LAUSR

Dear Editor, We read with great interest the paper by Ulici et al., BTreatment of the aneurysmal bone cyst by percutaneous intracystic sclerotherapy using ethanol ninety five percent in children^ published online in February 2018 [1]. We appreciate the authors’ work for clinical practice on this topic. Traditional management of aneurysmal bone cyst (ABC) is surgical intervention including en block resection and intralesional curettage. Currently, there is a shift to noninvasive procedures, including sclerotherapy, with clinical response rates up to 85% [2]. In this study, the authors describe a technique of intracystic injection with ethanol for the treatment of aneurysmal bone cyst (ABC) in children. After confirmed histological exam in all patients, the percutaneous intracystic injection with ethanol 96% was performed under general anaesthesia and under fluoroscopic guidance. They repeated the ethanol injection after three months if the radiological healing criteria were not met. After the mean follow-up period of 11 months, the recurrence didn’t occur in their series. We congratulate the authors on this interesting technique and the well-designed study. However, we have few remarks about this paper: Nowadays, there is an increased interest in the medical community for percutaneous intracystic treatment in skeletally immature patients with ABC. There were proposed several agents to inject in order to promote healing of the ABC and reduce the recurrence rate. Previous percutaneous treatments with ethibloc and polidocanol were discarded due the high complication rates for ethibloc, and, respectively, non-approval in United States for polidocanol [3, 4]. In this situation, ethanol represents a good option to the doxycycline treatment proposed by Shiels et al. [3, 4]. In both situations, intracystic injection is performed under imagistic guidance and under general anaesthesia. Ethanol 96%, as a sclerosing agent, has an advantage over doxycycline due to its simpler manipulation formula. Doxycycline is delivered intracystic combined with a foaming agent, whereas ethanol is injected directly after the cystogram. Ghanem et al. [5] reported also ABCs healing in 11 out of 16 patients with a single Surgiflo and alcohol injection. Repeated injections are performed both for doxycycline and ethanol, but the mean number of injections is lower for the ethanol 96% [1, 3]. Our concerns regarding the present study are related to the follow-up period. After a mean follow-up period of 11 months and a maximum follow-up period of 19 months, the healing rate, with no recurrences, was 100%. The presented follow-up period is shorter than the mean recurrence rate for this lesion ranging from 18 to 24 months [6]. But more than 50% of the patients have longer follow-up than 18 months, creating the conditions to capture potential recurrences. On the other hand, Ghanem et al. [5] concluded that the ABCs healing is due to the injection of the Surgiflo and the alcohol association has only an adjuvant effect. Ulici et al. [1] showed in this study that the sclerosing effect is produced by the high concentration alcohol (ethanol 96%), but they lack in explaining the mechanism of action. Despite these comments, the authors’ preliminary results have provided an alternative technique for percutaneous sclerotherapy for children with ABC. We look forward to further studies from the authors. * Dan Ionuţ Cosma [email protected]