Selective intra-arterial chemoembolization of pelvic and spine bone metastases

A study on short-term efficacy and safety of Iodine-125 brachytherapy coupled with preoperative arterial chemoembolization for hypervascular spinal metastasis

PURPOSE

Hypervascular spinal metastatic malignancies can cause severe pain and intraoperative bleeding and selection of appropriate treatment can be challenging. This study aimed to observe the short-term efficacy and safety of Iodine-125 brachytherapy (125I BT) combined with preoperative transcatheter arterial chemoembolization (TACE) for hypervascular spinal metastasis.

METHODS

This study included a total of 33 patients (39 lesions) with hypervascular spinal metastasis. All of them carried out a regimen of TACE followed by 125I BT under CT guidance. A brachytherapy planning system has been utilized for the purpose of designing treatment plans and optimizing dose distribution. Pain relief was evaluated using a numeric rating scale (NRS) and intraoperative bleeding was recorded. Follow-up was conducted for 6 months to observe the local control rate and clinical complications.

RESULTS

All patients tolerated combined treatment well and intraoperative blood loss of every patient was not more than 10 ml. The 2- and 6- month local disease control rates were 92.3% and 83.8%. The NRS scores for thirty-three tumor patients before surgery and after one week, two, and six months of surgery were recorded as 7.33 ± 1.80, 7.39 ± 1.89, 3.15 ± 2.35, and 4.16 ± 2.15, respectively. The NRS score 2 months after treatment was found considerably lower in comparison to the NRS score before operation (p < 0.05).

CONCLUSIONS

According to our findings, 125I BT as well as preoperative TACE leads to perioperative hemostasis, pain alleviation, and reduced tumor burden, indicating that this combined treatment could be effective and promising for hypervascular spinal metastases.

Palliative Arterial Embolization for Metastases of the Sternum

BACKGROUND

To investigate the safety and efficacy of palliative arterial embolization for metastases of the sternum.

MATERIALS AND METHODS

This study included 10 consecutive patients (5 M, 5 F; mean age 58.1; range 37-70) with metastases of the sternum from different primary tumors, treated with palliative arterial embolization using NBCA-Lipiodol between January 2007 and June 2022. Four patients received a second embolization at the same site, for a total of 14 embolizations. Data on technical and clinical success, as well as changes in tumor size, were collected. All embolization-related complications were evaluated according to the CIRSE classification system for complications.

RESULTS

Post-embolization angiography showed occlusion of more than 90% of the pathological feeding vessels in all procedures. Pain score and analgesic drug consumption were reduced by 50% in all 10 patients (100%, p < 0.05). The mean duration of pain relief was 9.5 months (range 8 to 12 months, p < 0.05). Metastatic tumor size was reduced from a mean of 71.5 cm³ (range 41.6 to 90.3 cm³) pre-embolization to a mean of 67.9 cm³ (range 38.5 to 86.1 cm³) at the 12-month follow-up (p < 0.05). None of the patients experienced embolization-related complications.

CONCLUSION

Arterial embolization is safe and effective as a palliative treatment for patients with metastases of the sternum who did not benefit from radiation therapy or experienced recurrence in symptoms.

Chemoembolization for Symptomatic Metastatic Epidural Spinal Cord Compression Refractory to Re-radiotherapy

PURPOSE

To evaluate the efficacy of chemoembolization for inoperable metastatic epidural spinal cord compression (MESCC) refractory to re-radiotherapy.

METHODS

Nineteen consecutive patients with recurrent MESCC after re-radiotherapy who had undergone chemoembolization were retrospectively analyzed. Outcome measures were pain relief rate, neurological improvement rate, objective response rate, and adverse events. MESCC degree classification was assessed using Bilsky grades. Pain assessment was performed using Numerical Rating Scale, and neurological function was evaluated using the Frankel classification.

RESULTS

The median follow-up period was 7 (range 2-44) months. All participants had MESCC grade 2 or higher and had severe pain. Fifteen patients (79%) had neurological deficits, and ten had Frankel classification C and five had D. Symptoms were relieved in almost all patients the day following chemoembolization. Pain relief was achieved in 18 of 19 (95%) patients; the median decrease in Numerical Rating Scale score was 8 (range 0-10; p < 0.001). Neurological improvement was achieved in 11 of 15 patients (73%); the median increase in Frankel classification was 1 (range 0-2; p = 0.006). Ten of 19 (53%) patients showed a reduction in MESCC; the median decrease in Bilsky grade was 1 (range 0-2; p = 0.005). There was no correlation between the change in Bilsky grade and pain relief (p = 0.421). However, the decrease in Bilsky grade significantly improved neurological symptoms (p = 0.01). No serious adverse events occurred.

CONCLUSION

Chemoembolization may be a useful palliative treatment modality for MESCC refractory to re-radiotherapy.

LEVEL OF EVIDENCE

Level 3b, Follow up Study.

Clinical features and outcomes of metastatic bone tumors of the pelvis

OBJECTIVE

The number of patients with metastatic bone tumors of the pelvis (MBTP) has increased, and the risk of metastasis and recurrence in the pelvic bones is difficult to assess. Therefore, we investigated the clinical features and oncological outcomes of patients with MBTP.

METHODS

We analyzed the clinical features and oncological outcomes of MBTP in 72 patients (42 men, 30 women; mean age, 50.5 years) from 2008 to 2017. Recurrence in the pelvic bones and survival rates were analyzed with regard to patients' potential contributing factors.

RESULTS

Enneking region I was the area most commonly containing MBTP (47.3%). Low- and high-grade tumors were identified in 40 and 32 patients, respectively. The most common pathological type was adenomatous carcinoma (34.7%), and the most common primary lesion was lung cancer (20.8%). The 3-year overall recurrence rate within the pelvic bones was 34.7%, and the 5-year overall survival rate was 29.2%.

CONCLUSION

Patients with MBTP have a high risk of recurrence in the pelvic bones and poor survival after multimodal treatment. Pelvic recurrence might be affected by the metastatic involvement, tumor grade, surgical margins, and type of surgery, whereas the survival rate tends to be associated with the tumor grade.

Iodine-125 radioactive seed brachytherapy as a treatment for spine and bone metastases: A systematic review and meta-analysis

AIM

To evaluate the analgesic efficacy, safety, and local tumor control of iodine-125 (¹²⁵I) seed brachytherapy (BT) for the management of spine and bone metastases.

METHODS

A systematic literature search was conducted using PubMed, the Cochrane Library, and Scopus databases. Data regarding patient demographics, tumor characteristics, procedural parameters, and clinical outcomes were extracted and analyzed.

RESULTS

Fourteen studies (7 prospective, 7 retrospective) were included, accounting for 689 patients, in our review. Analgesic efficacy was assessed at baseline and various postoperative time points. Significant improvement in pain was noted at 4- and 24-week follow-ups (p < 0.01). Interestingly, all studies that combined ¹²⁵I seed BT with cement augmentation reported relatively higher levels of pain reduction (mean pain reduction ≥4 points) as compared to the studies which applied ¹²⁵I seed BT as a stand-alone therapy (mean pain reduction ≥2 points), at the last follow-up. Local tumor control rates ranged widely from 14% to 100% at varying follow-ups. Median overall survival ranged between 10 months and 25 months. The overall complication rate was 19% (130/689) and mainly included minor subcutaneous hemorrhage, fever, myelosuppression, and seed displacement. Metrics assessing performance and quality of life demonstrated significant improvements from baseline to posttreatment.

CONCLUSION

¹²⁵I seed BT, alone or in conjunction with cement augmentation, may be a viable salvage therapy in appropriately selected patients. However, further studies are needed to analyze the long-term efficacy of this intervention as a palliative and curative modality.

Transarterial Chemoembolization for the Palliation of Painful Bone Metastases Refractory to First-Line Radiotherapy

PURPOSE

To compare the efficacy and safety of transarterial chemoembolization for the palliation of radiotherapy (RT)-failure bone metastases (BMs) with those of re-radiotherapy (Re-RT) in achieving pain relief.

MATERIALS AND METHODS

Fifty consecutive patients with RT-failure BMs who had undergone Re-RT (23 patients) and transarterial chemoembolization (27 patients) were retrospectively analyzed. The primary endpoint was clinical response, and the secondary endpoints were objective response and adverse events. Pain assessment was performed using the numerical rating scale, and tumor response was evaluated using the modified Response Evaluation Criteria in Solid Tumors. Pain relief was defined as lack of pain with no analgesic usage (complete pain response) or a decrease in pain score by ≥3 points with analgesic usage (partial pain response).

RESULTS

The pain relief rates in the Re-RT and transarterial chemoembolization groups were 57% and 92%, respectively (P = .006). The median pain relief duration was 2 and 3 months in the Re-RT and transarterial chemoembolization groups, respectively (P = .002). The 6-month pain-free survival rates were 30% and 51% in the Re-RT and transarterial chemoembolization groups, respectively (P = .08). The median tumor reduction rates were -4% and 9% in the Re-RT and transarterial chemoembolization groups, respectively (P < .001). The objective response rates were 0% and 11% in the Re-RT and transarterial chemoembolization groups, respectively (P = .29). No serious adverse events or complications were observed.

CONCLUSIONS

Transarterial chemoembolization achieved a superior response rate and longer duration of palliation in symptomatic RT-failure BMs.

Transcatheter arterial embolization for relapsed spinal metastatic paraganglioma: A case report

Spinal metastasis is a rare presentation of paraganglioma and an effective therapy for nonresectable spinal metastatic paraganglioma (MPG) has not yet been established. We report the case of a 42-year-old woman with metastatic spinal cord compression caused by a relapsed spinal MPG after decompressive surgery. We performed transcatheter arterial embolization (TAE) in addition to systemic chemotherapy. After TAE, the neurologic symptoms improved, and the back pain was reduced. After 3 sessions of TAE, MRI revealed that the tumor at the level of the seventh thoracic vertebra had shrunk and the pressure on spinal cord had decreased. TAE might be a feasible treatment option for spinal MPG, even after surgery or irradiation.

Palliative embolization for metastases of the spine

BACKGROUND

To present palliative selective and superselective arterial embolization with N-butyl-cyanoacrylate for cancer patients with spinal metastases.

MATERIALS AND METHODS

We studied the files of 164 cancer patients (94 men and 70 women; mean age 57.6 years; range 35-81 years) treated from March 2003 to March 2013 with 178 selective arterial embolization procedures for metastases of the spine from variable primary cancers. We evaluated the technical success of the embolization procedure with post-procedural angiography, the clinical effect in pain relief, need for analgesics and tumor size reduction, and the embolization-related complications.

RESULTS

Post-embolization angiography showed complete occlusion of the pathological feeding vessels in all procedures. Pain score and need for analgesics reduced by 50 % in 159 patients (97 %); no response was achieved in five patients with metastases of the sacrum. The mean duration of pain relief was 9.2 months (range 1-12 months). Metastatic tumor size reduced from a mean of 5.5 cm (range 3.5-7.5 cm) pre-embolization to a mean of 4.5 cm (range 3-5 cm) at the 6-month follow-up; the difference was not statistically significant. Ninety-three patients (56.7 %) experienced embolization-related complications the most common being post-embolization syndrome (80 patients, 48.8 %) followed by leg paresthesias (ten patients, 6 %), and rupture of a lumbar artery (one patient, 0.6 %).

CONCLUSION

Selective arterial embolization with N-butyl-cyanoacrylate should be considered for pain palliation of patients with metastases of the spine. However, pain relief is temporary, and complications, although minor may occur.

Spinal intraarterial chemotherapy: interim results of a Phase I clinical trial

OBJECT Despite advances in therapies using radiation oncology and spinal oncological surgery, there is a subgroup of patients with spinal metastases who suffer from progressive or recurrent epidural disease and remain at risk for neurological compromise. In this paper the authors describe their initial experience with a novel therapeutic approach that consists of intraarterial (IA) infusion of chemotherapy to treat progressive spinal metastatic disease. METHODS The main inclusion criterion was the presence of progressive, metastatic epidural disease to the spine causing spinal canal compromise in patients who were not candidates for the standard treatments of radiation therapy and/or surgery. All tumor histological types were eligible for this trial. Using the transfemoral arterial approach and standard neurointerventional techniques, all patients were treated with IA infusion of melphalan in the arteries supplying the epidural tumor. The protocol allowed for up to 3 procedures repeated at 3- to 6-week intervals. Outcome measures included physiological measures: 1) periprocedural complications according to the National Cancer Institute's Common Terminology Criteria for Adverse Events; and 2) MRI to assess for tumor response. RESULTS Nine patients with progressive spinal metastatic disease and cord compression were enrolled in a Phase I clinical trial of selective IA chemotherapy. All patients had metastatic disease from solid organs and were not candidates for further radiation therapy or surgery. A total of 19 spinal intraarterial chemotherapy (SIAC) procedures were performed, and the follow-up period ranged from 1 to 7 months (median 3 months). There was 1 serious adverse event (febrile neutropenia). Local tumor control was seen in 8 of 9 patients, whereas tumor progression at the treated level was seen in 1 patient. CONCLUSIONS These preliminary results support the hypothesis that SIAC is feasible and safe.

Bone tumor imaging, then and now: review article

BACKGROUND

Musculoskeletal tumor imaging is a focused subspecialty of musculoskeletal radiology. The goals of imaging and techniques employed are continually evolving and often slightly different from those used in other musculoskeletal diseases. As these techniques change, it is occasionally useful to review what is new.

QUESTIONS/PURPOSES

The question addressed in this manuscript is what are the most interesting/relevant changes in each modality of musculoskeletal tumor imaging over the past 38 years, the length of time the newly emeritus chair of the Radiology and Imaging Department of Hospital for Special Surgery has been at the hospital.

METHODS

This review is primarily expert opinion based in examining techniques used at the institutions of the authors, with support from current literature.

RESULTS

The techniques of computed tomography (CT) and magnetic resonance imaging (MRI) are new to the imaging armamentarium, and ultrasound and nuclear medicine techniques have advanced considerably with technology. Although radiographs have also evolved, the changes are less apparent, except in how they are currently processed, viewed, and stored.

CONCLUSIONS

Radiographic evaluation is still critical to evaluating bone tumors. Newer techniques also play an important role in diagnosing and treating these neoplasms.

Management of painful pelvic bone metastasis of renal cell carcinoma using embolization, radio-frequency ablation, and cementoplasty: a prospective evaluation of efficacy and safety

PURPOSE

To measure the impact on pain relief and patient quality of life using embolization radio-frequency ablation and cementoplasty (ERC) for local combination therapeutic management of painful pelvic bone metastasis of renal cell carcinoma (RCC).

MATERIALS AND METHODS

This prospective monocentric registry was approved by our Local Institutional Review Board. Between January 2008 and January 2013, all consecutive patients who fully met the inclusion criteria were enrolled in the ERC-procedure prospective registry. They were assigned to follow-up at discharge and again at 1 and 6 months. Efficacy was evaluated using a pain visual analog scale (VAS), and narcotic consumption and quality of life were assessed using the Brief Pain Inventory questionnaire.

RESULTS

Fifty-two patients were enrolled, among whom 58 lesions were treated. Technical success was obtained in all procedures. The median VAS score decreased from 7 ± 1.4 (ranges 5-10) at baseline to 3 ± 1.5 (ranges 0-6) at discharge, 2 ± 1.5 (ranges 0-5) at 1 month (p < 0.0001), and 2 ± 1.6 (ranges 0-5) at 6 months. In 28 patients (54 %), narcotic consumption was halved at discharge and halved in 40 (77 %) patients at 1 and 6 months compared with baseline. Five patients had complete pain relief at 1 month. A major improvement in quality of life, especially regarding mood and motion, was observed in all patients.

CONCLUSION

This specific approach to painful bone metastasis is efficient and safe and yields sustained results. The ERC procedure could be suggested for patients with RCC bone metastasis.

[Management of spinal metastases of lung cancer]

INTRODUCTION

Spinal metastases of lung cancer occur frequently and lead to the risk of spinal cord compression. Our objective is to clarify the management of this disease, emphasizing, in particular the use of prognostic scores.

BACKGROUND

The first step is to evaluate the characteristics of the spinal lesion and its impact on the autonomy and quality of life of the patient. A clinical examination is complemented by imaging procedures, such as X-rays, MRI of the spine, and PET scanning. The precise characterization of the spinal lesion permits the calculation of a predictive score for mechanical stability. The characteristics of the disease (number of metastatic sites, therapeutic possibilities, co-morbidities) can be used in decision-making.

VIEWPOINTS

The use of prognostic scores is recommended by the Global Spine Tumour Study Group (GSTSG) for the management of spinal metastases. Among these scores, the most used are the Tokuhashi index, and the Tomita classification. They help to identify the treatment modalities, sometimes combined that might be used in the management: surgery, vertebral resection, tumour embolisation, radiotherapy, chemotherapy.

CONCLUSIONS

The management of spinal metastases of lung cancer should be multidisciplinary. Use of prognostic scores should be encouraged to identify optimal management.

Intercostal artery pseudoaneurysm formation after irinotecan transarterial chemoembolization of a spinal metastasis from colorectal cancer

Over the past decade, irinotecan has become one of the first-line chemotherapeutic agents used in the treatment of metastatic colorectal cancer. Recently, irinotecan has been administered transarterially in order to perform chemoembolization in the liver. In the limited number of reports available to date using this approach, serious adverse effects have not yet been reported. In this paper, we describe the formation of an intercostal artery pseudoaneurysm after transarterial chemoembolization with irinotecan-eluting beads in a patient with spinal metastasis from colorectal cancer.

2012 European thyroid association guidelines for metastatic medullary thyroid cancer

Distant metastases are the main cause of death in patients with medullary thyroid cancer (MTC). These 21 recommendations focus on MTC patients with distant metastases and a detailed follow-up protocol of patients with biochemical or imaging evidence of disease, selection criteria for treatment, and treatment modalities, including local and systemic treatments based on the results of recent trials. Asymptomatic patients with low tumor burden and stable disease may benefit from local treatment modalities and can be followed up at regular intervals of time. Imaging is usually performed every 6-12 months, or at longer intervals of time depending on the doubling times of serum calcitonin and carcinoembryonic antigen levels. Patients with symptoms, large tumor burden and progression on imaging should receive systemic treatment. Indeed, major progress has recently been achieved with novel targeted therapies using kinase inhibitors directed against RET and VEGFR, but further research is needed to improve the outcome of these patients.

[Chemoembolization of symptomatic bone metastases: technical considerations and therapeutic effectiveness]

Chemoembolization of bone metastases is defined by the intraarterial perfusion of a chemotherapy agent followed by microparticles embolization to improve tissue impregnation. This technique increases the local concentration of the chemotherapy agent. Tumor response (stable or reduced tumor size) is achieved in 30-80% of cases with symptomatic relief in over 80% of cases. The indications, technical considerations, and effectiveness of this procedure will be reviewed.

Palliative interventions for pain in cancer patients

Pain is a debilitating problem that is common to most patients with cancer at some time during the course of their disease. Conventional therapies such as opiate analgesics and radiation therapy provide suboptimal and limited relief. Novel image-guided interventions have made a significant impact in the management of this difficult problem. This article reviews some of the most promising image-guided techniques for relieving bone and visceral pain in patients suffering from cancer.

Characterizing clinicopathological findings of transarterial chemoembolization for Wilms tumor

PURPOSE

We characterized the clinicopathological changes after transarterial chemoembolization for treatment of Wilms tumor.

MATERIALS AND METHODS

A total of 44 consecutive patients with Wilms tumor were randomized to undergo transarterial chemoembolization preoperatively or to undergo surgery only. We compared the clinicopathological findings of resected tumor from the 2 groups.

RESULTS

Tumor-free survival at 2 years in the group undergoing transarterial chemoembolization was significantly higher compared to the control group (p <0.01), and tumor related recurrence and deaths within 1 year were significantly lower in the study group than in controls (p <0.01). Average tumor shrinkage was 48.2% in the study group. Average area of necrosis in tumor sections was 63.5% in the study group and 15% in controls (AUC 2.78, p <0.01). Percentage of tumor with moderate to severe interstitial fibrosis was 64% (14 of 22 patients) in the study group and 18% (4 of 22) in controls (AUC 2.72, p <0.01). Comparative rates of percentage of tumor demonstrating grade III to IV lymphocytic infiltration were 73% (16 of 22 patients) and 18% (4 of 22, chi-square 11.6, p <0.01), median mitotic index in tissues 1.4 and 0.19 (AUC 55.7, p <0.01), and median apoptotic index of tumor cells 28.1 and 12.8 per 10 microscopic fields (AUC 109.00, p <0.05). Expression of p53 and Bcl-2 protein did not differ between the groups, but Bax protein expression was significantly higher in the study group (85% vs 40%, p <0.05).

CONCLUSIONS

Transarterial chemoembolization induces tumor cell necrosis, degeneration and apoptosis, while also boosting interstitial fibrous tissue hyperplasia and lymphocyte infiltration. These histopathological findings could help explain the basis of the better clinical outcome in patients with Wilms tumor who underwent preoperative transarterial chemoembolization.

Percutaneous techniques in the treatment of spine tumors: what are the diagnostic and therapeutic indications and outcomes?

STUDY DESIGN

Systematic review of the literature.

OBJECTIVE

Should cement augmentation procedures such as vertebroplasty and kyphoplasty be used in patients with painful compression fractures associated with metastatic spine disease? What is the role of embolization in the treatment of metastatic spine disease?

SUMMARY OF BACKGROUND DATA

Vertebral augmentation is commonly employed in treating osteoporotic fractures and is now increasingly used in the management of pain in patients with spinal tumors. Intra-arterial and transcutaneous embolization techniques are also available in the management of spinal tumors. To date, the effectiveness and safety of these procedures have not been adequately demonstrated.

METHODS

A review of the English literature was performed in Pub-Med. One search was performed using the following keywords: cancer, tumor, vertebroplasty, kyphoplasty, vertebral augmentation, outcome, safety, pain, and quality of life. A Second search was performed using the keywords: embolization, spinal, and tumors. Original studies reporting on at least 10 patients were included and systematically reviewed. The results were reviewed and discussed through consensus among a multidisciplinary panel of expert members of the Spine Oncology Study Group. Recommendations were made according to the Guyatt Guidelines.

RESULTS

A total of 1665 abstracts were identified. Twenty-eight articles using vertebroplasty reported on 877 patients and 1599 treated levels. Medical and neurologic complications varied from 0% to 7.1% and 0% to 8.1%, respectively. Twelve articles using kyphoplasty reported on 333 patients and 481 treated levels. Medical complication rates varied from 0% to 0.5%, without any neurologic complications. Pain and functional outcomes were universally successful using either technique. Ten studies on embolization reported on 330 patients. There were 4 permanent complications (1.4%). Complete or partial embolization was possible in 97.5% with an estimated reduction of intraoperative blood loss of 2.3 L.

CONCLUSION

There is strong recommendation and moderate evidence for vertebral augmentation as safe and effective in providing pain relief and improving functional outcome in patients with vertebral body fractures and axial pain due to metastatic disease. There is a strong recommendation and very low evidence for embolization techniques as safe and effective in decreasing intraoperative blood loss in hypervascular tumors.

Medullary thyroid cancer: management guidelines of the American Thyroid Association

BACKGROUND

Inherited and sporadic medullary thyroid cancer (MTC) is an uncommon and challenging malignancy. The American Thyroid association (ATA) chose to create specific MTC Clinical Guidelines that would bring together and update the diverse MTC literature and combine it with evidence-based medicine and the knowledge and experience of a panel of expert clinicians.

METHODS

Relevant articles were identified using a systematic PubMed search and supplemented with additional published materials. Evidence-based recommendations were created and then categorized using criteria adapted from the United States Preventive Services Task Force, Agency for Healthcare Research and Quality.

RESULTS

Clinical topics addressed in this scholarly dialog included: initial diagnosis and therapy of preclinical disease (including RET oncogene testing and the timing of prophylactic thyroidectomy), initial diagnosis and therapy of clinically apparent disease (including preoperative testing and imaging, extent of surgery, and handling of devascularized parathyroid glands), initial evaluation and treatment of postoperative patients (including the role of completion thyroidectomy), management of persistent or recurrent MTC (including the role of tumor marker doubling times, and treatment of patients with distant metastases and hormonally active metastases), long-term follow-up and management (including the frequency of follow-up and imaging), and directions for future research.

CONCLUSIONS

One hundred twenty-two evidence-based recommendations were created to assist in the clinical care of MTC patients and to share what we believe is current, rational, and optimal medical practice.

Sacral tumors and management

The evaluation and complex treatments of sacral tumors require a multidisciplinary approach. Because of the complex anatomy conditions and biomechanics of the lumbo-pelvic junction, surgical treatment of sacral neoplasms is one of the most challenging fields in spine. Here, diagnostic process and surgical and nonsurgical treatment options for sacral tumors are summarized based on the literature and on the authors' own experiences.

[Image-guided ablation of bone tumors: review of current techniques]

Multiple interventional radiology techniques are available for percutaneous ablation of bone tumors: alcohol, laser, radiofrequency, microwave, ultrasound, and cryogenic ablation. Several indications have already been validated, including radiofrequency ablation of osteoid osteoma and bone metastases, with results superior to conventional treatment. More indications should be added over the coming years. The purpose of this article is to review the principles of the different ablation techniques, summarize their respective indications and results and discuss their implementation and the eventual combination with cementoplasty techniques.

Transcatheter and ablative therapeutic approaches for solid malignancies

The purpose of this article is to present in a concise manner an overview of the most widely used locoregional transcatheter and ablative therapies for solid malignancies. An extensive MEDLINE search was performed for this review. Therapies used for liver cancer were emphasized because these therapies are used most commonly in the liver. Applications in pulmonary, renal, and bone tumors were also discussed. These approaches were divided into catheter-based therapies (such as transcatheter arterial chemoembolization, bland embolization, and the most recent transcatheter arterial approach with drug-eluting microspheres), ablative therapies (such as chemical [ethanol or acetic acid injection]), and thermal ablative therapies (such as radiofrequency ablation, laser induced thermotherapy, microwave ablation, cryoablation, and extracorporeal high-intensity focused ultrasound ablation). A brief description of each technique and analysis of available data was reported for all therapies. Locoregional transcatheter and ablative therapies continue to be used mostly for palliation, but have also been used with curative intent. A growing body of evidence suggests clear survival benefit, excellent results regarding local tumor control, and improved quality of life. Clinical trials are underway to validate these results. Image-guided transcatheter and ablative approaches currently play an important role in the management of patients with various types of cancer-a role that is likely to grow even more given the technological advances in imaging, image-guidance systems, catheters, ablative tools, and drug delivery systems. As a result, the outcomes of patients with cancer undoubtedly will improve.

Transarterial embolization of primary and secondary tumors of the skeletal system

Percutaneous transcatheteral embolizations of primary and secondary bone tumors are important minimal invasive angiographic interventions of the skeletal system. In most of the cases embolization is performed for preoperative devascularization or as a palliative measure to treat tumor-associated pain or other tumor bulk symptoms. The transarterial embolization of primary and secondary tumors of the skeletal system has been developed to a safe and very effective method. Indications, techniques, results and complications of this minimal invasive interventional therapy for treatment of primary and secondary bone tumors are described and discussed and compared with the newer literature and our own results.

Surgical management of metastatic spine tumors

Recent advances in diagnostic tests and radiologic imaging, and the development of novel chemotherapeutic agents and radiation methods have greatly altered the treatment options in patients who have spinal tumors. Improvements in fundamental understanding of the mechanisms of bone metastases, developments in spinal instrumentation, and recent introduction of recombinant bone morphogenetic proteins for spinal reconstruction offer promising strategies in selected patients. Clear applications of the fundamental surgical oncology still apply to spinal tumors. This article considers recent advances in management of the metastatic tumors to the spine.

Image-guided ablation of painful metastatic bone tumors: a new and effective approach to a difficult problem

Painful skeletal metastases are a common problem in cancer patients. Although external beam radiation therapy is the current standard of care for cancer patients who present with localized bone pain, 20-30% of patients treated with this modality do not experience pain relief, and few further options exist for these patients. For many patients with painful metastatic skeletal disease, analgesics remain the only alternative treatment option. Recently, image-guided percutaneous methods of tumor destruction have proven effective for treatment of this difficult problem. This review describes the application, limitations, and effectiveness of percutaneous ablative methods including ethanol, methyl methacrylate, laser-induced interstitial thermotherapy (LITT), cryoablation, and percutaneous radiofrequency ablation (RFA) for palliation of painful skeletal metastases.

Preoperative embolization in spinal and pelvic metastases

The role of preoperative embolization should be evaluated for the surgical treatment of spinal and pelvic metastases. Selective embolization was performed in 32 patients (19 men, 13 women; mean age 63.4 years) before surgery by anterior resection of spinal metastases (n = 21) or pelvic metastases (n = 11). Evaluation parameters consisted of the intraoperative blood loss, the need for blood replacement, and the operating time. There was a significant difference in blood loss and transfusion requirements in the spinal group (P = 0.02) as well as in the pelvic group (P = 0.05) compared to a nonembolized control group of spinal (n = 20) and pelvic (n = 10) metastases. The operating time in the embolized group was shorter, but the difference was not significant. Surgical revision was required in two cases in the embolized spinal group owing to necrosis of the psoas muscle. No neurological deficit was observed that could be attributed to the embolization procedure. Preoperative embolization is thus a suitable method for reducing intraoperative blood loss and transfusion requirements in hypervascularized spinal and pelvic metastases.