Technique

Radiography and computed tomography (CT) scan must be performed prior to alcohol injection to assess the location and extent of the lytic process, the presence of cortical destruction or fracture, and the presence of soft tissue involvement. Alcohol injection is performed under strict

FIGURE 1 (A and B) Contrast injection into a metastasis of the ilium. Despite cortical osteolysis, no leak of contrast into the adjacent soft tissue is detected. Ethanol injection can be performed with caution.

sterile conditions in patients under conscious sedation or general anesthesia, because severe pain may occur during ethanol injection.

CT guidance is usually performed for both needle placement and injection monitoring to allow precise assessment of the bone and soft-tissue involvement (especially for the pelvic bones, the posterior arch of a vertebra, or the anterior part of a vertebral body with involvement of the adjacent soft tissue), but fluoroscopic guidance can be used in the appendicular skeleton, especially for femoral lesions (2,3). Ultrasound guidance has also been reported for skull and sternal metastases (1,4).

Percutaneous ethanol injection is technically easy to perform. A thin (20-22-gauge) needle is first inserted into the lesion, and a mixture of lidocaine (1%) and contrast material is injected first to assess the expected distribution of ethanol and to decrease the pain produced by the ethanol injection (Figs. 1 and 2). If leakage of contrast media is detected, especially into the joint space, the needle is repositioned and a second test injection is performed. If no contrast material is visualized, the needle has been positioned intravascularly and needs to be repositioned.

Next, a solution of 95% ethanol is injected slowly. Injection volume depends on lesion size and the diffusion of the contrast material. A volume of 1 to 4mL is usually sufficient for osteolytic lesions, but in patients with extensive soft-tissue involvement, the volume used can reach 20 to 30 mL. One or more injections may be performed at different parts of the lesion, or multiple lesions may be injected on the same day. Also, repeat injections performed over several weeks may further improve pain relief and decrease tumor size.

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