Radiographic Local Tumor Control and Pain Palliation of Sarcoma Metastases within the Musculoskeletal System with Percutaneous Thermal Ablation

Comparative study of immune response to local tumor destruction modalities in a murine breast cancer model

Introduction

Immunotherapy is revolutionizing the management of multiple cancer types. However, only a subset of patients responds to immunotherapy. One mechanism of resistance is the absence of immune infiltrates within the tumor. In situ vaccine with local means of tumor destruction that can induce immunogenic cell death have been shown to enhance tumor T cell infiltration and increase efficacy of immune checkpoint blockade.

Methods

Here, we compare three different forms of localize tumor destruction therapies: radiation therapy (RT), vascular targeted photodynamic therapy (VTP) and cryoablation (Cryo), which are known to induce immunogenic cell death, with their ability to induce local and systemic immune responses in a mouse 4T1 breast cancer model. The effects of combining RT, VTP, Cryo with anti-PD1 was also assessed.

Results

We observed that RT, VTP and Cryo significantly delayed tumor growth and extended overall survival. In addition, they also induced regression of non-treated distant tumors in a bilateral model suggesting a systemic immune response. Flow cytometry showed that VTP and Cryo are associated with a reduction in CD11b+ myeloid cells (granulocytes, monocytes, and macrophages) in tumor and periphery. An increase in CD8+ T cell infiltration into tumors was observed only in the RT group. VTP and Cryo were associated with an increase in CD4+ and CD8+ cells in the periphery.

Conclusion

These data suggest that cell death induced by VTP and Cryo elicit similar immune responses that differ from local RT.

Update on Percutaneous Ablation for Sarcoma

PURPOSE OF REVIEW

To provide an update on the current state of percutaneous thermal ablation in the treatment of sarcoma.

RECENT FINDINGS

Data continue to accrue in support of ablation for local control and palliation of specific sarcoma subtypes such as extra-abdominal desmoid fibromatosis and for broader indications such as the treatment of oligometastatic disease. The synergistic possibilities of various combination therapies such as cryoablation and immunotherapy represent intriguing areas of active investigation. Histotripsy is an emerging non-invasive, non-thermal ablative modality that may further expand the therapeutic arsenal for sarcoma treatment. Percutaneous thermal ablation is a valuable tool in the multidisciplinary management of sarcoma, offering a minimally invasive adjunct to surgery and radiation therapy. Although there remains a paucity of high-level evidence specific to sarcomas, ablation techniques are demonstrably safe and effective for achieving local tumor control and providing pain relief in select patients and are of particular benefit in those with metastatic disease or requiring palliative care.

Safety and clinical efficacy of microwave ablation combined with percutaneous vertebroplasty in the treatment of multisegmental spinal metastases

OBJECTIVE

To evaluate the safety and efficacy of microwave ablation (MWA) combined with percutaneous vertebroplasty (PVP) in the treatment of multisegmental (2-3 segments) osteolytic spinal metastases.

MATERIALS AND METHODS

This study comprised a retrospective analysis of data from 20 patients with multisegmental (2-3 segments) osteolytic spinal metastases who received MWA combined with PVP. The visual analog scale (VAS) score, Oswestry Disability Index (ODI) score, Quality of Life Questionnaire-Bone Metastases 22 (QLQ-BM22), and local recurrence before and after the operation were measured. The occurrence of complications was observed to evaluate safety.

RESULTS

All operations were completed successfully with no serious complications. Transient nerve injury occurred in two cases, but recovered after symptomatic treatment. The bone cement leakage rate was 13.9% (6/43). The mean baseline VAS scores were 7.25 ± 0.91 before treatment and 7.25 ± 0.91, 3.70 ± 1.12, 2.70 ± 0.73, 2.40 ± 0.68, 2.25 ± 0.71, and 2.70 ± 0.92 at 1 day, 1 week, 1, 3, and 6 months after treatment; all values were significantly lower (P < 0.001). The mean baseline ODI score decreased from 56.90 ± 9.74 before treatment to 41.90 ± 7.09, 38.10 ± 7.93, and 38.80 ± 10.59 at 1, 3, and 6 months after treatment, respectively; all values were significantly lower (P < 0.001). The average QLQ-BM22 baseline score decreased from 54.10 ± 5.36 before treatment to 44.65 ± 5.22, 43.05 ± 4.78, 42.30 ± 4.06, and 42.15 ± 5.47 at 1 week, 1, 3, and 6 months after treatment; all values were significantly lower (all P < 0.001). The postoperative survival time of all patients was >6 months. In three patients, four vertebral segments recurred 6 months after operation.

CONCLUSION

MWA combined with PVP is a safe and effective treatment for multisegmental osteolytic vertebral metastases that can effectively relieve pain, improve spinal function, improve quality of life, and delay tumor progression. However, it is a long operation, necessitating good preoperative preparation and effective intraoperative pain relief measures.

Magnetic resonance-guided focused ultrasound versus percutaneous thermal ablation in local control of bone oligometastases: a systematic review and meta-analysis

BACKGROUND

The percutaneous thermal ablation techniques (pTA) are radiofrequency ablation, cryoablation, and microwave ablation, suitable for the treatment of bone oligometastases. Magnetic resonance-guided focused ultrasound (MRgFUS) is a noninvasive ablation technique.

OBJECTIVES

To compare the effectiveness and safety of MRgFUS and pTA for treating bone oligometastases and their complications.

METHODS

Studies were selected with a PICO/PRISMA protocol: pTA or MRgFUS in patients with bone oligometastases; non-exclusive curative treatment. Exclusion criteria were: primary bone tumor; concurrent radiation therapy; palliative therapy; and absence of imaging at follow-up. PubMed, BioMed Central, and Scopus were searched. The modified Newcastle-Ottawa Scale assessed articles quality. For each treatment (pTA and MRgFUS), we conducted two separate random-effects meta-analyses to estimate the pooled effectiveness and safety. The effectiveness was assessed by combining the proportions of treated lesions achieving local tumor control (LTC); the safety by combining the complications rates of treated patients. Meta-regression analyses were performed to identify any outcome predictor.

RESULTS

A total of 24 articles were included. Pooled LTC rate for MRgFUS was 84% (N = 7, 95% CI 66-97%, I2 = 74.7%) compared to 65% of pTA (N = 17, 95% CI 51-78%, I2 = 89.3%). Pooled complications rate was similar, respectively, 13% (95% CI 1-32%, I2 = 81.0%) for MRgFUS and 12% (95% CI 8-18%, I2 = 39.9%) for pTA, but major complications were recorded with pTA only. The meta-regression analyses, including technique type, study design, tumor, and follow-up, found no significant predictors.

DISCUSSION

The effectiveness and safety of the two techniques were found comparable, even though MRgFUS is a noninvasive treatment that did not cause any major complication. Limited data availability on MRgFUS and the lack of direct comparisons with pTA may affect these findings.

CONCLUSIONS

MRgFUS can be a valid, safe, and noninvasive treatment for bone oligometastases. Direct comparison studies are needed to confirm its promising benefits.

Image-Guided Ablation Therapies for Extrahepatic Metastases from Hepatocellular Carcinoma: A Review

The most common sites of extrahepatic metastases from hepatocellular carcinoma (HCC) are the lungs, intra-abdominal lymph nodes, bones, and adrenal glands, in that order. Although systemic therapies are a common treatment for patients with extrahepatic metastases, local ablative therapies for the extrahepatic metastatic lesions can be performed in selected patients. In this article, the literature on image-guided thermal ablation for metastasis to each organ was reviewed to summarize the current evidence. Radiofrequency ablation was the most commonly evaluated technique, and microwave ablation, cryoablation, and percutaneous ethanol injection were also utilized. The local control rate of thermal ablation therapy was relatively favorable, at approximately 70-90% in various organs. The survival outcomes varied among the studies, and several studies reported that the absence of viable intrahepatic lesions was associated with improved survival rates. Since only retrospective data from relatively small studies has been available thus far, more robust studies with prospective designs and larger cohorts are desired to prove the usefulness of thermal ablation for extrahepatic metastases from HCC.

Musculoskeletal oncology and thermal ablation: the current and emerging role of interventional radiology

The role of interventional radiology (IR) is expanding. With new techniques being developed and tested, this radiology subspecialty is taking a step forward in different clinical scenarios, especially in oncology. Musculoskeletal tumoral diseases would definitely benefit from a low-invasive approach that could reduce mortality and morbidity in particular. Thermal ablation through IR has already become important in the palliation and consolidation of bone metastases, oligometastatic disease, local recurrences, and treating specific benign tumors, with a more tailored approach, considering the characteristics of every patient. As image-guided ablation techniques lower their invasiveness and increase their efficacy while the collateral effects and complications decrease, they become more relevant and need to be considered in patient care pathways and clinical management, to improve outcomes. We present a literature review of the different percutaneous and non-invasive image-guided thermal ablation methods that are currently available and that could in the future become relevant to manage musculoskeletal oncologic diseases.

Ablative Techniques for Sarcoma Metastatic Disease: Current Role and Clinical Applications

Sarcomas are heterogenous mesenchymal neoplasms with more than 80 different histologic subtypes. Lung followed by liver and bone are the most common sites of sarcoma metastatic disease. Ablative techniques have been recently added as an additional alternative curative or palliative therapeutic tool in sarcoma metastatic disease. When compared to surgery, ablative techniques are less invasive therapies which can be performed even in non-surgical candidates and are related to decreased recovery time as well as preservation of the treated organ’s long-term function. Literature data upon ablative techniques for sarcoma metastatic disease are quite heterogeneous and variable regarding the size and the number of the treated lesions and the different histologic subtypes of the original soft tissue or bone sarcoma. The present study focuses upon the current role of minimal invasive thermal ablative techniques for the management of metastatic sarcoma disease. The purpose of this review is to present the current minimally invasive ablative techniques in the treatment of metastatic soft tissue and bone sarcoma, including local control and survival rates.

Minimally Invasive Interventional Procedures for Metastatic Bone Disease: A Comprehensive Review

Metastases are the main type of malignancy involving bone, which is the third most frequent site of metastatic carcinoma, after lung and liver. Skeletal-related events such as intractable pain, spinal cord compression, and pathologic fractures pose a serious burden on patients’ quality of life. For this reason, mini-invasive treatments for the management of bone metastases were developed with the goal of pain relief and functional status improvement. These techniques include embolization, thermal ablation, electrochemotherapy, cementoplasty, and MRI-guided high-intensity focused ultrasound. In order to achieve durable pain palliation and disease control, mini-invasive procedures are combined with chemotherapy, radiation therapy, surgery, or analgesics. The purpose of this review is to summarize the recently published literature regarding interventional radiology procedures in the treatment of cancer patients with bone metastases, focusing on the efficacy, complications, local disease control and recurrence rate.

Interventional Radiology in the Management of Metastases and Bone Tumors

Interventional Radiology (IR) has experienced an exponential growth in recent years. Technological advances of the last decades have made it possible to use new treatments on a larger scale, with good results in terms of safety and effectiveness. In musculoskeletal field, painful bone metastases are the most common target of IR palliative treatments; however, in selected cases of bone metastases, IR may play a curative role, also in combination with other techniques (surgery, radiation and oncology therapies, etc.). Primary malignant bone tumors are extremely rare compared with secondary bone lesions: osteosarcoma, Ewing sarcoma, and chondrosarcoma are the most common; however, the role of interventional radiology in this fiels is marginal. In this review, the main techniques used in interventional radiology were examined, and advantages and limitations illustrated. Techniques of ablation (Radiofrequency, Microwaves, Cryoablation as also magnetic resonance imaging-guided high-intensity focused ultrasound), embolization, and Cementoplasty will be described. The techniques of ablation work by destruction of pathological tissue by thermal energy (by an increase of temperature up to 90 °C with the exception of the Cryoablation that works by freezing the tissue up to -40 °C). Embolization creates an ischemic necrosis by the occlusion of the arterial vessels that feed the tumor. Finally, cementoplasty has the aim of strengthening bone segment weakened by the growth of pathological tissue through the injection of cement. The results of the treatments performed so far were also assessed and presented focused the attention on the management of bone metastasis.

Interventional Palliation of Painful Extraspinal Musculoskeletal Metastases

The musculoskeletal system is commonly involved by metastases, and skeletal-related events such as intractable pain due to direct osseous tumor involvement, pathologic fracture, and neurologic deficits as a result of nerve compression often adversely affect patient's quality of life. There have been substantial advances in percutaneous minimally invasive musculoskeletal oncologic interventions for the management of patients with musculoskeletal metastases including thermal ablations, cementation with or without osseous reinforcement via implants, osteosynthesis, neurolysis, and palliative injections which are progressively incorporated in clinical practice. These interventions are performed, in conjunction with or supplemented by adjuvant radiation therapy, systemic therapy, surgery, or analgesics, to achieve durable pain palliation, local tumor control, or cure. This article reviews minimally invasive percutaneous image-guided musculoskeletal oncologic interventions for the management of patients with extraspinal musculoskeletal metastases.

CIRSE Standards of Practice on Thermal Ablation of Bone Tumours

Background

Percutaneous thermal ablation is an effective, minimally invasive means of treating a variety of focal benign and malignant osseous lesions. To determine the role of ablation in individual cases, multidisciplinary team (MDT) discussion is required to assess the suitability and feasibility of a thermal ablative approach, to select the most appropriate technique and to set the goals of treatment i.e. curative or palliative.

Purpose

This document will presume the indication for treatment is clear and approved by the MDT and will define the standards required for the performance of each modality. CIRSE Standards of Practice documents are not intended to impose a standard of clinical patient care, but recommend a reasonable approach to, and best practices for, the performance of thermal ablation of bone tumours.

Methods

The writing group was established by the CIRSE Standards of Practice Committee and consisted of five clinicians with internationally recognised expertise in thermal ablation of bone tumours. The writing group reviewed the existing literature on thermal ablation of bone tumours, performing a pragmatic evidence search using PubMed to search for publications in English and relating to human subjects from 2009 to 2019. Selected studies published in 2020 and 2021 during the course of writing these standards were subsequently included. The final recommendations were formulated through consensus.

Results

Recommendations were produced for the performance of thermal ablation of bone tumours taking into account the biologic behaviour of the tumour and the therapeutic intent of the procedure. Recommendations are provided based on lesion characteristics and thermal modality, for the use of tissue monitoring and protection, and for the appropriately timed application of adjunctive procedures such as osseus consolidation and transarterial embolisation.

Results

Percutaneous thermal ablation has an established role in the successful management of bone lesions, with both curative and palliative intent. This Standards of Practice document provides up-to-date recommendations for the safe performance of thermal ablation of bone tumours.

Body Interventional MRI for Diagnostic and Interventional Radiologists: Current Practice and Future Prospects

Clinical use of MRI for guidance during interventional procedures emerged shortly after the introduction of clinical diagnostic MRI in the late 1980s. However, early applications of interventional MRI (iMRI) were limited owing to the lack of dedicated iMRI magnets, pulse sequences, and equipment. During the 3 decades that followed, technologic advancements in iMRI magnets that balance bore access and field strength, combined with the development of rapid MRI pulse sequences, surface coils, and commercially available MR-conditional devices, led to the rapid expansion of clinical iMRI applications, particularly in the field of body iMRI. iMRI offers several advantages, including superior soft-tissue resolution, ease of multiplanar imaging, lack of ionizing radiation, and capability to re-image the same section. Disadvantages include longer examination times, lack of MR-conditional equipment, less operator familiarity, and increased cost. Nonetheless, MRI guidance is particularly advantageous when the disease is best visualized with MRI and/or when superior soft-tissue contrast is needed for treatment monitoring. Safety in the iMRI environment is paramount and requires close collaboration among interventional radiologists, MR physicists, and all other iMRI team members. The implementation of risk-limiting measures for personnel and equipment in MR zones III and IV is key. Various commercially available MR-conditional needles, wires, and biopsy and ablation devices are now available throughout the world, depending on the local regulatory status. As such, there has been tremendous growth in the clinical applications of body iMRI, including localization of difficult lesions, biopsy, sclerotherapy, and cryoablation and thermal ablation of malignant and nonmalignant soft-tissue neoplasms. Online supplemental material is available for this article. ^©RSNA, 2021.

Bone Metastases: State of the Art in Minimally Invasive Interventional Oncology

Bone is the third most common site involved by cancer metastases, and skeleton-related events such as intractable pain due to direct osseous tumor involvement, pathologic fracture, and neurologic deficits as a consequence of nerve or spinal cord compression often affect patients' functional independence and quality of life unfavorably. The annual medical-economic burden related to bone metastases is a substantial component of the total direct medical cost estimated by the National Institutes of Health. There have been substantial recent advances in percutaneous image-guided minimally invasive musculoskeletal oncologic interventions for the management of patients with osseous metastatic disease. These advances include thermal ablation, cementation with or without osseous reinforcement with implants, osteosynthesis, thermal and chemical neurolyses, and palliative injections, which are progressively incorporated into the management paradigm for such patients. These interventions are performed in conjunction with or are supplemented by adjuvant radiation therapy, systemic therapy, surgery, or analgesic agents to achieve durable pain palliation, local tumor control, or cure, and they provide a robust armamentarium for interventional radiologists to achieve safe and effective treatment in a multidisciplinary setting. In addition, these procedures are shifting the patient management paradigm in modern-era practice. The authors detail the state of the art in minimally invasive percutaneous image-guided musculoskeletal oncologic interventions and the role of radiologists in managing patients with skeletal metastases. ^©RSNA, 2021.

Interventional Therapies for Pain in Cancer Patients: a Narrative Review

PURPOSE OF REVIEW

Pain is a prevalent symptom in the lives of patients with cancer. In light of the ongoing opioid epidemic and increasing awareness of the potential for opioid abuse and addiction, clinicians are progressively turning to interventional therapies. This article reviews the interventional techniques available to mitigate the debilitating effects that untreated or poorly treated pain have in this population.

RECENT FINDINGS

A range of interventional therapies and technical approaches are available for the treatment of cancer-related pain. Many of the techniques described may offer effective analgesia with less systemic toxicity and dependency than first- and second-line oral and parenteral agents. Neuromodulatory techniques including dorsal root ganglion stimulation and peripheral nerve stimulation are increasingly finding roles in the management of oncologic pain. The goal of this pragmatic narrative review is to discuss interventional approaches to cancer-related pain and the potential of such therapies to improve the quality of life of cancer patients.

Retrospective analysis of CT-guided percutaneous cryoablation for treatment of painful osteolytic bone metastasis

This study aimed to evaluate the safety and effectiveness of CT-guided percutaneous cryoablation for treatment of painful osteolytic bone metastases. A total of 26 patients (36 bone metastases) treated with CT-guided percutaneous cryoablation between May 2012 and June 2016 were enrolled in this retrospective study. All procedures were performed under local anesthesia. A visual analog scale (VAS) was used to evaluate pain before the procedure and at 1 day, 1 month, 3 months, and 6 months after the procedure. Complications during and after the procedure were recorded and graded by the Clavien-Dindo classification. The mean VAS pain score was 7.1 ± 1.1 (range, 4-10) before cryoablation. It was significantly lower at all timepoints after treatment: 2.1 ± 1.7 (P < 0.0001) at 1 day after treatment, 1.3 ± 1.8 (P < 0.0001) at 1 month, 1.6 ± 1.7 (P < 0.0001) at 3 months, and 1.8 ± 1.3 (P < 0.0001) at 6 months. The response rates were 91.7%, 94.4%, 91.7%, and 94.4%, respectively, at 1 day, 1 month, 3 months, and 6 months after cryoablation; the complete response rates were 22.2%, 41.7%, 36.1%, and 22.2%, respectively. Adverse events (skin frostbite, nerve injury, pathologic fracture) occurred in 3 patients. CT-guided percutaneous cryoablation under local anesthesia appears to be a safe and effective treatment for painful osteolytic bone metastases. Prospective clinical trials on large samples needed to confirm this conclusion.

Thermal Ablation of Bone Metastases

Image-guided, minimally invasive, percutaneous thermal ablation of bone metastases has unique advantages compared with surgery or radiation therapy. Thermal ablation of osseous metastases may result in significant pain palliation, prevention of skeletal-related events, and durable local tumor control. This article will describe current thermal ablation techniques utilized to treat bone metastases, summarize contemporary evidence supporting such thermal ablation treatments, and outline an approach to percutaneous ablative treatment.