Ablation of Musculoskeletal Metastases: Pain Palliation, Fracture Risk Reduction, and Oligometastatic Disease
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
References (57)
- et al.
Cryoablation of recurrent sacrococcygeal tumors
J Vasc Interv Radiol
(2012) - et al.
Meta-analysis of dose-fractionation radiotherapy trials for the palliation of painful bone metastases
Int J Radiat Oncol Biol Phys
(2003) - et al.
The role of evoked potential monitoring in operative management of type I and type II thoracoabdominal aortic aneurysms
Semin Thorac Cardiovasc Surg
(2003) - et al.
Percutaneous cryoablation of metastatic lesions from non-small-cell lung carcinoma: Initial survival, local control, and cost observations
J Vasc Interv Radiol
(2012) - et al.
Percutaneous cryoablation of metastatic renal cell carcinoma for local tumor control: Feasibility, outcomes, and estimated cost-effectiveness for palliation
J Vasc Interv Radiol
(2012) - et al.
Percutaneous cryoablation of musculoskeletal oligometastatic disease for complete remission
J Vasc Interv Radiol
(2013) - et al.
Is there a favorable subset of patients with prostate cancer who develop oligometastases?
Int J Radiat Oncol Biol Phys
(2004) - et al.
Image-guided palliation of painful metastases using percutaneous ablation
Tech Vasc Interv Radiol
(2007) - et al.
Ablation of skeletal metastases: Current status
J Vasc Interv Radiol
(2010) - et al.
Lethal isotherms of cryoablation in a phantom study: Effects of heat load, probe size, and number
J Vasc Interv Radiol
(2009)
Microwave ablation technology: What every user should know
Curr Probl Diagn Radiol
Image-guided ablation therapy of bone tumors
Semin Ultrasound CT MR
Thermal ablation of painful bone metastases
Tech Vasc Interv Radiol
Treatment of bone metastases with microwave thermal ablation
J Vasc Interv Radiol
Image-guided percutaneous thermal ablation of bone tumors
Acad Radiol
Combined cementoplasty and radiofrequency ablation in the treatment of painful neoplastic lesions of bone
J Vasc Interv Radiol
Critical review and state of the art in interventional oncology: Benign and metastatic disease involving bone
Radiology
Ablation of osteoid osteomas with a percutaneously placed electrode: A new procedure
Radiology
Primary treatment of chondroblastoma with percutaneous radio-frequency heat ablation: Report of three cases
Radiology
Radiofrequency ablation: Another treatment option for local control of desmoid tumors
Skeletal Radiol
Early experience with percutaneous cryoablation of extra-abdominal desmoid tumors
Skeletal Radiol
Chondroblastoma: Radiofrequency ablation—Alternative to surgical resection in selected cases
Radiology
Primary bone malignancy: Effective treatment with high-intensity focused ultrasound ablation
Radiology
Noninvasive treatment of malignant bone tumors using high-intensity focused ultrasound
Cancer
Percutaneous radiofrequency ablation of chordoma
AJR Am J Roentgenol
Bone metastases: Pathophysiology and management policy
J Clin Oncol
Palliation of metastatic bone pain: Single fraction versus multifraction radiotherapy—A systematic review of the randomised trials
Cochrane Database Syst Rev
The management of acetabular insufficiency secondary to metastatic malignant disease
J Bone Joint Surg Am
Cited by (46)
ACR Appropriateness Criteria <sup>®</sup> Management of Vertebral Compression Fractures
2018, Journal of the American College of RadiologyCitation Excerpt :In addition, there is a debate as to the timing of VA as there is a small risk of tumor extravasation [120]. Percutaneous thermal ablation procedures are considerations when spinal metastases do not respond to RT, the cumulative tolerance of the spinal cord to radiation has been reached, or inclusion criteria in clinical trials preclude RT [121-125]. RFA and VA may also be an effective alternative for patients who cannot be offered or cannot tolerate RT [126].
Interventional oncologic procedures for pain palliation
2019, Presse MedicaleCitation Excerpt :Indications include patients with localized and at least moderate (> 4/10 Numeric Visual Scale units) pain [7]. Percutaneous ablation has been reported as an efficacious and safe procedure for cancer pain reduction with no evidence up-to-date reporting superiority of one technique over the other [7,25,26]. Comparative trials between radiotherapy and percutaneous ablation report earlier, superior and longer lasting pain reduction after combined therapies versus radiotherapy solely performed [27,28].
Ablative Techniques for Sarcoma Metastatic Disease: Current Role and Clinical Applications
2023, Medicina (Lithuania)