size activity in osteoid osteoma but needs fur- underlying cause. MRI is more sensitive with pain duration (P=0.092). In their study, ther evaluation to investigate its specific than CT scan for detection of reactive diaphyseal osteoid osteomas displayed a role and accuracy in diagnosis of osteoid changes in soft tissue and surrounding bone lower ratio of nidus mineralization as com- osteoma.34,35 edema. Klontzas et al. reported that the pared to those in epiphyseal and metaphy- half-moon sign of bone marrow edema was seal locations.23 MRI associated with the presence of osteoid Dynamic contrast-enhanced CT helps in MRI is more sensitive than CT scan for osteoma in femoral neck. The half-moon differentiating osteoid osteoma from bone detection of reactive changes in soft tissue. sign is highly specific and sensitive for cysts and chronic osteomyelitis, specifically MRI is a reliable method of visualizing the presence of osteoid osteoma in the femoral Brodie abscess which are avascular. In these nidus. The MRI appearance of nidus neck with 94.7% specificity and 100% sen- cases the tumor nidus shows rapid early depends on its location in the cortex. The sitivity and positive and negative predictive closer the lesion is to the medullary zone, arterial enhancement and appears hypervas- values of 91.7% and 100%, respectively 24-26 the greater the role of MRI in recognizing cular. (D). But some authors have questioned this the nidus compared to CT scan. However, Spinal osteoid osteoma is better charac- high specificity as the half-moon sign of compared to MRI, CT scan is more specific terized by CT. The nidus is visible as low- bone marrow edema in femoral neck can be for identifying a nidus.36,37 The appearance density area in posterior elements. seen in intermediate-grade stress fractures of nidus on MRI is variable depending on Surrounding sclerosis of the ipsilateral of the femoral neck on MRI. It has therefore mineralization and its vascularity. Nidus on pedicle, lamina, or transverse process may been recommended that if clinical features MR T1 weighted sequence appears as round be present. are suggestive of osteoid osteoma, then CT lesion, slightly hyper intense to intermedi- should be performed to determine the pres- Bone scintigraphy ate signals to adjacent muscle and hyper ence of a potentially occult nidus on MRI.35 Technetium-99-labeled bone scintigra- intense to heterogeneous signals on T2 phy has high sensitivity for confirming weighted and STIR sequences (Figure 4B Pitfall of imaging diagnosis of osteoid osteoma. The sensitivi- and C). Nidus can be hypointense in all The diagnosis of osteoid osteoma on ty of skeletal scintigraphy for detection is sequences, depending on vascularity and imaging can be challenging in cases where 100%.27 On bone scan characteristic feature mineralization. Tumor enhancement is vari- there are severe associated inflammatory is very intense, round activity at nidus sur- able, can be diffuse or heterogeneous changes such as a prominent periosteal rounded by less intensity of reactive bone. (Figure 4C). The surrounding osteosclerosis reaction, exaggerated synovial hypertrophy, This is known as double density sign.28 The appears as low signal on both T1- and T2- joint effusion, extensive bone marrow and 38,39 increased intensity of nidus is because of weighted sequences. There is high soft tissue edema. In cases of significant increased bone turn over. The less intense potential of misdiagnosing osteoid osteoma associated periosteal reaction and soft tissue peripheral radiotracer uptake, represents the as neoplastic lesion or oversight it when edema in a young patient, the differential host bone tumor response (Figure 4) The other modalities are not used for diagnosis. diagnoses of osteomyelitis or malignant sign is infrequently seen with spinal osteoid Small lesions may be hard to isolate on MRI bone tumor, such as Ewing sarcoma have to osteoma because of less peripheral sclerosis as nidus signal is frequently similar to that be considered. A small nidus obscured by 38 in vertebral bodies.29 A study done by of surrounding cortex. Although CT is the extensive bone marrow and soft-tissue PARK et al found out that all the patients in modality of choice in diagnosis of osteoid edema needs to be differentiated from trau- their study with or without conclusive osteoma, but in patients with atypical clini- matic injury or infection. For accurate and appearance on plain radiography, were cor- cal presentations, in whom the pain does not correct radiological diagnosis it is mandato- rectly identified on bone scintigraphy. They respond to NSAIDs and where no obvious ry to identify the nidus. recommended that if the radionuclide imaging is positive, CT scans should be next imaging modality for further evaluation but in cases where radionuclide imaging is negative, MRI should be done for the diagnosis of other underlying bone pathologies.22 PET PET may have role in initial diagnosis and post treatment follow-up. A study previ- ously reported that tumor nidus exhibits 18FFDG-avid glucose metabolism, whereas the surrounding sclerosis does not. In follow up cases of radiofrequency ablation (RFA), hypermetabolic activity is absent. Some authors suggested role of PET specifically in cases of spinal osteoid osteoma. But this modality requires more research work to be done to prove its utility in diagnosis and follow up.30-33 In addition to FDGPET/CT, 68Ga- PSMA PET/CT, which is used in prostate Figure 5. A 14 years old boy osteoid osteoma of right femur. A) axial and B) coronal CT images show hypoattenuating nidus with surrounding sclerosis. cancer staging and restaging, has been used

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morbidity of open procedures, several per- bone-producing tumor. Nonoperative treat- Treatment cutaneous techniques using CT guidance ment with NSAIDs is an appropriate option have been used. These include trephine for pain control. Surgical options should be excision, cryoablation, radiofrequency abla- considered when conservative treatment Non-operative 47-51 Non-operative treatment can be consid- tion and laser thermocoagulation. Fine fails or is not indicated for or not opted for ered as an option since the natural history of drills, bone trephine, Tru-Cut needles, and by the patient. Minimally invasive methods cannulated curettes have been used with including CT-guided excision and RF abla- osteoid osteoma is that of spontaneous heal- 40 40 41 percutaneous CT guided techniques per- tion have shown promise with highly suc- ing. Moberg and Golding reported res- formed in the outpatient setting. Using per- cessful outcomes. olution of symptoms with conservative cutaneous CT guided resection, Sans and management in osteoid osteoma within 6 to colleagues52 showed a cure rate of 84% at 15 years. Use of aspirin or other nons- 3.7 years with two complications of femoral teroidal anti-inflammatory medications References fractures at 2 months. For osteoid osteomas (NSAIDs) decreases this time to 2 to 3 of the hip Muscolo and colleagues53 showed 1. Greenspan A. Benign bone-forming years.42,43 Use of this nonoperative treat- superior results of percutaneous resection lesions: osteoma, osteoid osteoma, and ment option risks the potential side effects guided by CT. osteoblastoma. Skelet Radiol of protracted NSAID treatment. In anatom- Roqueplan and colleagues54 reported 1993;22:485-500. ical areas where osteoid osteoma is not eas- percutaneous CT guided trephine resection 2. Jaffe HL. Osteoid-osteoma: a benign ily accessible surgically, this may be a success rate of 95% at 2 years. Two patients osteoblastic tumor composed of viable treatment option. However caution got skin burns and one had meralgia. The osteoid and atypical bone. Archiv Surg should be exercised with this option, as same authors reported 94% success rate 1935;31:709-28. there are some reports that these tumors with interstitial laser ablation at 2 years and 3. Lee EH, Shafi M, Hui JH. Osteoid progress to osteoblastoma with prolonged complications of infection, tendonitis, osteoma: a current review. J Pediatr NSAID treatment.44 hematoma, and common peroneal nerve Orthop 2006;26:695-700. Surgical management injury. 4. Kitsoulis P, Mantellos G, Vlychou M. Osteoid osteoma. Acta Orthop Belg Surgical treatment is an option for Percutaneous thermocoagulation of 2006;72:119-25. patients with severe pain and those not osteoid osteoma was reported by de Berg 55 5. Ward WG, Eckardt JJ, Shayestehfar S, responding to NSAIDs. This option should and colleagues successfully in 17 patients. 56 et al. Osteoid osteoma diagnosis and also be considered for those patients not Hoffman et al. reported 5-year results of management with low morbidity. Clin willing to tolerate pain and those at particu- radiofrequency ablation with confirmed Orthop Relat Res 1993;291:229-35. lar risk of long-term renal and gastrointesti- cure in 38 of 39 patients. Complications in 6. Ghanem I. The management of osteoid nal complications of NSAIDs. Moreover in this series included one broken drill and one 57 osteoma: updates and controversies. children with open physes, continued pres- case of infection. Papathanassiou et al. in Curr Opin Pediatr 2006;18:36-41. ence of these tumors can lead to growth dis- their series of 21 patients over 5 years 7. Boscainos PJ, Cousins GR, turbances like limb length discrepancies, reported a primary cure rate of 89.6% that Kulshreshtha R, et al. Osteoid osteo- scoliosis and osteoarthritis.45 Available pro- increased to 93% if a second treatment was 58 ma. Orthopedics 2013;36:792-800. cedures include CT-guided radiofrequency required. Rosenthal and colleagues report- 8. Mungo DV, Zhang X, O’Keefe RJ, et (RF) ablation, en bloc resection, and CT- ed their results of CT guided RF ablation in al. COX1 and COX2 expression in guided percutaneous excision. 263 patients. A total of 271 procedures were performed of which 249 were for initial osteoid osteomas. J Orthop Res En bloc resection tumor treatment, 14 for recurrence after 2002;20:159-62. For symptomatic relief, the entire nidus open excision, and 8 for recurrence after 9. Hasegawa T, Hirose T, Sakamoto R, et has to be excised. Complete removal of the prior RF ablation. They reported 2 minor al. Mechanism of pain in osteoid osteo- sclerotic reactive bone however, is not complications and recommended RF abla- mas: an immunohistochemical study. required. Preoperative roentgenograms and tion as the treatment of choice with 91% Histopathology 1993;22:487-91. CT scans delineate the location of the nidus. clinical success, brief recovery and low 10. Schulman L, Dorfman HD. Nerve This resection has the drawback of an open complication rate. fibers in osteoid osteoma. J Bone Joint surgical approach with excision of sclerotic It is important to note that irrespective Surg Am 1970;52:1351-6. bone leaving behind a bone defect which of the technique used, a biopsy is required 11. Baruffi M, Volpon J, Neto JB, may require bone grafting and internal fixa- to confirm the diagnosis. In order to evalu- Casartelli C. Osteoid osteomas with tion with consequent restrictions on postop- ate complete removal of the nidus, several chromosome alterations involving 22q. erative activities and weight bearing. With techniques have been used which include Cancer Genet Cytogenet this approach, intraoperative localization of roentgenograms, CT scans, and microradi- 2001;124:127-31. the tumor may be challenging leading to ography of specimens. Table l59-118 is a syn- 12. Bhusnurmath S, Hoch B. Benign bone- partial removal and potential recurrence. opsis of the published literature referencing forming tumors: Approach to diagnosis For structurally critical anatomical sites like all case series with more than 15 patients and current understanding of pathogen- the femoral neck, one can consider deroof- listing the treatment and outcomes. esis. Surg Pathol Clin 2012;5:101-16. ing and curettage. For intra-articular loca- 13. Fletcher CD, Unni KK, Mertens F. tions of the tumor, arthroscopic excision is a Pathology and genetics of tumours of possible option.46 soft tissue and bone. Paris: Iarc; 2002. Conclusions 14. Akhlaghpoor S, Ahari AA, Ahmadi CT guided percutaneous techniques SA, et al. Histological evaluation of Over the years, to reduce the surgical Osteoid osteoma is a distinct benign drill fragments obtained during osteoid

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osteoma radiofrequency ablation. and pinhole magnification scintigra- PD, et al. Clinicopathologic features Skelet Radiol 2010;39:451-5. phy. Pediatr Radiol 1996;26:222-5. and treatment of osteoid osteoma and 15. O’Connell JX, Nanthakumar SS, 30. Imperiale A, Moser T, Ben-Sellem D, osteoblastoma in children and adoles- Nielsen GP, Rosenberg AE. Osteoid et al. Osteoblastoma and osteoid osteo- cents. Orthop Clin N Am 1996;27:559- osteoma: the uniquely innervated bone ma: morphofunctional characterization 73. tumor. Modern Pathol 1998;11:175-80. by MRI and dynamic F-18 FDG 46. Atesok KI, Alman BA, Schemitsch 16. Dancer JY, Henry SP, Bondaruk J, et al. PET/CT before and after radiofrequen- EH, et al. Osteoid osteoma and Expression of master regulatory genes cy ablation. Clin Nucl Med osteoblastoma. J Am Acad Orthop Surg controlling skeletal development in 2009;34:184-8. 2011;19:678-89. benign cartilage and bone forming 31. Farid K, El-Deeb G, Vigneron NC. 47. Towbin R, Kaye R, Meza M, et al. tumors. Hum Pathol 2010;41:1788-93. SPECT-CT improves scintigraphic Osteoid osteoma: percutaneous exci- 17. Gitelis S, Schajowicz F. Osteoid osteo- accuracy of osteoid osteoma diagnosis. sion using a CT-guided coaxial tech- ma and osteoblastoma. Orthop Clini N Clin Nucl Med 2010;35:170-1. nique. AJR Am J Roentgenol Am 1989;20:313-25. 32. Banzo I, Hernandez-Allende R, Quirce 1995;164:945-9. 18. Laurence N, Epelman M, Markowitz R, Carril JM. Bone SPECT in an 48. Assoun J, Railhac J, Bonnevialle P, et RI, et al. Osteoid osteomas: a pain in osteoid osteoma of transverse process al. Osteoid osteoma: percutaneous the night diagnosis. Pediatr Radiol of first lumbar vertebra. Clin Nucl Med resection with CT guidance. Radiology 2012;42:1490-501. 2005;30:28-9. 1993;188:541-7. 19. Chai JW, Hong SH, Choi J-Y, et al. 33. Ryan P, Fogelman I. Bone SPECT in 49. Roger B, Bellin M-F, Wioland M, Radiologic Diagnosis of Osteoid osteoid osteoma of the vertebral lami- Grenier P. Osteoid osteoma: CT-guided Osteoma: From Simple to Challenging na. Clin Nucl Med 1994;19:144-5. percutaneous excision confirmed with Findings 1. Radiographics 34. Castello A, Lopci E. Incidental identi- immediate follow-up scintigraphy in 2010;30:737-49. fication of osteoid osteoma by 68Ga- 16 outpatients. Radiology 20. Davies AM, Sundaram M, James SJ. PSMA PET/CT. Eur J Nucl Med Mol 1996;201:239-42. Imaging of bone tumors and tumor-like Imag 2017 [Epub ahead of print]. 50. Mazoyer J-F, Kohler R, Bossard D. lesions: techniques and applications. 35. Carra BJ, Chen DC, Bui-Mansfield LT. Osteoid osteoma: CT-guided percuta- Springer Science and Business Media; The Half-Moon Sign of the Femoral neous treatment. Radiology 2009. Neck Is Nonspecific for the Diagnosis 1991;181:269-71. 21. Kransdorf MJ, Stull M, Gilkey F, of Osteoid Osteoma. Am J Roentgenol 51. Lenke LG, Sutherland CJ, Gilula LA. Moser Jr R. Osteoid osteoma. 2016;206:W54-W. Osteoid osteoma of the proximal Radiographics 1991;11:671-96. 36. Hachem K, Haddad S, Aoun N, et al. femur: CT-guided preoperative local- 22. Park JH, Pahk K, Kim S, et al. MRI in the diagnosis of osteoid osteo- ization. Orthopedics 1994;17:289-92. Radionuclide imaging in the diagnosis ma. J Radiol 1997;78:635-41. 52. Sans N, Galy-Fourcade D, Assoun J, et of osteoid osteoma. Oncol Lett 37. Spouge AR, Thain LM. Osteoid osteo- al. Osteoid Osteoma: CT-guided 2015;10:1131-4. ma: MR imaging revisited. Clin Imag Percutaneous Resection and Follow-up 23. Touraine S, Emerich L, Bisseret D, et 2000;24:19-27. in 38 Patients 1. Radiology al. Is pain duration associated with 38. Davies M, Cassar-Pullicino VN, 1999;212:687-92. morphologic changes of osteoid osteo- Davies MA, et al. The diagnostic accu- 53. Muscolo DL, Velun O, Acero GP, et al. mas at CT? Radiology 2014;271:795- racy of MR imaging in osteoid osteo- Osteoid Osteoma of the Hip: 804. ma. Skelet Radiol 2002;31:559-69. Percutaneous Resection Guided by 24. Levine E, Neff J. Dynamic computed 39. Assoun J, Richardi G, Railhac J-J, et Computed Tomography. Clin Orthop tomography scanning of benign bone al. Osteoid osteoma: MR imaging ver- Relat Res 1995;310:170-5. lesions: preliminary results. Skelet sus CT. Radiology 1994;191:217-23. 54. Roqueplan F, Porcher R, Hamzé B, et Radiol 1983;9:238-45. 40. Moberg E. The natural course of al. Long-term results of percutaneous 25. McGrath BE, Bush CH, Nelson TE, osteoid osteoma. J Bone Joint Surg Am resection and interstitial laser ablation Scarborough MT. Evaluation of sus- 1951;33:166-70. of osteoid osteomas. Eur Radiol pected osteoid osteoma. Clin Orthop 41. Golding JS. The natural history of 2010;20:209-17. Relat Res 1996;327:247-52. osteoid osteoma: with a report of twen- 55. de Berg JC, Pattynama PM, Obermann 26. Pinto CH, Taminiau AH, ty cases. J Bone Joint Surg WR, et al. Percutaneous computed- Vanderschueren GM, et al. Technical 1954;36:218-29. tomography-guided thermocoagulation considerations in CT-guided radiofre- 42. Bottner F, Roedl R, Wortler K, et al. for osteoid osteomas. Lancet quency thermal ablation of osteoid Cyclooxygenase-2 inhibitor for pain 1995;346:350-1. osteoma: tricks of the trade. Am J management in osteoid osteoma. Clin 56. Hoffmann R-T, Jakobs TF, Kubisch Roentgenol 2002;179:1633-42. Orthop Relat Res 2001;393:258-63. CH, et al. Radiofrequency ablation in 27. Wells RG, Miller JH, Sty JR. 43. Carpintero-Benitez P, Aguirre MA, the treatment of osteoid osteoma-5- Scintigraphic patterns in osteoid osteo- Serrano JA, Lluch M. Effect of rofe- year experience. Eur J Radiol ma and spondylolysis. Clin Nucl Med coxib on pain caused by osteoid osteo- 2010;73:374-9. 1987;12:39-44. ma. Orthopedics 2004;27:1188-91. 57. Papathanassiou ZG, Petsas T, 28. Helms CA. Osteoid Osteoma: The 44. Bruneau M, Polivka M, Cornelius JF, Papachristou D, Megas P. Double Density Sign. Clin Orthop George B. Progression of an osteoid Radiofrequency ablation of osteoid Relat Res 1987;222:167-73. osteoma to an osteoblastoma: case osteomas: five years experience. Acta 29. Roach P, Connolly L, Zurakowski D, report. J Neurosurg Spine 2005;3:238- Orthop Belg 2011;77:827. Treves S. Osteoid osteoma: compara- 41. 58. Rosenthal DI, Hornicek FJ, Torriani M, tive utility of high-resolution planar 45. Frassica FJ, Waltrip RL, Sponseller et al. Osteoid Osteoma: Percutaneous

[Orthopedic Reviews 2018; 10:7496] [page 117] Review

Treatment with Radiofrequency Cardiovasc Intervent Radiol Alvarez S, et al. Percutaneous comput- Energy 1. Radiology 2003;229:171-5. 2016;39:768-72. ed tomography-guided resection of 59. Bousson V, Leturcq T, Ea H-K, et al. 71. Outani H, Hamada K, Takenaka S, et non-spinal osteoid osteomas in 54 An open-label, prospective, observa- al. Radiofrequency ablation of osteoid patients and review of the literature. tional study of the efficacy of bisphos- osteoma using a three-dimensional Archiv Orthop Trauma Surg phonate therapy for painful osteoid navigation system. J Orthop Sci 2013;133:449-55. osteoma. Eur Radiol 2018;28:478-86. 2016;21:678-82. 84. Earhart J, Wellman D, Donaldson J, et 60. Santiago E, Pauly V, Brun G, et al. 72. Etemadifar MR, Hadi A. Clinical find- al. Radiofrequency ablation in the Percutaneous cryoablation for the ings and results of surgical resection in treatment of osteoid osteoma: results treatment of osteoid osteoma in the 19 cases of spinal osteoid osteoma. and complications. Pediatr Radiol adult population. Eur Radiol 2018:1-9. Asian Spine J 2015;9:386-93. 2013;43:814-9. 61. Nijland H, Gerbers J, Bulstra S, et al. 73. Petrilli M, Senerchia AA, Petrilli AS, et 85. Villani MF, Falappa P, Pizzoferro M, et Evaluation of accuracy and precision al. Computed tomography-guided per- al. Role of three-phase bone scintigra- of CT-guidance in Radiofrequency cutaneous trephine removal of the phy in paediatric osteoid osteoma eligi- Ablation for osteoid osteoma in 86 nidus in osteoid osteoma patients: ble for radiofrequency ablation. Nucl patients. PLoS One 2017;12:e0169171. experience of a single center in Brazil. Med Commun 2013;34:638-44. 62. Wu H, Lu C, Chen M. Evaluation of Radiol Brasil 2015;48:211-5. 86. Rehnitz C, Sprengel SD, Lehner B, et minimally invasive laser ablation in 74. Knudsen M, Riishede A, Lucke A, et al. CT-guided radiofrequency ablation children with osteoid osteoma. Oncol al. Computed tomography-guided of osteoid osteoma and osteoblastoma: Lett 2017;13:155-8. radiofrequency ablation is a safe and clinical success and long-term follow 63. Shields DW, Sohrabi S, Crane EO, et effective treatment of osteoid osteoma up in 77 patients. Eur J Radiol al. Radiofrequency ablation for osteoid located outside the spine. Dan Med J 2012;81:3426-34. osteoma-Recurrence rates and predic- 2015;62:5. 87. Neumann D, Berka H, Dorn U, et al. tive factors. Surgeon 2017 [Epub ahead 75. Hamdi M, Tarhouni L, Daghfous M, et Follow-up of thirty-three computed- of print]. al. Osteoid osteoma of the phalanx and tomography-guided percutaneous 64. Quraishi NA, Boriani S, Sabou S, et al. metacarpal bone: report of 17 cases. radiofrequency thermoablations of A multicenter cohort study of spinal Musculoskel Surg 2015;99:61-5. osteoid osteoma. Int Orthop osteoid osteomas: results of surgical 76. Sharma P, Mukherjee A, Karunanithi 2012;36:811-5. treatment and analysis of local recur- S, et al. 99mTc-Methylene diphospho- 88. Maric D, Djan I, Petkovic L, et al. rence. Spine J 2017;17:401-8. nate SPECT/CT as the one-stop imag- Osteoid osteoma: fluoroscopic guided 65. Erol B, Topkar MO, Tokyay A, et al. ing modality for the diagnosis of percutaneous excision technique-our Minimal invasive intralesional exci- osteoid osteoma. Nucl Med Commun experience. J Pediatr Orthop B sion of extremity-located osteoid 2014;35:876-83. 2011;20:46-9. osteomas in children. J Pediatr Orthop 77. Bourgault C, Vervoort T, Szymanski C, 89. Mahnken AH, Bruners P, Delbrück H, B 2017;26:552-9. et al. Percutaneous CT-guided radiofre- Günther RW. Radiofrequency ablation 66. Garge S, Keshava SN, Moses V, et al. quency thermocoagulation in the treat- of osteoid osteoma: initial experience Radiofrequency ablation of osteoid ment of osteoid osteoma: a 87 patient with a new monopolar ablation device. osteoma in common and technically series. Orthopaed Traumatol Surg Res Cardiovasc Intervent Radiol challenging locations in pediatric pop- 2014;100:323-7. 2011;34:579-84. ulation. Indian J Radiol Imaging 78. Raux S, Abelin-Genevois K, Canterino 90. Mylona S, Patsoura S, Galani P, et al. 2017;27:88. I, et al. Osteoid osteoma of the proxi- Osteoid osteomas in common and in 67. Karagöz E, Özel D, Özkan F, et al. mal femur: treatment by percutaneous technically challenging locations treat- Effectiveness of computed tomography bone resection and drilling (PBRD). A ed with computed tomography-guided guided percutaneous radiofrequency report of 44 cases. Orthopaed percutaneous radiofrequency ablation. ablation therapy for osteoid osteoma: Traumatol Surg Res 2014;100:641-5. Skelet Radiol 2010;39:443-9. initial results and review of the litera- 79. Rehnitz C, Sprengel SD, Lehner B, et 91. Akhlaghpoor S, Ahari AA, Shabestari ture. Polish J Radiol 2016;81:295. al. CT-guided radiofrequency ablation AA, Alinaghizadeh MR. 68. Miyazaki M, Arai Y, Myoui A, et al. of osteoid osteoma: correlation of clin- Radiofrequency ablation of osteoid Phase I/II multi-institutional study of ical outcome and imaging features. osteoma in atypical locations: a case percutaneous radiofrequency ablation Diagn Intervent Radiol 2013;19:330. series. Clin Orthop Relat Res for painful osteoid osteoma 80. Etienne A, Waynberger É, Druon J. 2010;468:1963-70. (JIVROSG-0704). Cardiovasc Interstitial laser photocoagulation for 92. Von Kalle T, Langendörfer M, Intervent Radiol 2016;39:1464-70. the treatment of osteoid osteoma: retro- Fernandez F, Winkler P. Combined 69. Masciocchi C, Zugaro L, Arrigoni F, et spective study on 35 cases. Diagn dynamic contrast-enhancement and al. Radiofrequency ablation versus Intervent Imaging 2013;94:300-10. serial 3D-subtraction analysis in mag- magnetic resonance guided focused 81. Jafari D, Shariatzade H, Mazhar FN, et netic resonance imaging of osteoid ultrasound surgery for minimally inva- al. Osteoid osteoma of the hand and osteomas. Eur Radiol 2009;19:2508- sive treatment of osteoid osteoma: a wrist: a report of 25 cases. Med J Islam 17. propensity score matching study. Eur Rep Iran 2013;27:62. 93. Sung K-S, Seo J-G, Shim JS, Lee YS. Radiol 2016;26:2472-81. 82. Farzan M, Ahangar P, Mazoochy H, Computed-tomography-guided percu- 70. Wallace AN, Tomasian A, Chang RO, Ardakani MV. Osseous tumours of the taneous radiofrequency thermoablation Jennings JW. Treatment of osteoid hand: a review of 99 cases in 20 years. for the treatment of osteoid osteoma-2 osteomas using a navigational bipolar Archiv Bone Joint Surg 2013;1:68. to 5 years follow-up. Int Orthop radiofrequency ablation system. 83. Reverte-Vinaixa MM, Velez R, 2009;33:215-8.

[page 118] [Orthopedic Reviews 2018; 10:7496] Review

94. Peyser A, Applbaum Y, Simanovsky N, tern of osteoid osteomas on computed 111. Cioni R, Armillotta N, Bargellini I, et et al. CT-guided radiofrequency abla- tomography and magnetic resonance al. CT-guided radiofrequency ablation tion of pediatric osteoid osteoma utiliz- imaging after thermocoagulation. of osteoid osteoma: long-term results. ing a water-cooled tip. Ann Surg Oncol Skelet Radiol 2007;36:813-21. Eur Radiol 2004;14:1203-8. 2009;16:2856-61. 103. Gangi A, Alizadeh H, Wong L, et al. 95. Blaskiewicz DJ, Sure DR, Hedequist Osteoid osteoma: percutaneous laser 112. Bisbinas I, Georgiannos D, Karanasos DJ, et al. Osteoid osteomas: intraoper- ablation and follow-up in 114 patients. T. Wide surgical excision for osteoid ative bone scan-assisted resection. J Radiology 2007;242:293-301. osteoma. Should it be the first-choice Neurosurg Pediatr 2009;4:237-44. 104. Peyser A, Applbaum Y, Khoury A, et treatment? Eur J Orthop Surg 96. Zampa V, Bargellini I, Ortori S, et al. al. Osteoid osteoma: CT-guided Traumatol 2004;14:151-4. Osteoid osteoma in atypical locations: radiofrequency ablation using a water- 113. Albisinni U, Rimondi E, Bianchi G, the added value of dynamic gadolini- cooled probe. Ann Surg Oncol um-enhanced MR imaging. Eur J 2007;14:591-6. Mercuri M. Experience of the Rizzoli Radiol 2009;71:527-35. 105. Fenichel I, Garniack A, Morag B, et al. Institute in radiofrequency thermal 97. Aschero A, Gorincour G, Glard Y, et al. Percutaneous CT-guided curettage of ablation of musculoskeletal lesions. J Percutaneous treatment of osteoid osteoid osteoma with histological con- Chemother 2004;16:75-8. osteoma by laser thermocoagulation firmation: a retrospective study and 114. Woertler K, Vestring T, Boettner F, et under computed tomography guidance review of the literature. Int Orthop al. Osteoid osteoma: CT-guided percu- in pediatric patients. Eur Radiol 2006;30:139. 2009;19:679-86. 106. Sierre S, Innocenti S, Lipsich J, et al. taneous radiofrequency ablation and 98. Vanderschueren GM, Obermann WR, Percutaneous treatment of osteoid follow-up in 47 patients. J Vasc Dijkstra SP, et al. Radiofrequency abla- osteoma by CT-guided drilling resec- Intervent Radiol 2001;12:717-22. tion of spinal osteoid osteoma: clinical tion in pediatric patients. Pediatr 115. Sans N, Galy-Fourcade D, Assoun J, et outcome. Spine 2009;34:901-3. Radiol 2006;36:115-8. al. Osteoid osteoma: CT-guided percu- 99. Lee MH, Ahn JM, Chung HW, et al. 107. Kjar RA, Powell GJ, Schilcht SM, et taneous resection and follow-up in 38 Osteoid osteoma treated with percuta- al. Percutaneous radiofrequency abla- neous radiofrequency ablation: MR tion for osteoid osteoma: experience patients. Radiology 1999;212:687-92. imaging follow-up. Eur J Radiol with a new treatment. Med J Austral 116.Rosenthal DI, Hornicek FJ, Wolfe 2007;64:309-14. 2006;184:563. MW, et al. Percutaneous radiofrequen- 100. Akhlaghpoor S, Tomasian A, 108. Cribb G, Goude W, Cool P, et al. cy coagulation of osteoid osteoma Shabestari AA, Ebrahimi M, Percutaneous radiofrequency thermo- compared with operative treatment. Alinaghizadeh M. Percutaneous coagulation of osteoid osteomas: fac- JBJS 1998;80:815-21. osteoid osteoma treatment with combi- tors affecting therapeutic outcome. nation of radiofrequency and alcohol Skelet Radiol 2005;34:702-6. 117. Nogues P, Marti-Bonmati L, Aparisi F, ablation. Clin Radiol 2007;62:268-73. 109. Martel J, Bueno Á, Ortiz E. et al. MR imaging assessment of juxta 101. Yang W-T, Chen W-M, Wang N-H, Percutaneous radiofrequency treatment cortical edema in osteoid osteoma in Chen T-H. Surgical treatment for of osteoid osteoma using cool-tip elec- 28 patients. Eur Radiol 1998;8:236-8. osteoid osteoma-experience in both trodes. Eur J Radiol 2005;56:403-8. 118. Loizaga J, Calvo M, Barea FL, et al. conventional open excision and CT- 110. Rimondi E, Bianchi G, Malaguti M, et Osteoblastoma and osteoid osteoma: guided mini-incision surgery. J al. Radiofrequency thermoablation of Chinese Med Assoc 2007;70:545-50. primary non-spinal osteoid osteoma: clinical and morphological features of 102. Vanderschueren GM, Taminiau AH, optimization of the procedure. Eur 162 cases. Pathol-Res Pract Obermann WR, et al. The healing pat- Radiol 2005;15:1393-9. 1993;189:33-41.

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