Shivani (name changed) is a pleasant 22-year-old lady from Haridwar. She noticed a dull aching pain in her wrist while carrying out her routine activities. Initially, she ignored the pain but when it became unbearable and constant she visited a local hospital. X-Ray was done and she was told that she has Bone Tuberculosis. The doctors also advised her to undergo a biopsy. An open biopsy was done but the result was negative for both infection and any tumor. She was empirically started on antibiotics for the bone infection. But the symptoms persisted so she came to Max Dehradun for the second opinion.
She consulted Dr. Vivek Verma, Bone and Soft tissue cancer specialist, in the Surgical oncology department at MSSH Dehradun. Dr Verma went through her detail history, symptoms and the investigation she had got done from the hospital.
“ She was evaluated with only X-ray and blood investigations earlier. Today we have the availability of diagnostic tools and when used judiciously we can diagnose a disease more accurately and advice correct treatment. Looking at her X-ray, I had two diagnoses in my mind – either it is a bone tumour or an infection. So I asked for MRI of the wrist to characterise the disease better”, said Dr Verma. MRI was done which showed multiple fluid levels in the lower end of ulna (forearm bone).
After MRI I was certain that we are dealing with a bone tumor – called ABC (Aneurysmal Bone Cyst). ABC is a type of locally aggressive bone tumor.
Dr Verma explains that bone tumors are of 2 types – benign and malignant. The malignant bone tumors are also called sarcomas which have a tendency to spread to other parts of the body and require complete removal of the bone (resection) along with radiotherapy or chemotherapy depending upon the type of sarcoma. Whereas benign tumors are locally aggressive but rarely spread to other body parts and they can be treated by cleaning the tumor (curettage) from the bone cavity while preserving the bone. The bone defect is reconstructed with bone grafts or bone cement. Dr Verma emphasises that not all benign tumors are the same and it is important to go to specialised centres, which have experience in dealing with bone tumors so that correct treatment is provided.
Dr Verma said that “We should never always assume any bone lesion to be infection/tuberculosis. Infections and tumor mimic each other on clinical signs, symptoms and in radiological appearance. The diagnosis has to be conformed to biopsy as both the diseases have a totally different spectrum of management.”
In the last decade, we have seen a lot of advances in the management of bone and soft tissue tumors. Some of the benign bone tumors which were previously treated with open surgery for curettage and bone grafts can now be treated effectively even without opening the bone. The aneurysmal bone cyst is one of such common bone tumor which can be treated effectively with a special procedure called “CUROPSY”.
How was the Procedure Performed?
Shivani underwent CUROPSY under local anaesthesia. We inserted a needle in the cavity and curetted the walls of the ulna bone under fluoroscopy guidance. The sample was also sent for biopsy to rule out any malignant cells. We injected a special chemical called polidocanol (a sclerosant) in the cavity. Shivani was able to go home after one hour.
Most of the times these tumors heal with one or two session of injections so there is no need to do any open surgery as we did in the past. This avoids the pain and delay healing due to bone grafts which are harvested from other sides. Also these can be done as day care procedures and the cost is reduced significantly.
Currently Shivani is doing very well. Her pain has resolved and she is able to carry out her routine work as before. Bone and Soft tissue cancer unit at MSSH Dehradun is dedicated to bring specialised services to the residents of Uttarakhand who had to travel to metro cities to avail such treatment.