TO THE EDITOR:
"Percutaneous Radiofrequency Coagulation of Osteoid Osteoma Compared with Operative Treatment" (80-A: 815—821, June 1998), by Rosenthal et al., is a comparison between percutaneous ablation of osteoid osteoma and operative treatment of osteoid osteoma by a group of knowledgeable, highly skilled orthopaedic oncologists and radiologists. The article raises two issues. One is specific to the article, and the other pertains to the role of interventional radiology in the management of patients.
The article did not present a broad perspective on the treatment of osteoid osteoma. The only time that nonoperative treatment was mentioned was in the second paragraph of the introduction, when the authors cavalierly dismissed medical treatment of osteoid osteoma by stating that the lesion "is usually removed because patients are unwilling to tolerate the pain and wish to avoid the long-term use of non-steroidal anti-inflammatory medications." This statement is totally unsubstantiated and is not consistent with the data presented in the study by Kneisl and me1.
Medical treatment is never mentioned as an option in the Discussion. Thus, in the last sentence, the authors summarized their findings by stating that "percutaneous ablation with radiofrequency is the preferred treatment for extraspinal osteoid osteoma because hospitalization is unnecessary, it has not been associated with complications, and it has been associated with a shorter period of recovery than has operative treatment." Medical treatment was not mentioned or put in the prospective therapeutic armamentarium for osteoid osteoma. On the basis of our study1, medical treatment can be used quite successfully to treat spinal osteoid osteoma and may be the preferred choice for spinal tumors given the fact that percutaneous ablation is contraindicated for such lesions. In addition, the medical treatment of osteoid osteoma does not necessitate anesthesia, is not associated with the pain of so-called noninvasive operations, and does not involve professional fees for radiology and operative treatment or hospital charges for anesthesia and use of the radiology suite. Thus, it is highly likely that the charges and costs associated with medical treatment are less than those associated with percutaneous ablation with radiofrequency. Also, unlike the situation after percutaneous ablation with radiofrequency, no recovery period is needed after medical treatment.
Thus, although I believe that percutaneous ablation with radiofrequency should be included in the choices of therapy for osteoid osteoma and is preferable to operative treatment in most instances, medical treatment may still be preferable to percutaneous ablation of tumors in the spine and in many other clinical situations.
Finally, I cannot help but raise the issue of the role of interventional radiology in therapy. The lead author, Dr. Rosenthal, is an accomplished bone radiologist and is, I am sure, quite skilled with this technique. However, I wonder if Dr. Rosenthal informs the patient of the medical and operative options and if he follows the patient postoperatively in an outpatient setting. I also wonder if interventional radiologists are trained in the preoperative and postoperative care of patients. These issues go beyond just this particular study. In this study, the information regarding the results of treatment was supplemented by a questionnaire and, most likely, a chart review. I believe that if radiologists are involved in therapy they have to see patients preoperatively and postoperatively in a multidisciplinary setting and understand how to inform patients of their medical and operative options in addition to seeing them postoperatively and treating their complications. Otherwise, they are truly only technicians.
Patients select treatment alternatives on the basis of the enthusiasm of the clinician. Does Dr. Rosenthal see the patient on an outpatient basis before an operation and explain the therapeutic options of medical treatment, operative treatment, and percutaneous ablation with radiofrequency? If Dr. Rosenthal had evaluated and followed the patients in an outpatient setting, he would have been able to gather better data than those obtained with the questionnaire.
I am concerned that interventional radiologists will use operative surrogates or primary-care physicians who have no training or knowledge of the risks and benefits of operative treatment of diseases. For instance, a pediatrician who hears about percutaneous ablation of osteoid osteoma may directly refer a patient who has a spinal osteoid osteoma to an interventional radiologist for this treatment. If the radiologist is inexperienced, he or she may attempt to do the procedure. Even if the radiologist does not manage the patient, the pediatrician will have wasted the patient's time and will have incurred more expense. Should a primary-care physician directly refer a patient to an interventional radiologist without having the patient evaluated by a clinician, such as an orthopaedic surgeon, who has knowledge of osteoid osteoma? This scenario could and will happen.
Michael A. Simon, M.D.: Section of Orthopaedic Surgery and Rehabilitation Medicine, Department of Surgery, The University of Chicago, 5841 South Maryland Avenue, MC 3079, Chicago, Illinois 60637
Dr. Rosenthal, Dr. Hornicek, Dr. Wolfe, Dr. Jennings, Dr. Gebhardt, and Dr. Mankin reply:
We are delighted that our article has piqued the interest of Dr. Simon, whose publications on the medical treatment of osteoid osteoma have been influential.
We agree that our article did not present a broad perspective on the treatment of osteoid osteoma. Such a perspective might be appropriate for a review article. We intended only to validate the use of radiofrequency by comparing it with operative treatment. However, we continue to believe that this comparison is appropriate because, as we stated, patients usually wish to have these tumors removed. This impression is based not only on our own experience but also on our review of the literature, in which we found that descriptions of operative treatment outweigh those of medical treatment by a tremendous margin.
The option of medical treatment is discussed with all patients, although we try to discourage it for those who have a lesion adjacent to an open growth plate or who have large effusions about a joint because we are concerned about the consequences of leaving lesions in these locations for long periods. A small number of patients elect medical treatment. We agree with Dr. Simon that medical treatment is a reasonable alternative for patients who want it and especially for those who have a spinal lesion, as long as they do not experience gastrointestinal side effects.
The other points raised by Dr. Simon do not bear directly on the content of our article but are a response to what he considers to be the implications of the article. He has a dark vision of inappropriate referrals and improper treatment resulting from the availability of the radiofrequency technique. He is alarmed by the fact that Dr. Rosenthal is not an orthopaedic surgeon and dismisses his medical training, experience, and practice.
For the record, all of the patients in our study were referred for radiofrequency treatment by orthopaedic surgeons. Dr. Rosenthal does see patients before and after the procedure. We do not believe in asking patients who have had an osteoid osteoma to return for office visits indefinitely. The questionnaire was used to obtain information from patients who had been released from active medical care.
Finally, the question regarding who should follow these patients after the immediate postprocedure period has more facets than Dr. Simon acknowledges. We are sensitive to the issue of so-called stealing of patients, and we believe that if the referring surgeon wishes to follow the patient after the procedure he or she should do so. Follow-up information thus is available only secondhand to the individual who performed the treatment. However, what is lost in immediacy is gained in objectivity, as the enthusiasm of the operator does not influence the appraisal of the results. We believe that such a collaborative approach has many advantages, and we commend it to Dr. Simon.
Daniel I. Rosenthal, M.D.; Francis J. Hornicek, M.D.; Michael W. Wolfe, M.D.; L. Candace Jennings, M.D.; Mark C. Gebhardt, M.D.; Henry J. Mankin, M.D.: Departments of Radiology (D. I. R.) and Orthopaedics (F. J. H., M. W. W., L. C. J., M. C. G., and H. J. M.), Massachusetts General Hospital, 32 Fruit Street, Boston, Massachusetts 02114