Percutaneous Management of Cancer Pain

Interventional Radiology Management of Bone Metastasis Pain: Strategies and Techniques

Osseous metastases are common in cancer patients, and pain is one of the most frequent associated symptoms. The management of cancer-related pain is still problematic worldwide with 40 to 50% of patients still being undertreated. A significant proportion of cancer patients will require discontinuation of traditional analgesic treatments such as opioids due to unsuccessful pain relief or severe unmanageable toxicity and may, therefore, benefit from alternative treatments. Over the last few decades, several interventional radiology (IR) minimally invasive treatment options have been introduced into the cancer pain management toolbox and can be proposed to cancer patients. This article reviews the main IR treatment options for painful bone metastases which include vertebral augmentation, percutaneous osteosynthesis, tumoral ablation, electrochemotherapy, intra-arterial therapies, and percutaneous neurolysis.

Robotic-assisted CT-guided percutaneous thermal ablation of abdominal tumors: An analysis of 41 patients

PURPOSE

Robotic assistance is rapidly evolving and may help physicians optimize needle guidance during percutaneous interventions. The purpose of the study was to report feasibility, safety, accuracy, immediate clinical success and short-term local tumor control after robotic-assisted computed tomography (CT)-guided thermal ablation of abdominal tumors.

MATERIALS AND METHODS

Forty-one patients who underwent percutaneous thermal ablation of abdominal tumors using robotic-assisted CT-guided were included. All ablations were performed with robotic assistance, using an optically-monitored robotic system with a needle guide sent to preplanned trajectories defined on three-dimensional-volumetric CT acquisitions with respiration monitoring. Endpoints were technical success, safety, distance from needle tip to planned trajectory and number of needle adjustments, and complete ablation rate.

RESULTS

Forty-one patients (31 men; mean age, 66.7 ± 9.9 [standard deviation (SD)] years [age range: 41-84 years]) were treated for 48 abdominal tumors, with 79 planned needles. Lesions treated were located in the liver (23/41; 56%), kidney (14/41;34%), adrenal gland (3/41; 7%) or retroperitoneum (1/41; 2%). Technical success was achieved in 39/41 (95%) patients, and 76/79 (96%) needle insertions. The mean lateral distance between the needle tip and planned trajectory was 3.2 ± 4.5 (SD) mm (range: 0-20 mm) before adjustments, and the mean three-dimensional distance was 1.6 ± 2.6 (SD) mm (range: 0-13 mm) after 29 manual depth adjustments (29/78; 37%) and 33 lateral adjustments (33/78; 42%). Two (2/79; 3%) needles required complete manual reinsertion. One grade 3 complication was reported in one patient (1/41; 2%). The overall clinical success rate was 100%. The 3-month local tumor control rate (progression free survival) was 95% (38/41).

CONCLUSION

These results provide further evidence on the use of robotic-assisted needle insertion regarding feasibility, safety, and accuracy, resulting in effective percutaneous thermal ablation of abdominal tumors.

Thermal Ablation Combined with Immune Checkpoint Blockers: A 10-Year Monocentric Experience

PURPOSE

We report a 10-year experience in cancer therapy with concomitant treatment of percutaneous thermal ablation (PTA) and immune checkpoint blockers (ICBs).

MATERIAL AND METHODS

This retrospective cohort study included all patients at a single tertiary cancer center who had received ICBs at most 90 days before, or 30 days after, PTA. Feasibility and safety were assessed as the primary outcomes. The procedure-related complications and immune-related adverse events (irAEs) were categorized according to the Common Terminology Criteria for Adverse Events v5.0 (CTCAE). Efficacy was evaluated based on overall survival (OS), progression-free survival (PFS), and local progression-free survival (LPFS) according to the indication, ablation modality, neoplasm histology, and ICB type.

RESULTS

Between 2010 and 2021, 78 patients (57% male; median age: 61 years) were included. The PTA modality was predominantly cryoablation (CA) (61%), followed by radiofrequency ablation (RFA) (31%). PTA indications were the treatment of oligo-persistence (29%), oligo-progression (14%), and palliation of symptomatic lesions or prevention of skeletal-related events (SREs) (56%). Most patients received anti-PD1 ICB monotherapy with pembrolizumab (n = 35) or nivolumab (n = 24). The feasibility was excellent, with all combined treatment performed and completed as planned. Ten patients (13%) experienced procedure-related complications (90% grade 1-2), and 34 patients (44%) experienced an irAE (86% grade 1-2). The only factor statistically associated with better OS and PFS was the ablation indication, favoring oligo-persistence (p = 0.02). Tumor response was suggestive of an abscopal effect in four patients (5%).

CONCLUSIONS

The concomitant treatment of PTA and ICBs within 2-4 weeks is feasible and safe for both palliative and local control indications. Overall, PTA outcomes were found to be similar to standards for patients not on ICB therapy. While a consistently reproducible abscopal effect remains elusive, the safety profile of concomitant therapy provides the framework for continued assessment as ICB therapies evolve.

Palliative Radiofrequency Ablation Therapy for Intractable Cancer-Related Pain Due to Malignant Psoas Syndrome: Case Report

Uncontrollable cancer pain is a highly feared and debilitating symptom. The effectiveness of radiofrequency ablation (RFA) for osseous metastases with intractable cancer-related pain refractory to pharmacological therapy has been reported previously. This case report is the first to demonstrate the use of RFA to achieve pain relief in a patient suffering severe pain caused by para-aortic lymph node metastasis. A 55-year-old male complained of intractable pain in the left groin and perineum due to malignant psoas syndrome caused by metastatic para-aortic lymph nodes. The pain was refractory to medications including opioids and nerve blocks. Considering the dermatome indicating referred pain and the imaging findings, RFA of the area of invasion was performed at the L3 level. The severe pain was relieved within 24 hours without any complications. Opioids were tapered at each postoperative outpatient visit. We discuss the use of RFA for control of intractable cancer-related pain refractory to medication, including opioids.

Multimodal locoregional procedures for cancer pain management: a literature review

Pain is the most common and fearsome symptom in cancer patients, particularly in the advanced stage of disease. In cancer pain management, the first option is represented by analgesic drugs, whereas surgery is rarely used. Prior to considering surgical intervention, less invasive locoregional procedures are available from the wide pain management arsenal. In this review article, comprehensive information about the most commonly used locoregional options available for treating cancer pain focusing on interventional radiology (neurolysis, augmentation techniques, and embolization) and interventional radiotherapy were provided, also highlighting the potential ways to increase the effectiveness of treatments.

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.

Celiac Plexus Cryoneurolysis

Intractable, chronic abdominal pain from upper abdominal malignant and benign diseases is a significant challenge for healthcare providers and burden on the healthcare system. While opioid analgesics are commonly used to provide pain relief, the adverse effects of chronic opioid use cannot be overlooked. Celiac plexus neurolysis via chemical or thermal means represents an alternative minimally invasive approach to provide palliative pain relief and increase patients' quality of life. Through the use of computed tomography guidance, celiac plexus neurolysis can be performed by accurately targeting the celiac plexus, while minimizing risks to adjacent structures. Historically, celiac plexus neurolysis was performed via instillation of ethanol or phenol; however, within the past decade cryoablation has gained increasing use with potentially fewer side effects.

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.

Percutaneous imaging-guided techniques for the treatment of benign neuropathic pain

To date, conservative management including physical and/or systemic pharmacologic therapy is considered as the first line approach for the management of neuropathic pain syndromes. In the era of an opioid overdose crisis with an increased concern upon the risks and harms arising from the misuse of medicines for pain management, percutaneous minimally invasive techniques such as nerve infiltrations as well as neurolysis or neuromodulation techniques can be proposed to control pain and improve life quality. Computed tomography can serve as an ideal guiding technique due to its specific characteristics including precise anatomic delineation, high spatial resolution and good tissue contrast. The purpose of this review is to make the reader familiar with the most common indications for minimally invasive imaging-guided techniques in patients with neuralgia and provide current evidence regarding technical considerations.