The role of percutaneous transarterial embolization in the management of spinal bone tumors: a literature review

Tumor Microenvironment Triggered In Situ Coagulation of Supramolecularly Engineered Platelets for Precise Tumor Embolization

Although embolization therapy has demonstrated success in impeding tumor growth, concerns persist regarding potential tumor recurrence and inadvertent embolization of non-target tissues. In this study, drawing inspiration from the natural targeting and coagulation process of platelets in injured blood vessels, platelets are engineered by integrating acid-sensitive, morphology-transformable nanoparticles onto their surface through supramolecular conjugation (PLT-NP). The nanoparticles are constructed through the self-assembly of a β-amyloid derived peptide (FFVLK) terminally functionalized with Fmoc, hexahistidine (His6), and a polyethylene glycol (PEG)-functionalized cyclodextrin (CD). The supramolecularly engineered platelets actively accumulate in the tumor tissue upon inducing a tumor blood vessel injury through tumor resection. In response to the local acidic microenvironment, the nanoparticles undergo a morphological transformation into nanofibers via spontaneous assembly of FFLVK into fibril structures through hydrogen bonding and β-sheet interactions, to artificially enhance the coagulation and aggregation of platelets, causing occlusion of tumor blood vessels. The supramolecularly engineered platelets efficiently embolize tumor blood vessels in a specific manner, effectively suppressing tumor growth, metastasis, and recurrence, thus offering a promising paradigm for combating cancer.

Pain Management in Pediatrics: What the IR has to Offer

Pediatric pain management presents unique challenges due to the intrinsic characteristics of children such as their developmental stages, communication barriers, and varying pain perceptions. Life-limiting conditions affecting children are a growing medical concern, requiring a comprehensive, multidisciplinary approach to improve quality of life or ensure a dignified end of life. Interventional radiology (IR) plays a critical role in this strategy, similar to its role in adult care. Not only life-limiting conditions pose a challenge in pediatric chronic pain management, but also other benign chronic diseases (e.g., cystic fibrosis, muscular dystrophy, neurodegenerative disorders, metabolic disorders). This review focuses on specific IR strategies for pediatric pain management, including ablation, embolization/chemoembolization, and nerve blocks. It emphasizes the importance of tailored approaches for pediatric patients, considering genetic disorders and oncological diseases, which may require a diverse range of IR treatments. The aim is to provide a summary of these interventional techniques and highlight the unique considerations necessary for effective pediatric pain management.

How Arterial Embolization Is Transforming Treatment of Oncologic and Degenerative Musculoskeletal Disease

BACKGROUND

Arterial embolization is a minimally invasive treatment that occludes blood vessels supplying pathological tissue. Developed to control bleeding without surgery, it has evolved over decades and is now applied in musculoskeletal oncology as a preoperative treatment, palliative care, or standalone therapy for select tumors. Recently, its use has expanded globally in treating chronic pain syndromes and osteoarthritis.

MATERIALS AND METHODS

We reviewed the literature on arterial embolization in various musculoskeletal conditions. The focus was on established oncologic indications for primary and metastatic bone or soft tissue tumors, and emerging evidence on degenerative diseases like osteoarthritis, inflammatory musculoskeletal pathology, and intractable pain. Emphasis was placed on leading studies regarding efficacy, complications, and recurrence rates.

DISCUSSION

Arterial embolization has progressed from bleeding control to a versatile therapeutic option in musculoskeletal medicine. It offers symptom relief, reduces tumor size, and improves quality of life. Applications include oncologic interventions and management of degenerative and inflammatory conditions. Despite its benefits, variations in complications and recurrence rates highlight the need for standardized protocols and further research.

CONCLUSIONS

Arterial embolization is a safe and effective minimally invasive tool in the multidisciplinary management of a wide range of musculoskeletal pathologies. Ongoing research is crucial to understand long-term efficacy, optimize protocols, and broaden its applications.

The application of interventional methods in control of blood loss during giant upper extremity tumor resection

BACKGROUND

The purposes of this retrospective study were to determine the efficacy of interventional methods in control of intraoperative blood losses and investigate the perioperative complications.

METHODS

The cases of 44 patients in whom a giant upper extremity tumor had been operated between 2008 and 2022 were analyzed retrospectively. Of these, 29 patients were treated with interventional methods (Group A) and 15 were treated without (Group B). Group A was further divided based on the intervention methodss: Group C (combination of balloon occlusion and transarterial embolization [TAE], n = 11) and Group D (single TAE, n = 18). Within Group D, patients were categorized based on the timing of TAE relative to surgery into Group E (TAE on the same day as surgery) and Group F (TAE performed days before surgery). We compared demographic features, blood loss, ICU admission rates, and use of vasopressors during surgery.

RESULTS

We collected clinical records from 44 patients diagnosed with a giant upper extremity tumor who underwent surgery. Group sizes were as follows: A (29), B (15), C (11), D (18), E (7), and F (11). Tumor volumes in the interventional and non-interventional groups were similar (704.19 ± 812.77 cm³ vs. 1224.53 ± 1414.01 cm³, P = 0.127). Blood plasma transfusion was significantly higher in Group B compared to Group A (425.33 ± 476.20 ml vs. 155.90 ± 269.67 ml, P = 0.021). Although overall blood loss did not significantly differ between Group A and Group B (467.93 ± 302.08 ml vs. 1150 ± 1424.15 ml, P = 0.087), the rate of massive bleeding (defined as blood loss over 1000 ml) was lower in Group A (6.9% vs. 46.47%, P = 0.004). The proportion of minors (patients aged less than 18) in Group C was significantly higher than in Group D (27.7% vs. 0.00%, P = 0.045). The amount of RBC transfusion was also significantly higher in Group C compared to Group D (458.18 ± 292.22 ml vs. 164.44 ± 224.03 ml, P = 0.021). No significant perioperative complications were observed.

CONCLUSIONS

Interventional techniques have been shown to reduce both blood loss and the necessity for blood transfusions in patients with large upper extremity tumors. Furthermore, no significant perioperative complications have been observed.

The use of interventional procedures for cancer pain. A brief review

CONTEXT

Pain is a common experience in people living with cancer. Concerns around opioid prescribing have seen a move toward a multi-modality management approach, which includes interventional pain procedures.

PURPOSE

In this paper we discuss the interventional pain procedures used to treat cancer pain at two major tertiary centers in Australia.

METHODS AND RESULTS

This expert review provides practical insights on cancer pain management from healthcare providers in different specialties. These insights can be used to guide the management of a wide range of cancer pain types.

CONCLUSIONS

Furthermore, this review identifies the need for a systematic and comprehensive approach to the management of cancer pain that is broader than that of a single specialty. With recent advances in pain management procedures, an interdisciplinary approach is essential in order to provide an up to date, patient tailored approach to pain management. This review will help inform the development of a cancer pain intervention registry.

Effect of denosumab in treatment of unresectable spine and sacrum giant cell tumor of bone

Giant cell tumor of bone (GCTB) is a rare tumor of the bone that is locally invasive. Surgery is the primary treatment that is usually done by intralesional curettage. In pelvis and spine surgery may be associated with high rate of complications, recently, Denosumab has been proposed for the treatment of these tumors in latter anatomical regions. Denosumab may be administered alone or as an adjuvant to surgery. This study aimed to assess the treatment effects of Denosumab in patients with unresectable GCTB. This study was a case series. Patients with unresectable GCTB of vertebra and sacrum were enrolled in this study. Patients received 120 mg of monthly Denosumab and additional doses on days 8th and 15th of treatment. Images of patients before and after treatment were evaluated. Nine patients with a median age of 30 years with spine and sacrum GCTB were included in this study. The median time of treatment with denosumab was 28 months (range: 3-67). Tumor control was seen in all patients. According to Inverse Choi density/size (ICDS), criteria objective response (complete response and partial response) was seen in 8 patients, and one had stable disease. Based on CT scan images, in 4 patients (44.44%), less than 50% of the transverse diameter of the tumor became ossified, and in the other five patients (55.55%), more than 50% of the tumor's transverse diameter became ossified. The median tumor volume before treatment was 829 cm3, and after treatment was 504 cm3 which was significantly reduced (P = 0.005). No complication related to therapy was seen. Tumor response was seen in all patients, and tumor control according to ICDS criteria was evident in all cases. This finding was in line with previous studies. Clinical improvement of signs and symptoms was also seen in all patients. Generally, our study demonstrates a sustained clinical benefit and tumor response with Denosumab, as tumor response ≥ 24 weeks was evident in all cases. No side effects were seen in patients despite long-term treatment with Denosumab.

Efficacy of Subtraction Computed Tomography Arteriography During Preoperative Embolization in Spinal Tumors

Background

This study aimed to evaluate the efficacy of subtraction computed tomography arteriography (s-CTA) during preoperative embolization in spinal tumors.

Methods

The study analyzed 17 vertebrae in 13 patients who underwent preoperative embolization before spinal fixation surgery for malignant spinal tumors to decrease blood loss at our hospital from 2019 to 2021. Their ages ranged from 56 to 88 years (average, 73.5 years). Metastatic bone tumors were most common, including five cases originating as lung carcinomas and three as renal cancers. After digital subtraction angiography of selected tumor-feeding arteries and non-subtraction CTA (ns-CTA) were performed, s-CTA was conducted using data obtained from both procedures. A clarity score of the boundary between the normal bone and tumor was derived for each patient, which was then classified into four grades (good, 3 points; fair, 2 points; faint, 1 point; poor, 0 points) by two experienced radiologists, followed by a comparison between the s-CTA and ns-CTA groups using the Wilcoxon signed-rank test.

Results

Clarity scores were significantly higher in the s-CTA group than in the ns-CTA group (P < 0.001). The agreement of Cohen's coefficients between the two radiologists was κ = 0.724 in s-CTA scoring and κ = 0.622 in ns-CTA scoring, which were moderately matched. Seven arteries were not embolized due to insufficient tumor contrast enhancement and their poor relation to the surgical invasion zone. No complications were observed during or after embolization.

Conclusion

S-CTA successfully distinguished between tumor and normal bone and may help avoid unnecessary embolization.

Current state of preoperative embolization for spinal metastasis - A survey by the EANS spine section

Introduction

Preoperative embolization (PE) for spinal metastasis can be used to reduce tumor blood supply in selected patients. The decision whether and when to perform PE varies largely among spine surgeons and centers.

Research question

The aim was to understand the current decision-making process in European spine centers.

Material and methods

The European Association of Neurosurgical Societies (EANS) spine section designed a 13-item online survey. It was distributed to neurosurgical residents and board-certified neurosurgeons between 7th of February and May 5, 2023.

Results

We analyzed 120 survey responses. Most participants were board-certified neurosurgeons (71%) or residents (26%) in university hospitals (76%). Routinely performed PE was stated not a common practice in 62%. Of those using PE, 25% indicated to perform it in selected cases requiring vertebral body replacement. Reasons for not performing PE included lack of time (44%), unclear benefits (25%), no significant bleeding without PE (19%), and significant bleeding despite PE (8%). Most participants opted for PE < 24h before surgery, but in a separate anesthesia (54%). More experienced participants were more likely to observe reduced blood loss (BL) after PE (p = 0.014). The most common reported complications were neurological deterioration due to spinal cord infarction (n = 15) and swelling due to tumor necrosis (n = 13).

Discussion and conclusions

PE is still not a routine among European spine surgeons and is considered mostly for elective cases with hypervascularized tumors scheduled in a separate anesthesia <24h before tumor resection. Most participants noted reduced intraoperative BL, but also a risk of procedure-related complications.

Musculoskeletal Interventional Oncology: A Contemporary Review

Musculoskeletal interventional oncology is an emerging field that addresses the limitations of conventional therapies for bone and soft-tissue tumors. The field's growth has been driven by evolving treatment paradigms, expanding society guidelines, mounting supportive literature, technologic advances, and cross-specialty collaboration with medical, surgical, and radiation oncology. Safe, effective, and durable pain palliation, local control, and stabilization of musculoskeletal tumors are increasingly achieved through an expanding array of contemporary minimally invasive percutaneous image-guided treatments, including ablation, osteoplasty, vertebral augmentation (with or without mechanical reinforcement via implants), osseous consolidation via percutaneous screw fixation (with or without osteoplasty), tumor embolization, and neurolysis. These interventions may be used for curative or palliative indications and can be readily combined with systemic therapies. Therapeutic approaches include the combination of different interventional oncology techniques as well as the sequential application of such techniques with other local treatments, including surgery or radiation. This article reviews the current practice of interventional oncology treatments for the management of patients with bone and soft-tissue tumors with a focus on emerging technologies and techniques.

Treatment progress of spinal metastatic cancer: a powerful tool for improving the quality of life of the patients

Spinal metastasis is a common secondary malignant tumor of the bone, often resulting in spinal cord and nerve root compression, leading to obvious pain and related compression symptoms. This condition has a high incidence and mortality rate. The treatment approach for most patients with spinal metastasis is primarily palliative. Consultation with a multidisciplinary team is widely accepted as a comprehensive treatment approach for patients with spinal metastases. With advancements in research and technology, the evaluation and treatment of spinal metastatic cancer are continuously evolving. This study provides an overview of surgical treatment, minimally invasive treatment, and radiotherapy for spinal metastatic cancer and also analyzes the clinical effects, advantages, and current limitations associated with various treatment approaches.

Vertebral Primary Bone Lesions: Review of Management Options

The assessment and treatment of vertebral primary bone lesions continue to pose a unique yet significant challenge. Indeed, there exists little in the literature in the way of compiling and overviewing the various types of vertebral lesions, which can often have complicated intervention strategies. Given the severe consequences of mismanaged vertebral bone tumors-including the extreme loss of motor function-it is clear that such an overview of spinal lesion care is needed. Thus, in the following paper, we aim to address the assessment of various vertebral primary bone lesions, outlining the relevant nonsurgical and surgical interventional methods. We describe examples of primary benign and malignant tumors, comparing and contrasting their differences. We also highlight emerging treatments and approaches for these tumors, like cryoablation and stereotactic body radiation therapy. Ultimately, we aim to emphasize the need for further guidelines in regard to correlating lesion type with proper therapy, underscoring the innate diversity of vertebral primary bone lesions in the literature.

The treatment of aneurysmal bone cysts

PURPOSE OF REVIEW

Aneurysmal bone cysts are rare, locally aggressive bone tumors. Optimal treatment of ABCs is still matter of debate as therapies including sclerotherapy, selective arterial embolization and systemic treatment with denosumab are increasingly utilized, in addition to or instead of traditional curettage. The purpose of this review is to discuss current concepts and difficulties in diagnosing and treating primary ABCs, based on latest available literature.

RECENT FINDINGS

In diagnostics, multiple new fusion partners of USP-6 have been described on next-generation sequencing specifically for primary ABCs. In a recent systematic review, failure rates of percutaneous injections and surgery were comparable. In a literature review, the use of denosumab seemed effective but resulted in multiple cases of severe hypercalcemia in children.

SUMMARY

Accurately diagnosing primary ABC is crucial for treatment decisions. Curettage remains a valid treatment option, especially with adjuvant burring, autogenous bone grafting and phenolization. Percutaneous sclerotherapy represents a solid alternative to surgery, with polidocanol showing good results in larger studies. Systematic therapy with denosumab exhibits favorable results but should be reserved in the pediatric population for unresectable lesions, as it may result in severe hypercalcemia in children. When selecting a treatment option, localization, stability and safety should be considered.

Comparison of the prognostic factors of total en bloc spondylectomy and total piecemeal spondylectomy in patients with Enneking stage III giant cell tumor in the thoracic and lumbar spine

PURPOSE

To compare total en bloc spondylectomy with marginal margins against piecemeal spondylectomy with intralesional margins in the surgical treatment of Enneking stage III spinal giant cell tumor (GCT) in terms of local recurrence.

METHODS

A retrospective survival analysis of patients with Enneking stage III GCT who underwent TES with marginal margins or total piecemeal spondylectomy with intralesional margins was performed between January 2006 and April 2020. Local recurrence-free survival (LRFS) was the time between the date of surgery and recurrence. Factors with p-values < 0.05 in the univariate analysis were included in the multivariate analysis using proportional hazard analysis.

RESULTS

Sixty patients (25 men and 35 women) with a mean age of 35.6 (range 11-71) years were included. The mean follow-up duration was 93 (range 24-198) months. Two patients were lost to follow-up 6 and 14 years after the procedure. Over a 10-year period, the recurrence rate was 13.3%. The 2-, 5-, and 10-year LRFS rates were 95%, 88%, and 78%, respectively. Univariate analysis identified total piecemeal spondylectomy and no adjuvant radiotherapy as prognostic factors for LRFS. Multivariate Cox-regression models showed a significant association between local recurrence and total piecemeal spondylectomy and no adjuvant radiotherapy.

CONCLUSION

TES with marginal margins is better than total piecemeal spondylectomy with intralesional margins owing to its lower postoperative recurrence rate. Adjuvant radiotherapy should be administered to reduce postoperative recurrence rates.

Update on Interventional Radiology of the Spine

Interventional radiologists now perform spinal interventions routinely for diagnostic and therapeutic purposes. New technologies for the management of spine pathologies have emerged with promising results in terms of safety and efficacy. Interventional radiology techniques in the spine include percutaneous biopsy and therapies for intervertebral disk herniation or spinal stenosis, facet and sacroiliac joint pathologies, vertebral and sacral fractures, and metastases. These techniques can also be easily combined one with the other or to further therapeutic approaches including systemic therapies, surgical approaches, and radiotherapy. This review provides a comprehensive overview of current percutaneous imaging-guided interventional radiology techniques in the spine. It will help readers become familiar with the most common indications, learn about different technical considerations during performance, and review the available evidence. Controversies concerning new products and technical approaches are also addressed.

A Cohort Study to Evaluate the Efficacy and Value of CT Perfusion Imaging in Patients with Metastatic Osteosarcoma after Chemotherapy

Objective

A case-control study was conducted to explore the efficacy of cohort study and value of CT perfusion imaging in patients with metastatic osteosarcoma after chemotherapy.

Methods

Eighty patients with metastatic osteosarcoma treated in our hospital from March 2020 to December 2021 were divided into two groups. According to their different treatment methods, the chemotherapy+antiangiogenesis group had 36 cases and the chemotherapy group had 44 cases. All patients were scanned by 64-slice spiral CT before and after treatment. The differences of tumor volume and perfusion parameters before and after treatment were compared, and the correlation between perfusion parameters and tumor microvessel density (MVD) was analyzed. The receiver working curve (ROC curve) was used to evaluate the efficacy of the two groups after chemotherapy.

Results

Blood flow (BF), blood volume (BV), Pallak blood volume (PBV), and time to start (TTS) in the antitumor angiogenesis+chemotherapy group were significantly lower than those before treatment (P < 0.05). Microvessel density was positively correlated with PS, BF, BV, and PBV (P < 0.05). The reduction rate of BV and BF in the remission group after treatment was significantly higher than that in the nonremission group. When the BV and BF decline rates were 47.37% and 21.53% and the areas under the curve were 0.968 and 0.916, respectively, the diagnostic effect was the best. When the decrease rate of BV was 47.48% and the decrease rate of BF was 21.55%, the sensitivity was 94.72% and 89.56% and the specificity was 91.31% and 91.31%.

Conclusion

The reduction rate of BV and BF in CT perfusion imaging is of high value in evaluating the efficacy of radiotherapy and chemotherapy in patients with NSCLC and can provide more objective basis for observing the changes and judging the prognosis of osteosarcoma after treatment.

State of the Art and New Concepts in Giant Cell Tumor of Bone: Imaging Features and Tumor Characteristics

Giant cell tumor of bone (GCTB) is classified as an intermediate malignant tumor due to its locally aggressive behavior, burdened by high local recurrence rate. GCTB accounts for about 4-5% of all primary bone tumors and typically arises in the metaphysis and epiphyses of the long tubular bones. Mutation of gene H3F3A is at the basis of GCTB etiopathogenesis, and its immunohistochemical expression is a valuable method for practical diagnosis, even if new biomarkers have been identified for early diagnosis and for potential tumor recurrence prediction. In the era of computer-aided diagnosis, imaging plays a key role in the assessment of GCTB for surgical planning, patients' prognosis prediction and post treatment evaluation. Cystic changes, penetrating irregular margins and adjacent soft tissue invasion on preoperative Magnetic Resonance Imaging (MRI) have been associated with a higher rate of local recurrence. Distance from the tumor edge to the articular surface and thickness of unaffected cortical bone around the tumor should be evaluated on Computed Tomography (CT) as related to local recurrence. Main features associated with local recurrence after curettage are bone resorption around the graft or cement, soft tissue mass formation and expansile destruction of bone. A denosumab positive response is represented by a peripherical well-defined osteosclerosis around the lesion and intralesional ossification. Radiomics has proved to offer a valuable contribution in aiding GCTB pre-operative diagnosis through clinical-radiomics models based on CT scans and multiparametric MR imaging, possibly guiding the choice of a patient-tailored treatment. Moreover, radiomics models based on texture analysis demonstrated to be a promising alternative solution for the assessment of GCTB response to denosumab both on conventional radiography and CT since the quantitative variation of some radiomics features after therapy has been correlated with tumor response, suggesting they might facilitate disease monitoring during post-denosumab surveillance.