SESSION TYPE: Cancer Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Percutaneous vertebroplasty is becoming the standard of care to relieve pain and augment vertebral bone strength in symptomatic osteoporotic collapse, osteolytic metastasis, and myeloma. Polymethyl methacrylate (PMMA), a rapidly setting bone cement, is injected under fluoroscopic or CT guidance. This technique has gained popularity with marked pain relief achieved in over 90% of patients obviating the need for surgery. Previous case series have described pulmonary vascular embolism of PMMA as incidental findings.
CASE PRESENTATION: 63 year old with untreated Multiple Myeloma presented with a one day history of sudden onset dyspnea and left-sided pleuritic chest pain unrelated to exertion, two weeks after undergoing vertebroplasty. Chest radiographs revealed cement material in vertebrae and in the left pulmonary vascular tree, but clear lung fields. A CT angiogram of the chest revealed cement material embolization (noted on prior chest radiograph) without associated thrombus. On examination, patient’s pulse was 120 bpm at rest; pulse oximetry at 93% room air. Dyspnea improved with supplemental oxygen. Labs were unremarkable.
DISCUSSION: Case series have shown the that PMMA embolization has an incidence of 4.6%. Most patients with this condition are asymptomatic, however this patient developed symptoms later suggesting an in situ thombosis at the site of prior embolus. The prompt relief of symptoms with oxygen supplementation and anticoagulation therapy was consistent with a clinical diagnosis of pulmonary embolism. The patient was discharged on enoxaparin. The need for anticoagulation in this setting is not well defined in patients without a history of malignancy. The risk of in situ thrombosis at the sites of PMMA embolization is unknown.
CONCLUSIONS: PMMA embolization to the pulmonary vasculature is relatively common following vertebroplasty. Most instances are asymptomatic, but symptoms can develop weeks after the embolization, likely as a result of in situ thombosis. An index of suspicion and exclusion of alternative causes of dyspnea is imperative. Treatment with anticoagulation should be individualized based on the specific risk profile, since the long term impact of in situ pulmonary vascular thrombosis associated with these PMMA embolizations are unknown.
1) Pulmonary embolism of polymethyl methacrylate during percutaneous vertebroplasty and kyphoplasty. Choe DH, Marom EM, Ahrar K, Truong MT, Madewell JE. AJR Am J Roentgenol. 2004 Oct;183(4):1097-102.
2) Frequency and outcome of pulmonary polymethylmethacrylate embolism during percutaneous vertebroplasty. Venmans A, Lohle PN, van Rooij WJ, Verhaar HJ, Mali WP. AJNR Am J Neuroradiol. 2008 Nov;29(10):1983-5. Epub 2008 Aug 21.
DISCLOSURE: The following authors have nothing to disclose: Ahmer Faruki, Georgie Eapen
No Product/Research Disclosure InformationUniversity of Texas Health Science Center at Houston, Houston, TX