Ablation of Musculoskeletal Metastases: Pain Palliation, Fracture Risk Reduction, and Oligometastatic Disease

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Thermal ablation is an effective, minimally invasive alternative to conventional therapies in the palliation of painful musculoskeletal metastases and an emerging approach to obtain local tumor control in the setting of limited metastatic disease. Various thermal ablation technologies have been applied to bone and soft tissue tumors and may be used in combination with percutaneous cement instillation for skeletal lesions with or at risk for pathologic fracture. This article reviews current practices of percutaneous ablation of musculoskeletal metastases with an emphasis on radiofrequency ablation and cryoablation of painful skeletal metastases.

Introduction

Percutaneous thermal ablation is increasingly being used to treat both benign and malignant tumors in the musculoskeletal system with either curative or palliative intent. Indications for curative ablation include treatment of benign tumors, most commonly osteoid osteomas, as well as emerging approaches to limited or oligometastatic disease. Alternatively, ablation of painful skeletal metastases has become an important tool in the arsenal of multidisciplinary palliative care teams. Appropriate application of ablative techniques in the treatment of patients with bone and soft tissue tumors requires proper patient selection, comprehension of different ablative technologies, employment of adjunctive techniques to avoid complications, and realistic expectations of outcomes based on the literature.

Ablative treatment of primary musculoskeletal tumors is not covered in this review. In brief, osteoid osteomas were the first tumors treated by radiofrequency ablation (RFA) in any organ system more than 20 years ago, and percutaneous ablation has since become well established as the primary approach to treat osteoid osteoma.1, 2 Other benign primary musculoskeletal tumors, including chondroblastomas and desmoid tumors, have been successfully treated with ablative techniques and reported in case series.3, 4, 5, 6 Few series of ablation of primary bone malignancy have been reported.7, 8 Local recurrences of chordomas in the sacrococcygeal region have also been successfully managed with percutaneous ablation.9, 104, 5

Skeletal metastases are common, reported in up to 85% of patients with breast, prostate, and lung cancers at autopsy.11 The prognosis for patients with these metastases varies by primary tumor type, with some surviving only a few months and other patients in whom metastatic malignancy becomes a chronic disease to be managed over many years. Regardless of tumor histology, osseous metastases may cause intractable pain, pathologic fracture, and impaired mobility, all of which may reduce patient performance status and quality of life.11 Pain relief and reduction of adverse skeletal events related to metastases may require a combination of analgesic medications, bisphosphonates, systemic chemotherapy, hormonal therapy, and radiopharmaceuticals. Despite this armamentarium, metastatic bone pain is frequently undertreated, with some patients continuing to experience moderate to severe pain despite high doses of opioid analgesics or suffering side effects of these medications. Radiation therapy (RT) remains the standard treatment in the management of bone metastases; pain relief occurs in approximately 60% of patients, and about one-third of patients achieve a complete pain response.12, 13 Moreover, pain relief after RT may require weeks to occur and is often temporary.12 Surgery in the setting of skeletal metastases is usually reserved for recent or impending pathologic fractures and may not be possible in patients with cancer with poor functional status or advanced disease. Thermal ablation serves as an important, minimally invasive, local treatment alternative to these conventional therapies for palliation of pain.

Section snippets

Painful or Otherwise Symptomatic Tumors

Pain should be evaluated using a standardized assessment tool, commonly the Numeric Rating Scale for pain, a simple scale from 0 (no pain) to 10 (worst pain imaginable), which can be administered verbally or graphically. In clinical trials, the brief pain inventory, including several questions assessing pain and its effect, also on a 0-10 scale, is most useful. Palliative ablation of a painful musculoskeletal metastasis is indicated in patients with at least moderate pain (worst pain ≥4 of 10

Anesthesia

Thermal ablation usually requires moderate sedation, regional anesthesia, or general anesthesia to place applicators precisely and treat thermal-induced intraprocedural pain. The level of anesthesia used for ablation treatments varies by practice. Moderate sedation or regional anesthesia may be adequate for treatment of small, easily accessible lesions, whereas general anesthesia is often required for more technically challenging masses. Epidural analgesia or patient-controlled analgesia may be

Complications

Complications following thermal ablation of bone and soft tissue tumors generally present in the immediate postprocedural period. Thermal injuries to the skin from heat- or cold-based ablation may be managed conservatively, with topical use of silver sulfadiazine or bacitracin usually sufficient for management of these complications. Hemorrhage, less common than following ablation of solid parenchymal organs, can occur and may require close patient monitoring, volume resuscitation, blood

RFA

Two large multicenter prospective trials have shown RFA to be safe and effective in palliation of painful skeletal metastases.44, 45, 46 In the first study, 59 of 62 patients (95%) experienced a clinically significant decrease in pain (≥2 point drop in worst pain in a 24-hour period).44, 46 Significant complications seen in 4 patients (6.5%) included exacerbation of pre-existing tumor-cutaneous fistulae in 3 patients and a pathologic fracture in a large acetabular metastasis in one patient. The

Conclusion

Thermal ablation of bone and soft tissue metastases is safe and effective in the palliation of pain. These ablation techniques may be combined with cementoplasty in lesions at risk for pathologic fracture, particularly those in weight-bearing locations. Prospective comparison studies between different ablation techniques and standard therapies, such as RT, are needed to distinguish the relative benefits of these therapies for palliation of painful metastatic lesions. Local control of limited

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