European Conference on Interventional Oncology

April 24-27 | Vienna, Austria

April 24-27 | Vienna, Austria

April 24-27 | Vienna, Austria

April 24-27 | Vienna, Austria

April 24-27 | Vienna, Austria

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ProgrammeTopic highlightsBone ablation for pain palliation

Bone Ablation for pain palliation: when and how

We spoke to Dr. Jack Jennings to learn more about his presentation at ECIO 2022.

You can now watch this session on demand! 

Bone is the third most common system involved by cancer metastases, and skeletal-related events, such as intractable pain due to direct osseous tumour involvement, pathologic fracture, and neurologic deficits as a consequence of nerve or spinal cord compression often unfavourably affect a patient’s functional independence and quality of life. The spine is the most common site of osseous metastases, affecting approximately 40% of patients with metastatic disease. Considering the large health care economic burden, the limitations of therapeutic options including radiation therapy, systemic therapies, and surgery, as well as morbidity associated with osseous metastases, particularly in the spine, investigators have exploited and demonstrated the safety and effectiveness of minimally invasive percutaneous thermal ablation, which can be combined with vertebral augmentation/cementoplasty for pathologic fracture prevention and stabilisation, for the management of painful osseous metastatic disease.

To evaluate the “when” requires a thorough clinical evaluation done in a multi-disciplinary fashion in association with medical, surgical, and radiation oncologists. The most important questions to determine are: Is the lesion the aetiology of the patient’s pain? How severe is there pain? What is their performance status? Is the patient’s pain localised to one or a few discernible locations, or do they have diffuse pain?  What is the patient’s life expectancy and performance status? Is the pain local, mechanical, radicular or a combination? Is the lesion unstable and is surgical consultation necessary? Has there been prior radiation and or surgery? Are there underlying degenerative changes that may be the source of a patient’s pain? Is ablation even necessary and will cement alone suffice for mechanical pain in weight-bearing bones? To answer these questions requires an in-person consultation with a complete history and physical examination. Other important considerations are lesion size and morphology, lytic, blastic, or mixed nature of the lesion, associated soft tissue component, vascularity, and involvement of weight-bearing bone, and proximity to vital structures (i.e. skin, nerves, spinal cord, vessels, cartilage, viscera and soft tissues).  Cross-sectional imaging including MRI and CT is paramount to determine these characteristics, allowing for pre-treatment planning and determination if thermoprotective techniques will be necessary to avoid complications.

Once you get to the “how” more than half of the battle is over, as successful ablation of bone lesions for palliation is highly dependent on treating the appropriate patients and lesions.  There are many tools in our armamentarium for percutaneous thermal ablation including radiofrequency, cryo-, microwave, and MR guided focused ultrasound ablation. Each modality has its advantages and limitations in the treatment of osseous lesions. Radiofrequency ablation (RFA) is the most published thermal modality for bone and is used primarily for lytic or mixed lytic-blastic bone lesions, geographic metastases with little or no extraosseous components, and challenging-to-access lesions (e.g. posterior central vertebral body and acetabulum) where access is feasible using navigational articulating electrodes. The main indications for the use of cryoablation for treatment of skeletal metastases include large tumours with complex geometry, bone metastases with large soft-tissue components, large tumours involving the posterior vertebral elements, paravertebral soft-tissue lesions, and blastic metastases. The use of microwave overlaps with both RFA and cryoablation including treatment of large tumours with complex geometry and osseous metastases with large soft-tissue components, osteoblastic metastases. It is increasingly being used in the treatment of spine lesions as well. MRI-guided high intensity frequency Ultrasound (HIFU) is a non-invasive form of thermal ablation for the treatment of skeletal metastases including primarily lytic or mixed lytic-blastic tumours with cortical disruption, extra-spinal osseous metastases, and bone tumours deeper than 1 cm from the skin surface.

These all have unique technical advantages, including navigational RFA probes to treat challenging lesions, including the posterior vertebral body, and with thermocouples for real-time evaluation of the ablation zone. Cryoablation allows visualisation of the low attenuating ice ball on CT, simultaneous use of several cryoprobes to achieve additive and sculpting overlapping ablation zones and availability of MRI-compatible cryoprobes. The advantages of microwave ablation include less susceptibility to the convective cooling effect and variable tumour tissue impedance resulting in more uniform and larger ablation zones, as well as heightened efficiency as compared with RFA, simultaneous use of multiple antennas to generate additive overlapping ablation zones, minimal risk of back-heating phenomenon in recently introduced antennas, and lack of contra-indication in patients with metallic implants.  HIFU ablation allows for MRI-guided 3D visualisation for precise treatment planning, real-time monitoring of the ablation zone with MR thermometry and continuous thermal mapping. All of these modalities have proven to be safe with a low risk of major complications.

Familiarity of interventional radiologists with the thorough clinical and imaging evaluation and these interventional tools with progressive incorporation in clinical practice and continued technological advances will further advance the role of radiologists in the multi-disciplinary palliative management of patients with painful osseous metastases.

Fig.1a: 53 yo female with metastatic synovial cell sarcoma admitted to hospital with painful right buttock pain and CT demonstrating a destructive lytic lesion involving the right posterior ilium

Fig.1b: Intra-procedural images demonstrate 1 of 2 cryoablation probes within the lesion and a low attenuation iceball extending beyond the borders of the lesion

Fig.1c: Patient had complete and durable pain resolution with follow up CT images demonstrating local control for greater than 2 years.

References

  1. Tomasian A and Jennings JW. Bone Metastases: State of the Art in Minimally Invasive Interventional Oncology- Essentials for Radiologists. Radiographics 2021 Sep-Oct 41(5);1475-1492.
  2. Auloge P, Cazzato RL, Rousseau C ,et al. Complications of percutaneous bone tumor cryoablation: a 10-year experience. Radiology 2019;291:521–528
  3. Cazzato RL, Palussière J, Auloge P, Rousseau C, Koch G, Dalili D, Buy X, Garnon J, De Marini P, Gangi A. Complications following percutaneous image-guided radiofrequency ablation of bone tumors: A 10-year dual center experience. 2020 Jul;296(1):227-235.
  4. Callstrom MR, Dupuy DE, Solomon SB ,et al. Percutaneous image-guided cryoablation of painful metastases involving bone: multicenter trial. Cancer 2013;119:1033–104
  5. Levy J, Hopkins T, Morris J, et al. Radiofrequency Ablation for the Palliative Treatment of Bone Metastases: Outcomes from the Multicenter OsteoCool Tumor Ablation Post-Market Study (OPuS One Study) in 100 Patients. J Vasc Interv Radiol.2020;31(11):1745-1752.
  6. Jennings JW, Prologo JD, Garnon J, Gangi A, Genshaft S, Abtin F, Huang AJ, Iannuccilli J, Pilleul F, Mastier C, Littrup PJ, De Baere T, Deschamps F. Cryoablation for Palliation of Painful Bone Metastases: the MOTION Multicenter Study. Radiology: Imaging Cancer. Vol 3.No. 2.
  7. Tomasian A, Gangi A, Wallace AN, Jennings JW. Percutaneous thermal ablation of spinal metastases: recent advances and review. AJR 2018;210:142–152
  8. Tomasian A, Jennings JW. Percutaneous Minimally Invasive Thermal Ablation of Osseous Metastases:Evidence-Based Practice Guidelines.Am J Roentgenol 2020,26:1-9.
  9. Callstrom MR, Dupuy DE, Solomon SB, et al. Percutaneous image-guided cryoablation of painful metastases involving bone:multicenter trial. Cancer 2013;119:1033–104
  10. Filippiadis DK, Tselikas L, Bazzocchi A, Efthymiou E, Kelekis A.Yevich S. Percutaneous Management of Cancer Pain. Current Oncology Reports 2020;22:43
  11. Tomasian A, Marlow J, Hillen TJ and Jennings JW. Complications of percutaneous radiofrequency ablation of spinal osseous metastases: An 8-year single center experience. Am J Roentgenol. 2021 Mar 31;1-7.

Jack Jennings

Washington University, St. Louis/US

Dr. Jack Jennings is a Professor of Radiology at Washington University’s Mallinckrodt Institute of Radiology and serves as the Chief of Musculoskeletal Radiology and Director of Musculoskeletal and Spine Intervention. He is actively involved in both interventional and interventional oncology societies in the U.S. and Europe and is a Fellow of CIRSE and ACR, serves as a board member of SIO, and is the President Elect for the American Society of Spine Radiology.  His main research interest lies in musculoskeletal and spine tumour ablation, bone and soft tissue biopsies, and osteoporotic and pathologic fracture treatment. He has been involved in multiple funded prospective studies and has been both the institutional and overall principal investigator on bone and spine tumour ablation trials.