Search

Recent Articles

IJMPO—A Journey of a Thousand Miles

Author : Padmaj S. Kulkarni

Coronavirus Disease 2019 Treatment—T-Cells Hold the Key in Severe Cases

Author : Kunal Das, Nitika Agrawal, Mansi Kala, Rakhee Khanduri

Why Is China Importing COVID-19 Vaccine Now?

Author : Purvish M. Parikh

Effect of Ethanol as an Adjuvant to Extended Curettage on Recurrence Rate of Unicameral Bone Cyst

CC BY-NC-ND 4.0 · Indian J Med Paediatr Oncol 2018; 39(02): 193-195

DOI: DOI: 10.4103/ijmpo.ijmpo_100_17

Abstract

Background: To assess the efficacy of ethanol as an adjuvant in the treatment of unicameral bone cyst (UBC). Materials and Methods: Surgically treated patients with UBC lesion were reviewed. Definite treatment of UBC lesions was conducted using a combined four-step alcohol-using approach, consisted of curettage, burring, ethanol 96%, and electrocauterization of the lesion, consecutively. Results: Twenty-one patients (mean age 14, range: 2–30, male 62%) were followed from 1 to 10 years. Among 18 cases, only one recurrence was seen in a 5-year-old boy with UBC of the left calcaneus. Conclusions: Using ethanol as an adjuvant may be a good choice for treatment of UBC lesions.

Publication History

Article published online:
23 June 2021

© 2018. Indian Society of Medical and Paediatric Oncology. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/.)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

Abstract

Objective:The objective of this study is to describe the incidence, clinical, laboratory and microbiological profile, treatment, and outcome of infections during induction chemotherapy in children with acute lymphoblastic leukemia (ALL). Materials and Methods: This was prospective, observational study. All children aged 1–14 years, newly diagnosed to have ALL and attending the Pediatric oncology division at our center were included. Induction chemotherapy was administered as per a modified Berlin-Frankfurt-Münster protocol. The study period was from January 2014 to June 2015. Results: Two hundred and twenty-seven patients with ALL were included in the study. One hundred and fifty episodes of infection occurred among 117 patients. Major sites of infection were lung (n = 35) and gastrointestinal tract (n = 30). Blood cultures were positive in 45 episodes (30.6%) with Gram negative organisms being the predominant isolates. The most common organisms isolated were Pseudomonas aeruginosa and Klebsiella spp. The response to antibiotics was good with only 18% of episodes requiring a third-line antibiotic. One hundred and thirty-six (90.6%) episodes resolved without sequelae. Overall induction mortality (12 out of 227-5.3%) was mainly accounted for by infections. Conclusions: Infections are the major cause of mortality and morbidity in patients with ALL on induction chemotherapy. The outcomes are good for the majority of patients if they receive adequate antibiotics early in the course of infection.

Keywords

Introduction

Infections are a major cause of mortality and morbidity in pediatric acute lymphoblastic leukemia (ALL), especially during induction chemotherapy. The chances of infection are more in these children due to the immunosuppression caused by the disease as well as the chemotherapy administered. Several studies have highlighted the fact that infections are more during induction chemotherapy compared to consolidation/maintenance chemotherapy. The data from major cooperative group trials also highlight the fact that the most important cause of treatment-related mortality (TRM) is infections. Information on the clinical and microbiological profile of infections is very important to reduce the morbidity and mortality and also to formulate an optimal antibiotic policy. The information on infections is more important in the Indian scenario where an improvement in the supportive care can probably improve our disease outcomes as well. However, this information regarding infectious complications in cancer care centers in India is limited. Our study is an attempt to describe the incidence of infectious complications, their profile, and outcomes in a well-defined cohort of pediatric patients receiving intensive induction chemotherapy at a tertiary care oncology center in South India.

Materials and Methods

A prospective, observational study was done to describe the clinical and microbiological profile, treatment, and outcome of infections during induction chemotherapy in children with ALL. All children (Age: 1–14 years) newly diagnosed to have ALL and seeking the services of the Pediatric Oncology Division at our center during the study (January 2014 to June 2015) were included. Institutional review board and ethical committee clearance were obtained.

Patients were divided into two risk groups (standard risk-SR and high risk-HR) based on age, presenting total white cell counts, immunophenotype, conventional karyotyping, FISH/PCR for Philadelphia chromosome-positive ALL, and steroid response. Induction chemotherapy was administered as per a modified Berlin-Frankfurt-Münster (BFM) protocol, for all. Phase IA of induction treatment consisted of three or four drugs depending on the risk stratification. From January 2014 to December 2014, standard risk patients received a three drug regimen (4 doses of vincristine (VCR), eight doses of L-asparaginase and steroids) while the high-risk patients received a four drug regimen (4 doses of VCR and daunorubicin (DNR), 8 doses of L – asparaginase and steroids). From January 2015, a revision in the treatment schedule was made with SR patients receiving two doses of DNR. The patients were then followed up regularly from start of induction till the completion of induction chemotherapy. They were evaluated further when they presented with clinical focus of infection or with fever.

Clinical data analyzed included the presence of fever, site of infection, and presence of hemodynamic instability. Laboratory data included the total count and differential count, platelet count, and C reactive protein (CRP). Blood cultures were taken from all patients. Two peripheral blood samples were taken if there was no central line. If the patient had a central line, one sample each was drawn from the peripheral and central line. Depending on the focus of infection, other relevant cultures were also taken. Chest X-ray was done only if clinically indicated. The data so obtained was also recorded on the pro forma.

On diagnosis of an infection, either due to fever or due to focus of infection, patients were started on antibiotics as per the standard antibiotic policy of the department – a-third generation cephalosporin with an aminoglycoside as first line, piperacillin – tazobactam ± aminoglycoside as second line and a carbapenem or colistin as third line antibiotic. If a Gram positive infection was suspected or cultures were positive for Gram positive organism, vancomycin, or linezolid was added. Antifungals were added empirically if fevers were persistent for more than 72–96 h or as treatment if cultures were positive. The treatment details with respect to the antibiotics used, change of antibiotics, addition of antifungals, and duration of treatment were also recorded. The need for supportive care in the form of use of inotropes and mechanical ventilation were also analyzed. The outcome of infection was also recorded. If chemotherapy was withheld due to the infection, the duration of withholding chemotherapy was recorded.

Results

Two hundred and twenty-seven patients were included in the study. The mean age at presentation was 5.87 ± 4.01 years. There were 130 males and 97 females with a male-to-female ratio of 1.34:1. One hundred and forty-four patients were in high-risk category and 83 patients were in standard risk category. All patients except one in the high-risk group were treated with a four-drug induction chemotherapy comprising VCR, DNR, L – asparaginase, and steroids. One patient was planned for three-drug induction because he had ataxia telangiectasia. Fifty-five patients in the standard risk group received 3 drug induction with VCR, L – asparaginase, and steroids and 28 patients received a regimen with 4 doses of VCR and 2 doses of DNR along with L – asparaginase and steroids.

Two patients were excluded – first patient with ALL on induction who developed varicella but was treated at another center, and hence, further details were not available; second patient who presented with tumor lysis syndrome expired within few hours of starting steroids and was excluded from the study.

Episodes of infection

150 episodes of infection occurred among 117 patients. Of the 83 SR patients, 38 developed infection, i.e., 45.8% and of the 144 HR patients, 79 developed infection, i.e., 54.9%. Fever was present at presentation in 112 episodes (74.6%) and absent in 38 episodes (25.4%).

Major sites of infection were lung (n = 35) and gastrointestinal tract (GIT) (n = 30). No definite focus of infection was evident in 28% (n = 42). [Table 1] shows the major sites of infection.

Table 1

Sites of infection

Evidence of hemodynamic instability were seen in the form of tachycardia (n = 43), hypotension (septic shock) (n = 21), and tachypnea (n = 23).

Laboratory investigations

CRP was done in 131 episodes. Values were <1 xss=removed>3 in 51 episodes, 20,000–50,000/mm3 in 45 episodes, and >50,000/mm3 in 54 episodes.

Profile of microorganisms

Blood cultures were done in 147 of the 150 episodes. There were 45 positive blood cultures, i.e., 30.6% of patients had a microbiologically defined infection. Most of the isolates were gram negative organisms (= 36; 80%). Three isolates were purely fungal – 6.7%. Two more fungal isolates occurred – in combination with pseudomonas. [Table 2] shows the profile of microorganisms isolated from the blood.

Focus of infection

n (%)

Lung

35 (25)

Gastrointestinal tract

30 (20)

Skin and subcutaneous tissue

14 (9.3)

Mucositis

8(5.3)

Urinary tract

4 (2.6)

Perianal

3 (2)

Lung + mucositis

3 (2)

Central nervous system

2 (1.3)

Central venous catheter

2 (1.3)

Lung + gastrointestinal tract

2 (1.3)

Otitis media

1 (0.6)

Skin + central venous catheter

1 (0.6)

Skin + otitis

1 (0.6)

Lung + skin

1 (0.6)

Varicella zoster

1 (0.6)

Fever without focus

42 (28)

Total

150

Table 2

Profile of microorganisms isolated in blood culture

Treatment details

One hundred and twenty-seven episodes were initially treated with first-line antibiotics, 19 episodes with second-line antibiotics and 4 episodes with third-line antibiotics based on the severity of infection. Eventually, 127 episodes received first line, 47 episodes received the second line, and 28 episodes received third-line antibiotics as per institutional protocol. Antifungals were given in 29 episodes (19.3%). 24 among them were empirical and the rest based on positive culture reports. Intensive supportive care in the form of inotropes or mechanical ventilation was required in 17 episodes (11.3%). Inotropes were required in 15 episodes of septic shock – dopamine/adrenaline/noradrenaline. Ventilation support was required in six episodes (4%) of whom one survived and 5 expired.

Outcome of infection

One hundred and thirty-six (90.6%) episodes resolved without sequelae. Twelve patients (8%) died (One of them had varicella with hepatitis and coagulopathy). Two patients survived with sequelae – one with perforation peritonitis requiring colostomy and one with persistent empyema requiring decortication. Overall, induction mortality (12 out of 227-5.3%) was mainly accounted for by infections.

Chemotherapy had to be withheld on 47 episodes. The median duration of withholding chemotherapy was 6.85 days.

Outcome of induction chemotherapy

Of the 227 patients, 208 patients (91.6%) attained remission at the end of 4 weeks of induction chemotherapy. 12 patients (5.3%) expired during induction. 6 patients (2.7%) did not attain remission at the end of 4 weeks of induction chemotherapy. One patient (0.4%) was given an extended induction for 6 weeks as an individualized decision based on multiple factors.

Analysis of risk factors for infection or outcome

We analyzed four factors using Chi-square test to assess whether they predict an increased risk of infection – age, gender, risk group, number of drugs received during induction chemotherapy. However, there was no statistically significant association.

CRP, blood culture positivity, and platelet count were assessed with respect to the outcome of infection using Fisher's exact test. None of the factors showed a statistically significant association with outcome of infection.

Analysis of factors affecting mortality

Mortality was assessed using Fisher's exact test with respect to the following factors: Age, risk, number of drugs used in induction chemotherapy, number of episodes of infection, tachypnea, tachycardia, hypotension, CRP, and platelet count. The only factors found to be significantly associated with mortality were tachycardia (P < 0 class="i" xss=removed>P < 0 class="i" xss=removed>P < 0>

Discussion

Our study was done to assess the incidence of infections during induction chemotherapy in children with ALL and to assess the clinical profile, laboratory parameters, microbiological profile, and the outcome of infections. The induction phase was selected to study the infection profile because this is the phase during which chance of infection is highest both due to the immunosuppressive nature of disease and the chemotherapy regimen used. In a study by Bakhshi et al., 166 of 222 (74.7%) episodes of infections in ALL occurred during induction and intensification/consolidation phase of chemotherapy and only 56 episodes (25.3%) occurred during maintenance phase of chemotherapy.[1]

Our study was done over a period of 1½ years and included 227 patients. 51.5% of patients developed at least one episode of infection during induction. The risk group or the induction protocol (4 drugs versus 3 drugs) did not affect the rates of infection though we would have expected a higher rate of infection with the 4 drug regimen. The most common focus of infection was lower respiratory tract (25%, n = 35) followed by GIT (20%, n = 30). Around one-third of patients had no definite focus of infection. In the previously quoted study by Bakhshi et al., pulmonary infections were the most common site of infection (27.3%), followed by HEENT (22.9%), gastrointestinal tract, blood, urinary tract and connective tissue, with a higher incidence of infections during the intensive phases of chemotherapy.[1] In a study from Egypt which included both ALL and AML patients during induction chemotherapy, oral mucositis was the most frequently detected site of infection (52%), followed by skin (34%), GIT, and lower respiratory tract infections.[2]

The danger signs noted in these episodes were tachycardia (28.6%), hypotension (14%), and tachypnea (15%). The presence of these danger signs had a statistically significant association with mortality. Hence, the occurrence of any of these signs during an episode of infection should alert the clinician regarding the severity of infection.

CRP levels were more than 1 mg/dL in 80% of episodes with 22% episodes having a CRP level more than 9 mg/dL. However, the CRP levels did not correlate with the outcome of infection or mortality. Another laboratory parameter analyzed was the platelet count. Studies have shown that presence of thrombocytopenia in sepsis is associated with increased mortality and poorer outcomes.[3],[4] In our study, low platelet count did not show a statistically significant association with the outcome of infection (P = 0.058) or mortality (P = 0.062). However, the P values showed a trend toward significance. A statistical significance could not be reached probably due to the small sample size.

Around one-third of patients had a positive blood culture (30.6%) with 80% of the isolates being gram negative organisms. Nearly 7% of isolates were fungal. Microbiological data from various other oncology centers in India also show a predominance of Gram-negative organisms which was observed in our study as well.[5],[6],[7],[8],[9] Further analyses did not show a significant correlation between blood culture positivity and laboratory parameters such as CRP or the outcome of infection.

Infections were the major cause of mortality during induction in our series. In an analysis of mortality in children with ALL from PGI Chandigarh by Marwaha et al., the induction mortality during the period 1998–2006 was 10% (n = 40) of which 20 had died of infection.[10] Large cooperative groups have also published data pertaining to their TRM and have shown that the major cause of TRM is infections and especially so during the induction period. In UK ALL 2003 trial, sepsis was the most common cause of TRM and risk of infection-related mortality was higher during induction.[11] In an analysis of the St. Jude experience of deaths during induction therapy and first remission of acute leukemia in childhood, infection was the most common cause of death. Fourteen died during disease remission induction: 11 died of infection, and 3 died of noninfectious causes.[12] Similar results have also been published by the Austrian BFM group and NOPHO group.[13],[14]

Conclusions

Infections were a major cause of morbidity and mortality in pediatric ALL during induction chemotherapy, in our series. Around half of the patients had at least one episode of infection; Gram-negative organisms were the predominant isolates in blood culture. Most infections respond well to standard antibiotic regimens.

Conflict of Interest

There are no conflicts of interest.

Abstract

Background: To assess the efficacy of ethanol as an adjuvant in the treatment of unicameral bone cyst (UBC). Materials and Methods: Surgically treated patients with UBC lesion were reviewed. Definite treatment of UBC lesions was conducted using a combined four-step alcohol-using approach, consisted of curettage, burring, ethanol 96%, and electrocauterization of the lesion, consecutively. Results: Twenty-one patients (mean age 14, range: 2–30, male 62%) were followed from 1 to 10 years. Among 18 cases, only one recurrence was seen in a 5-year-old boy with UBC of the left calcaneus. Conclusions: Using ethanol as an adjuvant may be a good choice for treatment of UBC lesions.

Keywords

Alcohol - ethanol - neoplasm - tumor - unicameral bone cyst

Introduction

Unicameral bone cyst (UBC), also known as simple or solitary bone cyst, is a primary benign bone lesion. Radiographically, it appears as a centric single cavity in the metaphysis of long bones such as in the proximal humerus and femur. Furthermore, it could be developed in flat bones (e.g., calcaneus). UBCs are almost exclusively seen in the first and second decades of life with male predominance. Often, UBCs are asymptomatic and may resolve spontaneously with skeletal maturity.[1],[2],[3] Radiographically, the UBC could be classified as active or latent based on its distance to the growth plate. When UBC is placed within 0.5 cm from the physis, it is termed as active, and if the distance is more than 0.5 cm, it is labeled as latent.[4],[5] Although the exact etiology of UBC is unknown, several theories such as trauma, elevated levels of prostaglandins, and venous congestion have been proposed.[6],[7],[8]

These ambiguities regarding the pathogenesis of UBC cause different methods of treatment and many controversies about the choice of the best treatment.[6],[9] Management options include observation, injection, decompression, and surgical techniques such as curettage and bone grafting in combination with different adjuvants. The aim of this study was to evaluate the usefulness of ethanol as an adjuvant in a combined four-step procedure including curettage, high-speed burring, ethanol 96%, and electrocauterization followed by grafting to reduce local recurrence of UBCs.

Materials and Methods

Study design

In this retrospective cross-sectional study, medical records of all the patients with UBC lesion treated from 2003 to 2013 were reviewed, retrospectively. Eligibility criteria were patients with histological diagnosis of UBC lesion and full documented medical, surgical, and follow-up records. The protocol of this study was conformed to the tenets of the Helsinki Declaration of 1975, as revised in 1983, and was approved by the Local Ethics Committee at our university.

Based on the patients' medical records, demographic data (age at the time of the surgery and gender), the primary symptom of the patient, exact location of UBC lesion, pathologic reports, and further surgeries were reviewed. Furthermore, the most recent available images were studied to determine any possible recurrences.

Surgical technique

Suspicious lesions were treated with biopsy and curettage to determine the exact pathology. Definite treatment of UBC lesions was conducted using our approach, called the combined four-step alcohol-using approach, consisted of extended curettage, high-speed burring, ethanol 96%, and electrocauterization of the lesion, consecutively.[10] Extended curettage was performed to remove all abnormal tissues. After using high-speed burr on the walls of the lesion, the defect was irrigated by normal saline. In the third step, ethanol 96% was carefully poured in the lesion with a syringe to fill it completely. Any possible spill of ethanol in the surrounding tissues was suctioned immediately. After 1 min, ethanol was evacuated by suction tube followed by irrigation with normal saline. This cycle was repeated three times. Following irrigation to eliminate the risk of explosion, electrocauterization of the lesion with monopolar coagulation diathermy set to 50 W was performed on the whole wall of the lesion. The protocol of combined four-step alcohol-using approach was carried out in lesions of any bone of the body irrespective of the size or location except in the spinal region. Finally, the void would be filled by autograft or allograft. We routinely used autograft from the iliac crest to fill the defect, but allograft should be used for larger defects in the children. Treating of pathological fractures was a little different; after extended curettage, the fracture was reduced and fixed. After covering the periphery of the fracture by multiple gauzes and using a suction tube to reduce the risk of ethanol leakage, ethanol was spilled in the lesion. After electrocauterization, a bone graft was impacted in the defect.

Statistical analysis

Data were entered into the Statistical Package for the Social Sciences software version 15.0 (SPSS Inc., Chicago, IL, USA). Demographic data and characteristics of lesions were presented using descriptive statistics.

Results

During the study period, 21 patients with histological diagnosis of UBC were involved. The follow-up period was 1–10 years. The mean age of the patients at the time of surgery was 14 (range: 2–30 years). As demonstrated in [Table 1], nearly half of the cases were between 10 and 20 years of age, and most of them were male (62%). About 62% of lesions were inactive and mostly seen on the left-sided limbs of the body (57%). Humerus was the most common location of UBC lesions (62%), followed by femur (28%). The most common presentation of lesions was a pathologic fracture (43%).

Table 1

Demographic data of patients and characteristics of unicameral bone cyst lesions

Totally recurrence has been observed in one patient among cases treated using combined four-step alcohol-using approach [Table 2]. This case was a 5-year-old boy with UBC of the left calcaneus treated using extended curettage with allograft insertion. He developed local recurrence of lesion 4 years after surgery. The recurrent lesion was treated again as the same as the first procedure. There is no evidence of recurrence in 5 years following the second operation.

Variables

n (%)

Age (years)

≤10

6 (28)

10-20

10 (48)

≥20

5 (24)

Gender

Male

13(62)

Female

8 (38)

Anatomic site of lesions

Femur

6 (28)

Humerus

13(62)

Fibula

1 (5)

Calcaneus

1 (5)

Side of lesions

Left limbs

12 (57)

Right limbs

9 (43)

First presentation of lesions

Pathologic fracture

10 (43)

Pain

6 (31)

Incidental

4 (21)

Mass

1 (5)

Table 2

Treatment methods and recurrence rate

Discussion

The main goals in the treatment of UBC lesions are complete healing without any recurrence, resolving pain, and decreasing the risk of pathologic fracture.[11] Although there is no any consensus on the best therapeutic modalities of UBC lesions, invasive interventions and surgical treatments are preferred instead of medical therapies such as diphosphonates and botulinum toxins.[6],[12] Intralesional injection of steroid or autologous bone marrow with or without demineralized bone marrow may be a useful technique to treat UBC lesions.[1],[13],[14] Decompression and drainage of cyst fluid using cannulated screws are another choice to treat UBCs.[15]

The classic management of UBC lesions is open curettage and bone grafting using autograft, allograft, or bone substitute. Instrumentation after curettage and bone grafting could be used to increase the stability.[9],[12],[16] Recurrence rate following open curettage and bone grafting or its substitute is about 25%–37%.[15],[17] Hence, using an adjuvant can reduce the risk of recurrence.

Hou et al. used ethanol cauterization as an adjuvant in a minimally invasive curettage approach in addition to synthetic calcium sulfate bone–graft substitute. They described shorter time to solid union in UBC lesions treated by ethanol as an adjuvant in comparison to the patients treated by open curettage and grafting. Moreover, no recurrence was seen in cases for which ethanol was used.[17]

Nowadays, intracystic injection of alcohol is the best choice of UBC treatment with low complication in some centers.[18] Moreover, the efficacy of ethanol to reduce recurrence rate after treatment of giant cell tumor, aneurysmal bone cyst, osteoid osteoma, skeletal metastasis, and other bone lesions has been described in the literature.[10],[19],[20],[21],[22] To the best of our knowledge, the efficacy of ethanol as an adjuvant therapy in UBC lesions has not been described yet. In our study, we evaluated healing and recurrence rate of UBC lesions after ethanol usage as an adjuvant with curettage and bone grafting. We had only one recurrence among 18 cases (5.5%) received combined four-step alcohol-using approach followed by grafting, either autograft or allograft.

The main limitation of our study was the number of patients. Hence, we could not assess the effect of other variable factors such as the patients' demographic data and tumor characteristics on healing or recurrence rate.

Discussion

The four-step alcohol-using approach may be a good choice of treatment with low recurrence in patients with UBC lesions. However, certainly, studies with better design and more sample size as well as extended follow-up are necessary.

Acknowledgment

This article has been obtained from a thesis submitted to the Shiraz University of Medical Sciences in partial fulfillment of the requirement for the degree of specialty in orthopedic surgery of Dr. Yaghoob Keikha. The project is sponsored by Bone and Joint Diseases Research Center, Shiraz University of Medical Sciences.

Conflict of Interest

There are no conflicts of interest.

References

  1. ascard E, Gomez-Brouchet A, Lambot K. Bone cysts: Unicameral and aneurysmal bone cyst. Orthop Traumatol Surg Res 2015; 101: S199-27
  2. evy DM, Gross CE, Garras DN. Treatment of unicameral bone cysts of the calcaneus: A Systematic review. J Foot Ankle Surg 2015; 54: 652-6
  3. ilkins RM. Unicameral bone cysts. J Am Acad Orthop Surg 2000; 8: 217-24
  4. affe HL, Lichtenstein L. Solitary unicameral bone cyst with emphasis on the roentgen picture: The pathological appearance and pathogenesis. Arch Surg 1942; 44: 1004-25
  5. adhim M, Sethi S, Thacker MM. Unicameral bone cysts in the humerus: Treatment outcomes. J Pediatr Orthop 2016; 36: 392-9
  6. retell-Mazzin J, Murphy RF, Kushare I, Dormans JP. Unicameral bone cysts: General characteristics and management controversies. J Am Acad Orthop Surg 2014; 22: 295-303
  7. ung AD, Anderson ME, Zurakowski D, Hornicek FJ, Gebhardt MC. Unicameral bone cyst: A retrospective study of three surgical treatments. Clin Orthop Relat Res 2008; 466: 2519-26
  8. hindell R, Huurman WW, Lippiello L, Connolly JF. Prostaglandin levels in unicameral bone cysts treated by intralesional steroid injection. J Pediatr Orthop 1989; 9: 516-9
  9. ee SY, Chung CY, Lee KM, Sung KH, Won SH, Choi IH. et alDetermining the best treatment for simple bone cyst: A decision analysis. Clin Orthop Surg 2014; 6: 62-71
  10. Solooki S, Keikha Y, Vosoughi AR. Can ethanol be used as an adjuvant to extended curettage in order to reduce the recurrence rate of aneurysmal bone cyst?. Rev Bras Ortop 2017; 52: 349-53
  11. Zhao JG, Ding N, Huang WJ, Wang J, Shang J, Zhang P. et alInterventions for treating simple bone cysts in the long bones of children. Cochrane Database Syst Rev 2014; 9: CD010847
  12. Kadhim M, Thacker M, Kadhim A, Holmes LJr. Treatment of unicameral bone cyst: Systematic review and meta analysis. J Child Orthop 2014; 8: 171-91
  13. Di BellaC, Dozza B, Frisoni T, Cevolani L, Donati D. Injection of demineralized bone matrix with bone marrow concentrate improves healing in unicameral bone cyst. Clin Orthop Relat Res 2010; 468: 3047-55
  14. Pavone V, Caff G, Di SilvestriC, Avondo S, Sessa G. Steroid injections in the treatment of humeral unicameral bone cysts: Long-term follow-up and review of the literature. Eur J Orthop Surg Traumatol 2014; 24: 497-503
  15. Hagmann S, Eichhorn F, Moradi B, Gotterbarm T, Dreher T, Lehner B. et alMid- and long-term clinical results of surgical therapy in unicameral bone cysts. BMC Musculoskelet Disord 2011; 12: 281
  16. Hou HY, Wu K, Wang CT, Chang SM, Lin WH, Yang RS. et alTreatment of unicameral bone cyst: Surgical technique. J Bone Joint Surg Am 2011; 93 Suppl 1: 92-9
  17. Hou HY, Wu K, Wang CT, Chang SM, Lin WH, Yang RS. et alTreatment of unicameral bone cyst: A comparative study of selected techniques. J Bone Joint Surg Am 2010; 92: 855-62
  18. Varshney MK, Rastogi S, Khan SA, Trikha V. Is sclerotherapy better than intralesional excision for treating aneurysmal bone cysts?. Clin Orthop Relat Res 2010; 468: 1649-59
  19. Lin WH, Lin TY, Chang CY, Wu K, Yang RS. Similar local control between phenol- and ethanol-treated giant cell tumors of bone. Clin Orthop Relat Res 2011; 469: 3200-8
  20. el-Mowafi H, Refaat H, Kotb S. Percutaneous destruction and alcoholisation for the management of osteoid osteoma. Acta Orthop Belg 2003; 69: 447-51
  21. Gangi A, Kastler B, Klinkert A, Dietemann JL. Injection of alcohol into bone metastases under CT guidance. J Comput Assist Tomogr 1994; 18: 932-5
  22. Filippiadis DK, Tutton S, Kelekis A. Percutaneous bone lesion ablation. Radiol Med 2014; 119: 462-9

Address for correspondence

Dr. Amir Reza Vosoughi
Bone and Joint Diseases Research Center, Department of Orthopedic Surgery, Chamran Hospital, Shiraz University of Medical Sciences
Shiraz 7194815644
Iran   

Publication History

Article published online:
23 June 2021

© 2018. Indian Society of Medical and Paediatric Oncology. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/.)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

Treatments

Subject, n (%)

Recurrence, n (%)

Biopsy and curettage

3 (14)

0

Extended curettage + autograft

13(62)

1 (7.7)

Extended curettage + allograft

5 (24)

0

Address for correspondence

Dr. Binitha Rajeswari
Division of Pediatric Oncology, Regional Cancer Centre
Thiruvananthapuram - 695 011, Kerala
India   

Publication History

Article published online:
23 June 2021

© 2018. Indian Society of Medical and Paediatric Oncology. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/.)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

Organism

n

Pseudomonas aeruginosa

9

Klebsiella species

8

Acinetobacter

6

Escherichia coli

5

Staphylococcus aureus

2

Methicillin-resistant Coagulase negative Staphylococci

2

Methicillin-resistant Staphylococcus aureus

1

Aeromonas

1

Burkholderia

1

Nonfermenting Gram-negative bacilli

1

Nonhemolytic Streptococci

1

Candida

3

Mixed growth of 2 organisms

5

Total

45

References

  1. ascard E, Gomez-Brouchet A, Lambot K. Bone cysts: Unicameral and aneurysmal bone cyst. Orthop Traumatol Surg Res 2015; 101: S199-27
  2. evy DM, Gross CE, Garras DN. Treatment of unicameral bone cysts of the calcaneus: A Systematic review. J Foot Ankle Surg 2015; 54: 652-6
  3. ilkins RM. Unicameral bone cysts. J Am Acad Orthop Surg 2000; 8: 217-24
  4. affe HL, Lichtenstein L. Solitary unicameral bone cyst with emphasis on the roentgen picture: The pathological appearance and pathogenesis. Arch Surg 1942; 44: 1004-25
  5. adhim M, Sethi S, Thacker MM. Unicameral bone cysts in the humerus: Treatment outcomes. J Pediatr Orthop 2016; 36: 392-9
  6. retell-Mazzin J, Murphy RF, Kushare I, Dormans JP. Unicameral bone cysts: General characteristics and management controversies. J Am Acad Orthop Surg 2014; 22: 295-303
  7. ung AD, Anderson ME, Zurakowski D, Hornicek FJ, Gebhardt MC. Unicameral bone cyst: A retrospective study of three surgical treatments. Clin Orthop Relat Res 2008; 466: 2519-26
  8. hindell R, Huurman WW, Lippiello L, Connolly JF. Prostaglandin levels in unicameral bone cysts treated by intralesional steroid injection. J Pediatr Orthop 1989; 9: 516-9
  9. ee SY, Chung CY, Lee KM, Sung KH, Won SH, Choi IH. et alDetermining the best treatment for simple bone cyst: A decision analysis. Clin Orthop Surg 2014; 6: 62-71
  10. Solooki S, Keikha Y, Vosoughi AR. Can ethanol be used as an adjuvant to extended curettage in order to reduce the recurrence rate of aneurysmal bone cyst?. Rev Bras Ortop 2017; 52: 349-53
  11. Zhao JG, Ding N, Huang WJ, Wang J, Shang J, Zhang P. et alInterventions for treating simple bone cysts in the long bones of children. Cochrane Database Syst Rev 2014; 9: CD010847
  12. Kadhim M, Thacker M, Kadhim A, Holmes LJr. Treatment of unicameral bone cyst: Systematic review and meta analysis. J Child Orthop 2014; 8: 171-91
  13. Di BellaC, Dozza B, Frisoni T, Cevolani L, Donati D. Injection of demineralized bone matrix with bone marrow concentrate improves healing in unicameral bone cyst. Clin Orthop Relat Res 2010; 468: 3047-55
  14. Pavone V, Caff G, Di SilvestriC, Avondo S, Sessa G. Steroid injections in the treatment of humeral unicameral bone cysts: Long-term follow-up and review of the literature. Eur J Orthop Surg Traumatol 2014; 24: 497-503
  15. Hagmann S, Eichhorn F, Moradi B, Gotterbarm T, Dreher T, Lehner B. et alMid- and long-term clinical results of surgical therapy in unicameral bone cysts. BMC Musculoskelet Disord 2011; 12: 281
  16. Hou HY, Wu K, Wang CT, Chang SM, Lin WH, Yang RS. et alTreatment of unicameral bone cyst: Surgical technique. J Bone Joint Surg Am 2011; 93 Suppl 1: 92-9
  17. Hou HY, Wu K, Wang CT, Chang SM, Lin WH, Yang RS. et alTreatment of unicameral bone cyst: A comparative study of selected techniques. J Bone Joint Surg Am 2010; 92: 855-62
  18. Varshney MK, Rastogi S, Khan SA, Trikha V. Is sclerotherapy better than intralesional excision for treating aneurysmal bone cysts?. Clin Orthop Relat Res 2010; 468: 1649-59
  19. Lin WH, Lin TY, Chang CY, Wu K, Yang RS. Similar local control between phenol- and ethanol-treated giant cell tumors of bone. Clin Orthop Relat Res 2011; 469: 3200-8
  20. el-Mowafi H, Refaat H, Kotb S. Percutaneous destruction and alcoholisation for the management of osteoid osteoma. Acta Orthop Belg 2003; 69: 447-51
  21. Gangi A, Kastler B, Klinkert A, Dietemann JL. Injection of alcohol into bone metastases under CT guidance. J Comput Assist Tomogr 1994; 18: 932-5
  22. Filippiadis DK, Tutton S, Kelekis A. Percutaneous bone lesion ablation. Radiol Med 2014; 119: 462-9