Osteoblastoma Treatment & Management
- Author: Fred Ortmann, MD; Chief Editor: Harris Gellman, MD more...
There are two primary indications for surgical management of an osteoblastoma within the musculoskeletal system. The first is obtaining a tissue sample that firmly establishes the diagnosis. "When tumor is the rumor, tissue is the issue" is a good rule to remember. It is frequently the case, however, that even with an appropriate, representative tissue sample, it may be very difficult to differentiate the aggressive (stage 3) lesions from osteosarcoma.
The second reason for surgical management is to eliminate the continued structural destruction of bony architecture by this aggressive tumor. It is important to emphasize that repairing the structural bony defect is the secondary consideration, in that it cannot be planned and implemented until diagnosis of the lesion is established.
No specific contraindications to the treatment of osteoblastoma have been documented. General precautions include avoiding harm to a growth plate when operating near one in the skeletally immature patient. When these tumors are removed from the spinal elements, meticulous care to protect the spinal cord during the procedure is mandatory. Similar precautions must be considered for the urinary bladder, the sacral plexus, and other associated pelvic organs when lesions are removed in these locations. Because all patients need some form of surgery in the management of this tumor, they must be able to tolerate anesthesia.
The use of radiation or chemotherapeutic measures to treat osteoblastoma has been controversial. Most authorities have maintained that neither treatment has any therapeutic effect on this lesion and that each has more risks than benefits. For instance, postirradiation sarcoma is a well-documented outcome in the management of benign tumors and makes this method of treatment inappropriate for benign, destructive surgically accessible tumors such as osteoblastoma.
The appropriate surgical treatment goal for osteoblastoma is complete excision of the lesion. For stage 2 lesions, the recommended treatment is extensive intralesional curettage followed by management of the resulting structural defect. After curettage of macroscopic material, a high-speed burr can be used to remove microscopic tumor back to a circumferential margin of normal appearing bony tissue. Curettage alone is usually inadequate.
In a study of 99 cases of osteoblastoma over 30 years (1974-2006), the local recurrence rate was approximately 24% after curettage alone and bone reconstruction of the resulting defect. The authors concluded that in select cases, recurrence can be minimized by more aggressive surgery.
For stage 3 lesions, wide resection is recommended to ensure removal of all tumor-bearing and any associated tumor (eg, aneurysmal bone cyst). Wide excision is defined as the excision of the tumor with a circumferential cuff of normal bone and soft tissue around the entity. Such excisions are usually curative for osteoblastoma with an associated aneurysmal bone cyst.[34, 35]
Weber et al compared the clinical success and costs of computed tomography (CT)-guided radiofrequency ablation (RFA) with those of open surgical resection for osteoblastoma as well as spinal osteoid osteoma (OO). They found RFA to be an efficient method for treating osteoblastoma, with results comparable to those of open surgery.
Preparation for surgery
Surgical excision of osteoblastomas must be carefully planned. For instance, embolization 24 hours before definitive surgery may be indicated to help control bleeding of an associated aneurysmal bone cyst; it can also be used to reduce intraoperative bleeding and facilitate complete excision in surgically difficult sites. A study of a small cohort of patients did not show any evidence of tumor relapse when preoperative embolization was used before surgical resection and reconstruction of cervical spine lesions.
Planning for reconstruction of any critical defect (ie, one in which bony stability is lost) also must be carried out before one may proceed with definitive surgery. For example, those lesions necessitating wide resection for adequate removal of the osteoblastoma may require facet resections that can create an unstable spine. Appropriate preoperative planning for stabilization of such a defect is required for this eventuality.
Preoperative embolization as an adjunct to surgical management of osteoblastoma may lead to reductions in intraoperative blood loss and blood transfusion volume.
Aggressive lesions must be removed by means of wide resection. If required, internal fixation must be planned for stabilization as noted above (see the images below).
Regardless of the method of resection, the surgical margins must be tumor-free if complete excision of the tumor is expected.
The application of external bracing, rehabilitation modalities, home healthcare, postoperative pain control, muscle relaxants, pulmonary and urinary tract care must be monitored and adequately managed during the postoperative period. Providing the patient and family with written expectations of healing times for the reconstructed site, as well as expected temporary and permanent functional limitations, is also appropriate in this period.
The most frequent immediate postoperative complications are as follows:
Wound, urinary tract, and lung infections
Hemorrhage at the operative site
Loss of bony stability of the surgical stabilization construct
Tumor recurrence occurs "late" (months to years) after the procedure, and planning for this eventuality must be done for a scheduled period after the definitive procedure. However, there are no universally accepted time intervals for the period within which such follow-up should occur, so the range is highly variable. A good rule is to continue these studies until the reported likelihood of regrowth of this tumor is small. It is also important to include chest films; giant cell tumor, osteoblastoma, and chondroblastoma have been reported to metastasize to the lungs.
Monitoring for signs and symptoms of infection and bleeding of the operative site, as well as for systemic signs of urinary tract and pulmonary complications, are important during the immediate postoperative period.
Scheduling appropriate studies to reevaluate the patient for local and distant spread after the definitive procedure is necessary at specific postoperative intervals and must be planned and discussed with the patient and family.
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