Radiofrequency ablation of bony metastatic disease

Percutaneous Vertebral Reconstruction (PVR) Technique of Pathological Compression Fractures: An Innovative Combined Treatment of Microwave Ablation, Bilateral Expandable Titanium SpineJack Implants Followed by Vertebroplasty

(1) Background: to retrospectively evaluate safety and efficacy of combined microwave ablation (MWA) and bilateral expandable titanium SpineJack (SJ) implants followed by vertebroplasty (VP) for the treatment of painful thoracolumbar pathological vertebral compression fracture. (2) Methods: from July 2017 to October 2022, twenty-eight patients (13 women and 15 men; mean age 68 ± 11 years) with a history of primary neoplasm and thirty-six painful vertebral metastases with vertebral compression fracture underwent combined MWA and bilateral expandable titanium SpineJack implants with vertebroplasty. We analyzed safety through complications rate, and efficacy through vertebral height restoration and pain decrease, evaluated using a visual analogue scale (VAS), and Functional Mobility Scale (FMS), and local tumor control. Contrast-enhanced CT scans were performed at 1, 3, and 6 months and a contrast-enhanced spine MRI at 6 months after the procedure. (3) Results: Technical success rate was 100%. No procedure-related major complications or death occurred. Vertebral height restoration was observed in 22 levels (58%), with a mean anterior height restoration of 2.6 mm ± 0.6 and a mean middle height restoration of 4.4 mm ± 0.6 (p < 0.001). Mean VAS score of pain evaluation on the day before treatment was 6.3 ± 1.5 (range 4-9). At the 6-month evaluation, the median VAS score for pain was 0.4 ± 0.6 (range 0-2) with a mean reduction of 93.65% (6.8 ± 0.7 vs. 0.4 ± 0.6; p < 0.000) compared with baseline evaluation. Contrast-enhanced CT scans were performed at 1, 3, and 6 months and a contrast-enhanced spine MRI was performed at 6 months after the procedure, showing no local recurrence, implant displacement, or new fractures in the treated site. (4) Conclusions: combined microwave ablation and bilateral expandable titanium SpineJack implants with vertebroplasty is a safe and effective procedure for the treatment of pathological compressive vertebral fractures. The vertebral stabilization achieved early and persistent pain relief, increasing patient mobility, improving recovery of walking capacity, and providing local tumor control.

Percutaneous CT-Guided Microwave Ablation Combined with Pedicle Screw Fixation Followed by Vertebroplasty (MASFVA): Initial Experience of a Minimally Invasive Treatment of Vertebral Metastases with Extension to the Vertebral Pedicle

(1) Background: The aim of this study was to retrospectively evaluate the safety and efficacy of a combined CT-guided percutaneous microwave ablation (MWA) and pedicle screw fixation followed by vertebroplasty (MASFVA) for the treatment and stabilization of painful vertebral metastases with vertebral pedicle involvement. (2) Methods: from January 2013 to January 2017 11 patients with 16 vertebral metastatic lesions (7 men and 5 women; mean age, 65 ± 11 years) with vertebral metastases underwent CT-guided microwave ablation and screw fixation followed by vertebroplasty (MASFVA). Technical success, complication rate, pain evaluation using a visual analogue scale (VAS), Oswestry Disability Index (ODI) and local tumor control were examined. (3) Results: Technical success rate was 100%. No procedure-related major complications occurred. VAS score decreased from 6.8 ± 0.7 to 0.6 ± 0.6. ODI score decreased from 3.1 ± 0.7 to 1.2 ± 0.4. All patients could walk independently without neurological complication after one week from the procedure. No new bone fractures or local disease recurrence occurred during a median follow-up of 12 months. (4) Conclusions: Our results suggest that MWA and percutaneous pedicle screw fixation followed by vertebroplasty for the treatment of painful vertebral metastases is a safe and effective procedure for painful vertebral metastases with vertebral pedicle involvement, allowing pain relief and local tumor control.

The Impact of Zoledronic Acid and Radioactive Iodine Therapy on Morbi-Mortality of Patients with Bone Metastases of Thyroid Cancer Derived from Follicular Cells

OBJECTIVE

Bone metastases bring greater morbi-mortality to patients with differentiated thyroid carcinoma (DTC). Treatment was limited to radioactive iodine (RAI) and local approaches. Currently, bisphosphonates are included in the therapeutic arsenal. The aim of this study is to evaluate the impact of bone metastases and their treatment with zoledronic acid (ZA) and RAI therapy.

METHODS

We retrospectively review 50 DTC patients with structurally evident bone metastases followed in a tertiary cancer center from 1994 to 2018. Clinical-pathologic characteristics, skeletal related events (SRE), and therapeutic approaches were recorded.

RESULTS

Among the 50 patients analyzed, 22 underwent ZA adjuvant therapy and 28 did not. Mortality rate was 44%. Those patients presented SREs more frequently (90.9 vs. 67.9% the survival group, p = 0.05) and also had a greater number of bone lesions (40.9 vs. 10.7% had more than 6 metastatic sites, p = 0.03). The same group of patients was analyzed before and after therapy with ZA and the incidence of SRE decreased from 1.81 (0-8) before therapy to 0.29 (0-7) after therapy (p = 0.006). Comparing similar groups of 22 patients treated with ZA with 28 patients not treated, there was a trend of better overall survival (OS) in the group that received this drug (147 vs. 119 months, p = 0.06) and significantly improvement when bone metastases were RAI avid 155 (125-185) versus 120 (85-157) months, p < 0.01. Conclusion : ZA can successfully diminish the chance of having new SRE and possibly affect OS in DTC patients with bone metastases. The positive impact of RAI adjuvant treatment on OS is directly associated with RAI uptake.

Multi-segmental spine image registration supporting image-guided interventions of spinal metastases

BACKGROUND

Radiofrequency ablation was introduced recently to treat spinal metastases, which are among the most common metastases. These minimally-invasive interventions are most often image-guided by flat-panel CT scans, withholding soft tissue contrast like MR imaging. Image fusion of diagnostic MR and operative CT images could provide important and useful information during interventions.

METHOD

Diagnostic MR and interventional flat-panel CT scans of 19 patients, who underwent radiofrequency ablations of spinal metastases were obtained. Our presented approach piecewise rigidly registers single vertebrae using normalized gradient fields and embeds them within a fused image. Registration accuracy was determined via Euclidean distances between corresponding landmark pairs of ground truth data.

RESULTS

Our method resulted in an average registration error of 2.35mm. An optimal image fusion performed by landmark registrations achieved an average registration error of 1.70mm. Additionally, intra- and inter-reader variability was determined, resulting in mean distances of corresponding landmark pairs of 1.05mm (MRI) and 1.03mm (flat-panel CT) for the intra-reader variability and 1.36mm and 1.28mm for the inter-reader variability, respectively.

CONCLUSIONS

Our multi-segmental approach with normalized gradient fields as image similarity measure can handle spine deformations due to patient positioning and avoid time-consuming manually performed registration. Thus, our method can provide practical and applicable intervention support without significantly delaying the clinical workflow or additional workload.

Chondromyxoid fibroma of the distal fibula treated by percutaneous radiofrequency ablation

BACKGROUND

Percutaneous radiofrequency ablation (RFA) has been shown to be an effective treatment for soft tissue lesions and also benign bone tumors, especially osteoid osteoma. There are limited data regarding this technique in other bone tumors, specifically larger and more aggressive ones.

PURPOSES

To describe the use of RFA as a definitive treatment and an alternative to traditional open surgery for the treatment of chondromyxoid fibroma (CMF), a benign but locally aggressive bone tumor.

CASE PRESENTATION

An 11.5-year-old girl was diagnosed with a 4-cm lytic bone lesion of the distal fibula. Evaluation, including biopsy, revealed CMF. It was managed by fluoroscopy-guided RFA only. Six-year follow-up demonstrated complete healing without damage to the adjacent distal fibular growth plate.

DISCUSSION AND CONCLUSIONS

RFA induces local heat in the ablation field and causes tissue necrosis. The depth of heat penetration and the size of heated sphere are accurately controlled by modern types of ablation probes and accurate positioning. The current report demonstrates the ability to use this percutaneous technique for larger and more aggressive bone tumors than has been indicated previously.

Combined Microwave Ablation and Cementoplasty in Patients with Painful Bone Metastases at High Risk of Fracture

PURPOSE

To retrospectively evaluate the effectiveness of computed tomography-guided percutaneous microwave ablation (MWA) and cementoplasty in patients with painful bone metastases at high risk of fracture.

MATERIALS AND METHODS

Thirty-five patients with 37 metastatic bone lesions underwent computed tomography-guided MWA combined with cementoplasty (polymethylmethacrylate injection). Vertebrae, femur, and acetabulum were the intervention sites and the primary end point was pain relief. Pain severity was estimated by visual analog scale (VAS) before treatment; 1 week post-treatment; and 1, 6, and 12 months post-treatment. Functional outcome was assessed by improved patient walking ability. Radiological evaluation was performed at baseline and 3 and 12 months post-procedure.

RESULTS

In all patients, pain reduction occurred from the first week after treatment. The mean reduction in the VAS score was 84, 90, 90 % at week 1, month 1, and month 6, respectively. Improved walking ability occurred in 100 and 98 % of cases at the 1- and 6-month functional outcome evaluations, respectively. At the 1-year evaluation, 25 patients were alive, and 10 patients (28 %) had died because of widespread disease. The mean reduction in the VAS score and improvement in surviving patients' walking ability were 90 and 100 %, respectively. No patients showed evidence of local tumor recurrence or progression and pathological fracture in the treated sites.

CONCLUSION

Our results suggest that MWA combined with osteoplasty is safe and effective when treating painful bone metastases at high risk of fracture. The number of surviving patients at the 1-year evaluation confirms the need for an effective and long-lasting treatment.

Irreversible electroporation ablation: is all the damage nonthermal?

PURPOSE

To determine whether high-dose irreversible electroporation (IRE) ablation induces thermal effects in normal liver tissue.

MATERIALS AND METHODS

Animal care and use committee approval was obtained prior to the experiments. IRE ablation (n = 78) was performed by a single four-person team in vivo in 22 porcine livers by applying electric current to two 1.3-cm-diameter circular flat-plate electrodes spaced 1 cm apart. Cardiac-gated IRE pulses (n = 40-360) were systematically applied at varying voltages (1500-2900 V). End temperatures at the ablation zone center were measured and were correlated with ablation time, energy parameters, and resultant treatment effect as determined at gross pathologic and histopathologic examination. Temperatures were then monitored at the center and periphery of four ablations created by using a four-electrode IRE array (3000 V, 90 pulses per electrode pair). Data were analyzed by using multivariate analysis of variance with multiple comparisons and/or paired t tests and regression analysis, as appropriate.

RESULTS

Temperature rose above the 34°C baseline after IRE in all flat-plate experiments and correlated linearly (R(2) = 0.39) with IRE "energy dose" (product of voltage and number of pulses) and more tightly in univariate analysis with both voltage and number of pulses. Thus, mean temperatures as high as 86°C ± 3 (standard deviation) were seen for 2500 V and 270 pulses. Ablations of 90 pulses or more at 2500 V produced temperatures of 50°C or greater and classic gross and histopathologic findings of thermal coagulation (pyknotic nuclei and streaming cytoplasm). For lower IRE doses (ie, 2100 V, 90 pulses), temperatures remained below 45°C, and only IRE-associated pathologic findings (ie, swollen sinusoids, dehydrated cells, and hemorrhagic infiltrate) were seen. For the four-electrode arrays, temperatures measured 54.2°C ± 6.1 at the electrode surfaces and 38.6°C ± 3.2 at the ablation zone margin.

CONCLUSION

In some conditions of high intensity, IRE can produce sufficient heating to induce "white zone" thermal coagulation. While this can be useful in some settings to increase tumor destruction, further characterization of the thermal profile created with clinical electrodes and energy parameters is therefore needed to better understand the best ways to avoid unintended damage when ablating near thermally sensitive critical structures.

Update on thyroid cancer treatment

Surgery and radioiodine therapy are usually effective for most patients with differentiated thyroid cancer. However, poorly differentiated and anaplastic thyroid carcinomas represent a challenge to physicians on the basis of the current cancer treatment modalities. These cancer subtypes are often lethal and refractory to radioiodine therapy as well as most of the common chemotherapy drugs. Several kinase inhibitors are promising targeted therapies for these malignancies; however, clinical trials involving these drugs have provided controversial results and their clinical use is still under debate. Advanced medullary thyroid carcinomas may also be refractory to conventional therapies and novel kinase inhibitors may also be useful to control tumor progression in certain patients. Novel evidence is emerging that thyroid cancer is a stem cell disease, thereby implying that the driving force of thyroid cancers is a subset of undifferentiated cells (thyroid cancer stem cells) with unlimited growth potential and resistance to conventional therapeutic regimens. Thyroid cancer stem cells have been proposed as responsible for tumor invasiveness, metastasis, relapse and differentiation. Therefore, drugs that selectively target these cells could serve as a cornerstone in the treatment of poorly differentiated thyroid cancer.

Measurement of temperature dependent changes in bone marrow using a rapid chemical shift imaging technique

PURPOSE

To provide quantitative temperature monitoring for thermal therapies in bone marrow by measuring temperature-dependent signal changes in the bone marrow of ex vivo canine femurs heated with a 980-nm laser at 1.5T and 3.0T.

MATERIALS AND METHODS

Using a multi-gradient echo (≤ 16) acquisition and signal modeling with the Stieglitz-McBride algorithm, the temperature sensitivity coefficients (TSC, ppm/°C) of water and multiple lipid components' proton resonance frequency (PRF) values are measured at high spatiotemporal resolutions (1.6 × 1.6 × 4 mm(3) , ≤ 5 seconds). Responses in R(2) * and amplitudes of each peak were also measured as a function of temperature simultaneously.

RESULTS

Calibrations demonstrate that lipid signal may be used to compensate for B(0) errors to provide accurate temperature readings (<1.0°C). Over a temperature range of 17.2-57.2°C, the TSCs after correction to a bulk methylene reference are -0.87 × 10(-2) ± 4.7 × 10(-4) ppm/°C and -0.87 × 10(-2) ± 4.0 × 10(-4) ppm/°C for 1.5T and 3.0T, respectively.

CONCLUSION

Overall, we demonstrate that accurate and precise temperature measurements can be made in bone marrow. In addition, the relationship of R(2) * and signal amplitudes with respect to temperature are shown to differ significantly where conformal changes are predicted by Arrhenius rate model analysis.

Palliation of painful metastatic disease involving bone with imaging-guided treatment: comparison of patients' immediate response to radiofrequency ablation and cryoablation

OBJECTIVE

The purpose of this article was to compare periprocedural analgesic requirements and hospital length of stay for treatment of patients with painful metastatic tumors involving bone using either percutaneous radiofrequency ablation (RFA) or cryoablation.

MATERIALS AND METHODS

A retrospective review was conducted of patients who underwent either imaging-guided cryoablation or imaging-guided RFA for painful metastatic tumors involving bone. The total analgesic usage for 24 hours after the procedure was expressed as a standard morphine-equivalent dose. Analgesic usage at admission served as a baseline for comparison. Total hospital stay was used as an additional measurement of procedure-related morbidity.

RESULTS

Fifty-eight patients underwent either cryoablation (n = 36) or RFA (n = 22) for painful metastatic tumors involving bone. Twenty-two primary tumors were treated. The most common treatment site was the pelvis (n = 31). There was no significant difference between the two groups with regard to tumor histologic type (p = 0.52) and location (p = 0.72). The median tumor diameter was 4.4 cm for the cryoablation group and 5.0 cm for the RFA group (p = 0.63). Pretreatment pain scores, measured on a scale of 0 to 10, were not significantly different between the two groups: 6.5 for cryoablation and 6.0 for RFA (p = 0.78). Analgesic use in the 24 hours immediately after the procedure decreased significantly by 24 morphine-equivalent doses after cryoablation, whereas it increased by a median of 22 morphine-equivalent doses after RFA (p = 0.03). Total hospital length of stay for patients undergoing cryoablation was a median of 2.5 days less than that for patients receiving RFA (p = 0.003).

CONCLUSION

The use of cryoablation compared with RFA is associated with a greater reduction in analgesic dose and shorter hospital stays after the procedure in the perioperative time frame.

EUS-guided Nd:YAG laser ablation of normal pancreatic tissue: a pilot study in a pig model

BACKGROUND

Laser ablation with a neodymium:yttrium aluminum garnet (Nd:YAG) laser can achieve a high rate of complete tissue necrosis and has been applied as a minimally invasive, palliative option in hepatocellular carcinoma, liver metastasis in colorectal cancer, and malignant thyroid nodules.

OBJECTIVE

To assess the in vivo feasibility of EUS-guided laser ablation with an Nd:YAG laser of normal pancreatic tissue of a porcine model.

DESIGN

Prospective investigation.

SETTING

Hospital animal laboratory.

SUBJECTS

Eight pigs.

INTERVENTIONS

EUS-guided puncture of the pancreatic tail with a laser-beam fiber. An Nd:YAG laser (1.064 nm) was used, with an output power of 2 and 3 W and a total delivered energy of 500 and 1000 J in continuous mode.

MAIN OUTCOME MEASUREMENTS

The 24-hour follow-up of the pigs was focused on clinical and laboratory aspects. Results of histological studies of the pancreas were obtained 24 hours after the procedure on necroscopy tissue.

RESULTS

There were no technical limitations to the performance of the procedure. Tissue necrosis, localized in the pancreatic parenchyma, was observed in all animals on histological examination. The volume of ablation tissue ranged from a mean of 314 mm(3) to 483 mm(3). The ablation area ranged from a mean of 49 mm(2) to 80 mm(2). No major postprocedure complications were recorded, and all the pigs survived at 24 hours.

LIMITATION

Animal study.

CONCLUSIONS

EUS-guided laser ablation of the pancreas with an Nd:YAG laser is feasible in a porcine model.

Radiofrequency and microwave tumor ablation in patients with implanted cardiac devices: is it safe?

PURPOSE

To identify malfunction of implanted cardiac devices during or after thermal ablation of tumors in lung, kidney, liver or bone, using radiofrequency (RF) or microwave (MW) energy.

MATERIALS AND METHODS

After providing written consent, 19 patients (15 men and 4 women; mean age 78 years) with pacemakers or pacemaker/defibrillators underwent 22 CT image-guided percutaneous RF or MW ablation of a variety of tumors. Before and after each procedure, cardiac devices were interrogated and reprogrammed by a trained cardiac electrophysiology fellow. Possible pacer malfunctions included abnormalities on electrocardiographic (EKG) monitoring and alterations in device settings. Our institutional review board approved this Health Insurance Portability and Accountability Act-compliant study. Informed consent for participation in this retrospective study was deemed unnecessary by our review board.

RESULTS

During 20 of 22 sessions, no abnormalities were identified in continuous, EKG tracings or pacemaker functions. However, in two sessions significant changes, occurred in pacemaker parameters: inhibition of pacing during RF application in one, session and resetting of mode by RF energy in another session. These changes did not, result in hemodynamic instability of either patient. MW ablation was not associated with, any malfunction. In all 22 sessions, pacemakers were undamaged and successfully reset to original parameters.

CONCLUSION

RF or MW ablation of tumors in liver, kidney, bone and lung can be performed safely in patients with permanent intra-cardiac devices, but careful planning between radiology and cardiology is essential to avoid adverse outcomes.

The use of radiofrequency ablation in the treatment of musculoskeletal tumors

Musculoskeletal tumors, both primary neoplasms and metastatic lesions, present a therapeutic challenge for the physician who wishes to provide palliative pain relief using the least invasive approach. The increasing sophistication of imaging modalities such as CT in precisely localizing neoplasm, coupled with the widespread use of radiofrequency ablation (RFA) for treatment of other types of tumor, has generated interest in using RFA to treat musculoskeletal tumors. Primary bone tumors (eg, osteoid osteoma) and metastatic bone tumors have been successfully treated with RFA. Success rates with RFA are equal to those with standard surgical curettage, but RFA has the advantage of decreased surgical morbidity. The procedure is relatively safe, is well-tolerated by the patient, and typically can be performed on an outpatient basis. The most common serious complication reported is localized skin necrosis, which occurs rarely. RFA appears to be a viable minimally invasive approach for palliative treatment of selected bone tumors.

Thermal ablation a comparison of thermal dose required for radiofrequency-, microwave-, and laser-induced coagulation in an ex vivo bovine liver model

RATIONALE AND OBJECTIVES

To compare thermal dosimetry metrics for specified diameters of coagulation achieved using three different ablation energy sources.

MATERIALS AND METHODS

204 ablations measuring 20, 30, or 40 +/- 2 mm were created in an ex-vivo bovine liver model using 1) 2.5 cm cluster RF electrodes (n = 114), 2) 3 cm microwave antennas (n = 45), and 3) 3 cm laser diffusing fibers (n = 45). Continuous temperature monitoring was performed 5-20 mm from the applicators to calculate: a) the area under the curve (AUC), b) cumulative equivalent minutes at 43 degrees C (CEM43), and c) Arrhenius damage integral (Omega) for the critical ablation margin (DOC), with results compared by multivariate analysis of variance and regression analysis.

RESULTS

The end temperatures at the margin of coagulation varied, and was lowest for the RF cluster electrode (33-58 degrees C), higher for laser (52-72 degrees C), and covered the widest range for microwave (42-95 degrees C). These end temperatures correlated with applied energy, as linear functions (r(2) = 0.74-0.96). The total heat needed to achieve ablation (AUC) varied with applied energy and coagulation diameter as negative exponential (RF and laser) or negative power (microwave) functions (r(2) = 0.82-0.98). Similarly, CEM43 values varied exponentially with energy and distance (r(2) = 0.52-0.76) over a wide range of values (10(12)). Likewise, Omega varied not only based upon energy source and DOC, but also as a positive linear correlation to applied energy and with sigmoid correlation to duration of ablation (r(2) = 0.85-0.97).

CONCLUSION

Our study demonstrates that the thermal dosimetry of ablation is not based solely on a fixed end temperature at the margin of the coagulation zone. Thermal dosimetry is not constant, but dependent on the type and amount of energy applied and distance suggesting the need to take into account the rate of heat transfer for ablation dosimetry.

Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer

BACKGROUND

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the publication of the American Thyroid Association's guidelines for the management of these disorders was published in 2006, a large amount of new information has become available, prompting a revision of the guidelines.

METHODS

Relevant articles through December 2008 were reviewed by the task force and categorized by topic and level of evidence according to a modified schema used by the United States Preventative Services Task Force.

RESULTS

The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to optimal surgical management, radioiodine remnant ablation, and suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using ultrasound and serum thyroglobulin as well as those related to management of recurrent and metastatic disease.

CONCLUSIONS

We created evidence-based recommendations in response to our appointment as an independent task force by the American Thyroid Association to assist in the clinical management of patients with thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

[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.

Palliative care in orthopaedic surgical oncology

Hundreds of thousands of Americans are affected every year by skeletal complications of oncologic disease. Recent developments in medical oncology, radiation oncology and radiology, particularly with respect to the use of bisphosphonate medication and radiofrequency techniques, have served to greatly lessen the morbidity associated with metastatic skeletal disease. Similarly, there has been significant advancement in the field of orthopaedic oncology in the areas of internal fixation, endoprosthetic implant design, and minimally invasive kyphoplasty technology. Given the palliative intent of intervention in this patient population, the goal of treatment of skeletal metastases must be optimization of limb function and ultimately, quality of life.

MRgFUS for pain relief as palliative treatment in recurrent cervical carcinoma: a case report

INTRODUCTION

Focused ultrasound under real-time MR guidance and control (MRgFUS) can be used for the thermal ablation of tissue. Currently this technique is used clinically for the noninvasive treatment of uterine leiomyomas and is in clinical evaluation for breast cancer, adenomyosis and other indications. MRgFUS is being tested for pain relief in patients suffering from bone metastases. This is the first case to report on MRgFUS for pain relief in patients suffering from recurrent cervical carcinoma.

CASE REPORT

A 29-year-old patient with recurrent squamous cell carcinoma of cervix following radical hysterectomy, chemotherapy and radiation was treated by MRgFUS due to pelvic mass unresponsive to conventional treatment that caused intractable pain. Following two treatments the patient experienced a marked reduction in pain and increase in Karnovsky Performance Status (KPS) from 50% to 80%.

DISCUSSION

Palliative treatment of pain with noninvasive MRgFUS in cases of recurrent cervical carcinoma may be a safe and efficient alternative to other invasive techniques.

Clinical outcome of percutaneous osteoplasty for pain caused by metastatic bone tumors in the pelvis and femur

We examined the pain-relieving effects in five patients who underwent percutaneous osteoplasty (POP) for pain caused by metastatic bone tumors in the pelvis and femur. Pain intensity, improvement of walking, and complications associated with POP were evaluated. Pain was measured using a numerical rating scale (NRS), with scores ranging from 0 (no pain) to 10 (worst pain imaginable). The patients were four men and one woman (mean age, 65 years). POP was performed in the pelvis in three patients and in the femur in two patients. Three of the subjects had already received radiation therapy at the lesion. The scores on the NRS on moving in the five patients before POP were 5, 8, 5, 4, and 7. After POP, the NRS scores decreased to 0, 0, 2, 0, and 1, respectively, within 72 hs. Three of the patients showed improvements in walking. There were no complications associated with POP. However, pathological fracture occurred, while walking, 4 days after POP in one patient. Percutaneous osteoplasty is a safe and effective treatment for pain caused by metastatic bone tumors in the pelvis and femur. However, care and attention should be paid to the risk of pathological fracture after POP of the femur.

Percutaneous image-guided thermal ablation and radiation therapy: outcomes of combined treatment for 41 patients with inoperable stage I/II non-small-cell lung cancer

PURPOSE

To evaluate the clinical outcomes in patients with early-stage non-small-cell lung cancer (NSCLC) after combined treatment with thermal ablation and radiation therapy (RT).

MATERIALS AND METHODS

Forty-one patients with inoperable stage I/II NSCLC tumors underwent thermal ablation and RT at our institution between 1998 and 2005. Thirty-seven radiofrequency (RF) ablation procedures and four microwave ablation procedures were performed. Ablations were followed by standard-fraction external-beam RT within 90 days (n = 27) or postprocedural brachytherapy (n = 14). Survival and local recurrence were the primary endpoints evaluated by Kaplan-Meier analysis.

RESULTS

The median follow-up was 19.5 months. The overall survival rates were 97.6% at 6 months, 86.8% at 1 year, 70.4% at 2 years, and 57.1% at 3 years. Patients with tumors smaller than 3 cm (n = 17) had an average survival time of 44.4 +/- 5.4 months (SE). Patients with tumors 3 cm or larger (n = 24) had an average survival time of 34.6 +/- 7.0 months (P = .08). Local recurrence occurred in 11.8% of tumors smaller than 3 cm after an average of 45.6 +/- 4.1 months and in 33.3% of the larger tumors after an average of 34.0 +/- 7.8 months (P = .03). Outcomes in the brachytherapy and RT groups did not differ significantly. Nine of 15 pneumothoraces required chest tube drainage (22.0%).

CONCLUSIONS

Thermal ablation followed by RT for inoperable stage I/II NSCLC has a relatively low rate of complications that are easily managed. Combined therapy may result in an improved survival compared with either modality alone.

Advances in musculoskeletal tumor imaging

In the last 2 decades, there has been a dramatic change in the clinical approach to the tumors of the musculoskeletal system. The role of medical imaging in diagnosis, staging,and eventual follow-up of patients who have musculoskeletal neoplasia has expanded. This article presents an overview of the role of imaging, recent advances in technology,and state-of-the-art techniques for evaluating musculoskeletal neoplasms. Conventional imaging modalities, ultrasound, CT, MRI, positron emission tomography, and image-guided interventions are discussed.

Radiofrequency treatment

This article discusses radiofrequency energy as a treatment of musculoskeletal tumors,focusing on osteoid osteomas. The technique has also been applied to a number of different primary musculoskeletal tumors and is increasingly being used as a palliative method in the management of painful skeletal metastases. Radiofrequency treatment of musculoskeletal tumors can be of great clinical value. When the low-power, highly limited methods are applied to small tumors such as osteoid osteomas, the technique is effective and exceptionally safe. Creation of larger thermal lesions, however, can be accompanied by significant risks, and the risk-to-benefit ratio should be carefully considered before undertaking such a treatment.

Use of an Arterial Tourniquet to Achieve Complete Radiofrequency Ablation of a Renal Metastasis

Radiofrequency (RF) coagulation of skeletal metastases is usually performed for pain relief. However, patients with solitary skeletal metastasis may benefit from more aggressive attempts to achieve local control. The authors report a case in which an arterial tourniquet was used to enhance the effectiveness of RF treatment of a calcaneal renal cell metastasis, leading to long-lasting local control with preservation of ambulation.

Radiofrequency induced thermotherapy: an alternative palliative treatment modality in head and neck cancer

Bipolar radiofrequency induced thermotherapy (RFITT) is a minimally invasive electrosurgical technique characterized by a precise controllable effect in the tissue. It has demonstrable efficacy, safety and reproducibility in the management of solid malignancies. Our aim was to assess the morbidity and efficacy of RFITT as a palliative treatment of head and neck cancer. Prospective, non-randomized case series and analysis. After evaluation by the multidisciplinary Head and Neck Tumour Board at Helsinki University Central Hospital, Finland, 12 consecutive patients with a head and neck cancer without curative treatment possibilities were enrolled into the study. Five patients had pharyngeal carcinomas, one had an unknown primary tumour growing through the skin on the neck, two had a recurrent malignant melanoma originating from the maxillary sinuses, one had a carcinoma of the tongue, two had laryngeal carcinomas, and one had a recurrent adenoid cystic carcinoma of the parotid gland. RFITT was performed with a CelonLabPrecision generator using appropriate electrodes. The treatment was administered under local or general anaesthesia. The subjective morbidity of the treatment was evaluated. The response to the treatment was assessed clinically and with radiological imaging when feasible. All but two of the patients received palliation to their disease. RFITT induced clinically a partial response in ten patients, and there were radiological detectable changes. There were no treatment related complications, and the patients tolerated the treatment well. RFITT in head and neck cancer patients is easy to perform, well tolerated, and induces reduction in the tumour mass. Continuous evaluation of RFITT treatment modality is warranted in selected palliative care patients.

Current role of image-guided ablative therapies in lung cancer

Lung cancer is the leading cause of cancer-related mortality in the USA. Until recently, lung cancer treatment options (dependent upon the tumor grading and staging at presentation, and patient comorbidities) included surgical resection (lobar or sublobar), chemotherapy and external-beam radiation therapy. While these options are still viewed as the primary standard of care, newer minimally invasive percutaneous ablative techniques such as radiofrequency ablation, microwave ablation and cryoablation are currently being examined as treatment alternatives, especially in the setting of the nonsurgical candidate. This review will focus on these three distinct thermoablative techniques in the percutaneous setting of lung cancer treatment.

Musculoskeletal interventional MR imaging

MR imaging guidance has great potential to direct the management of diagnostic and therapeutic procedures performed in the musculoskeletal region. To take full advantage of this excellent diagnostic tool, radiologists should also embrace the minimally invasive techniques available for MR imaging. This can be achieved by cooperation with clinical colleagues, multidisciplinary integration, and the development of efficient techniques for MR-guided procedures. By combining the excellent ability to recognize pathologic findings and the feasibility of performing interventional procedures, MR imaging is emerging as a powerful tool in diagnosing and treating musculoskeletal neoplasms and in performing minimally invasive procedures, such as spine injections.

Combined Radiofrequency Ablation and Adjuvant Liposomal Chemotherapy: Effect of Chemotherapeutic Agent, Nanoparticle Size, and Circulation Time

PURPOSE

To evaluate the effects of liposomal chemotherapeutic agent, nanoparticle size, and liposome circulation time on tissue coagulation and intratumoral drug uptake when radiofrequency (RF) ablation is combined with adjuvant intravenous liposomal chemotherapy in an animal breast tumor model.

MATERIALS AND METHODS

Ninety-one R3230 mammary adenocarcinoma nodules were implanted in 48 Fischer rats. First, standardized RF ablation was combined with intravenous liposomal doxorubicin, cisplatin, or 5-fluorouracil (35 tumors each). Second, three different-sized doxorubicin-containing nanoparticle preparations were combined with standardized RF ablation. Last, two doxorubicin-containing liposome preparations with different blood elimination half-lives were combined with RF ablation. Coagulation diameter and interstitial doxorubicin concentration were measured 48 hours after treatment and compared with use of statistical analysis.

RESULTS

All combinations of RF with liposomal chemotherapy caused significantly greater tumor necrosis than RF alone (P<.05). Significantly increased necrosis was observed with intravenous liposomal RF/doxorubicin and RF/cisplatin compared with intravenous liposomal RF/5-fluorouracil (P<.01). Greater coagulation was observed with RF combined with 100-nm nanoparticles compared with 20-nm or 250-nm nanoparticles (P=.01 and P=.04, respectively). Additionally, greater intratumoral doxorubicin uptake was observed in the group treated with 20-nm nanoparticles compared with those treated with other sizes of nanoparticles (P<.05). RF plus liposomal doxorubicin produced greater coagulation and intratumoral doxorubicin uptake than RF plus 1,2-dipalmitoyl-sn-glycero-3-phosphatidic acid (P<.05).

CONCLUSION

When combined with RF ablation, modification of adjuvant intravenous liposomal chemotherapy, including nanoparticle size, circulation time, and chemotherapeutic agent, can influence intratumoral drug accumulation and tissue coagulation.