CT guided cryoablation for locally recurrent or metastatic bone and soft tissue tumor: initial experience

Utility of Intraoperative Neuromonitoring to Protect against Adjacent Nerve Injury in Musculoskeletal and Lymph Nodal Cryoablation

PURPOSE

To demonstrate the utility of intraoperative neuromonitoring (IONM) as an effective method of passive thermoprotection against cryogenic injury to neural structures during musculoskeletal and lymph node cryoablation.

MATERIAL AND METHODS

Twenty-nine patients (16 men; mean age among men, 68.6 years [range, 45-90 years]; mean age among women, 62.6 years [range, 28-88 years]) underwent 33 cryoablations of musculoskeletal and lymph node lesions. Transcranial electrical motor-evoked potentials (MEPs) and somatosensory-evoked potentials (SSEPs) of target nerves were recorded throughout the ablations. Significant change was defined as waveform amplitude reduction greater than 30% (MEP) and 50% (SSEP). The primary outcomes of this study were immediate postprocedural neurologic deficits and frequency of significant MEP and SSEP amplitude reductions.

RESULTS

Significant amplitude reductions were detected in 54.5% (18/33) of MEP tracings and 0% (0/33) of SSEP tracings. Following each occurrence of significant amplitude reductions, freeze cycles were promptly terminated. Intraprocedurally, 13 patients had full recovery of amplitudes to baseline, 11 of whom had additional freeze cycles completed. In 5 of 33 (15.2%) cryoablations, there were immediate postprocedural neurologic deficits (moderate adverse events). Unrecovered MEPs conferred a relative risk for neurologic sequela of 23.2 (95% CI, 3.22-167.21; P < .001) versus those with recovered MEPs. All 5 patients had complete neurologic recovery by 12 months.

CONCLUSIONS

IONM (with MEP but not SSEP) is a reliable and safe method of passive thermoprotection of neurologic structures during cryoablation. It provides early detection of changes in nerve conduction, which when addressed quickly, may result in complete restoration of MEP signals within the procedure and minimize risk of cryogenic neural injury.

Percutaneous Cryoablation of Recurrent or Oligometastatic Tumors in Thoracoabdominal Soft Tissues: Safety, Effectiveness, and Technical Aspects

PURPOSE

To assess the effectiveness and safety of cryoablation (CRA) for the treatment of recurrent or oligometastatic solid tumors located in the thoracoabdominal soft tissues.

MATERIALS AND METHODS

Twenty-two percutaneous CRA procedures performed in 19 patients to treat recurrent or oligometastatic tumors in thoracoabdominal soft tissue were retrospectively examined. All procedures were performed between January 2015 and June 2021 under ultrasound and computed tomography (CT) guidance, and the most complex procedures were performed with CT-based navigation systems. The histology of the primary tumors included colorectal adenocarcinoma, squamous cell lung carcinoma, pancreatic adenocarcinoma, renal cell carcinoma, and hepatocellular carcinoma. Adverse events, technical success, and local tumor control were analyzed.

RESULTS

The mean age of the patients was 66.5 years, with a mean tumor size of 24.8 mm. The mean time of the procedures was 68 minutes, with a mean number of 2.5 cryoprobes used. Hydrodissection was performed in 63% of the procedures to protect the surrounding anatomical structures. The mean size of the ice ball, measured on axial CT scans at the end of the procedures, was 43.5 mm. No severe adverse events were observed. Technical success was achieved in all cases. Three patients experienced local tumor progression (2 residual disease and 1 recurrence), which were successfully treated with a second CRA procedure.

CONCLUSIONS

Percutaneous CRA is a safe and effective therapy in selected cases of recurrent or oligometastatic tumors in the thoracoabdominal soft tissues.

Complications of cryoprobe cryoablation as a surgical adjuvant for the treatment of metastatic carcinoma to bone, benign bone tumors, and soft tissue tumors: A series of 148 patients

BACKGROUND AND OBJECTIVE

This study describes the complication profile of modern cryoablation utilizing probes as an adjuvant during open surgical treatment of orthopedic tumors.

METHODS

A retrospective, single-surgeon study was performed for patients receiving cryoprobe cryoablation. Demographic information, malignancy-related and operative details, and clinical courses were collected. Outcomes assessed included rates of complications, recurrence, and correlations between the number of probes or cryoablation cycles performed.

RESULTS

In this 148-patient study, 67.6% had metastatic carcinoma to bone, 27.7% had benign bone tumors, and 4.7% had soft tissue tumors. An average of 3.4 ± 1.7 cryoablation probes were utilized and 1.7 ± 0.6 freezing cycles were performed. The overall cohort aggregate complication rate was 16.9%. These complications included postoperative fracture (3.4%), nerve palsy (2.7%), wound complications (7.4%), and infection (3.4%). The number of cycles and probes was significantly correlated with the incidence of aggregate complications in the overall cohort (Pearson = 0.162, p = 0.049) and metastatic bone cohort (Pearson = 0.222, p = 0.027). There were 13 recurrences.

CONCLUSION

This study describes the complication rates involving cryoablation probes used as surgical adjuvants. Greater probe number usage was correlated with increased aggregate complications in patients with metastatic disease to bone; meanwhile, more treatment cycles were associated with increased aggregate complications in the overall cohort.

The New Ice Age of Musculoskeletal Intervention: Role of Percutaneous Cryoablation in Bone and Soft Tissue Tumors

In the rapidly evolving field of interventional oncology, minimally invasive methods, including CT-guided cryoablation, play an increasingly important role in tumor treatment, notably in bone and soft tissue cancers. Cryoablation works using compressed gas-filled probes to freeze tumor cells to temperatures below -20 °C, exploiting the Joule-Thompson effect. This cooling causes cell destruction by forming intracellular ice crystals and disrupting blood flow through endothelial cell damage, leading to local ischemia and devascularization. Coupling this with CT technology enables precise tumor targeting, preserving healthy surrounding tissues and decreasing postoperative complications. This review reports the most important literature on CT-guided cryoablation's application in musculoskeletal oncology, including sarcoma, bone metastases, and bone and soft tissue benign primary tumors, reporting on the success rate, recurrence rate, complications, and technical aspects to maximize success for cryoablation in the musculoskeletal system.

Transarterial Embolization and Percutaneous Ablation of Primary and Metastatic Soft Tissue Tumors

Soft tissue tumors (STTs) include a range of benign and malignant tumors originating from soft tissues. Transarterial and percutaneous therapies are image-guided and minimally invasive approaches for managing primary and metastatic STTs. The objective of this review is to discuss transarterial and percutaneous therapies by examining the current literature, including indications, patient selection, safety, and effectiveness. Transarterial therapies (e.g., transarterial bland embolization and transarterial chemoembolization) involve the delivery of either embolic or chemotherapeutic particles using a catheter into arteries feeding the tumor, resulting in localized tumor destruction. Percutaneous therapies (e.g., radiofrequency ablation, cryoablation, irreversible electroporation, laser ablation, and magnetic resonance-guided high-intensity focused ultrasound) involve the delivery of either hot or cold temperatures, electrical current, laser, or ultrasound to specifically target tumor cells. Both therapies have been shown to be safe and effective for reducing morbidity and local control of STTs, specifically in patients who are surgically inoperable or who are unresponsive to conventional therapies. Accurate diagnosis, staging, and histological subtype identification are crucial for treatment selection. A multidisciplinary approach, a thorough understanding of tissue anatomy and surrounding structures, as well as individualized strategies based on assessment are essential for optimal patient care.

Myxofibrosarcoma landscape: diagnostic pitfalls, clinical management and future perspectives

Myxofibrosarcoma (MFS) is a common entity of adult soft tissue sarcomas (STS) characterized by a predilection of the extremities and a high local recurrence rate. Originally classified as a myxoid variant of malignant fibrous histiocytoma, this musculoskeletal tumor has been recognized since 2002 as a distinct histotype showing a spectrum of malignant fibroblastic lesions with myxoid stroma, pleomorphism and curvilinear vessels. Currently, the molecular pathogenesis of MFS is still poorly understood and its genomic profile exhibits a complex karyotype with a number of aberrations including amplifications, deletions and loss of function. The diagnosis is challenging due to the unavailability of specific immunohistochemical markers and is based on the analysis of cytomorphologic features. The mainstay of treatment for localized disease is represented by surgical resection, with (neo)-adjuvant radio- and chemotherapy. In the metastatic setting, chemotherapy represents the backbone of treatments, however its role is still controversial and the outcome is very poor. Recent advent of genomic profiling, targeted therapies and larger enrollment of patients in translational and clinical studies, have improved the understanding of biological behavior and clinical outcome of such a disease. This review will provide an overview of current diagnostic pitfalls and clinical management of MFS. Finally, a look at future directions will be discussed.

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.

Safety and Feasibility of Cryoablation during Immunotherapy in Patients with Metastatic Soft Tissue Sarcoma

PURPOSE

Patients with metastatic soft tissue sarcoma (STS) undergo a wide array of treatments, including surgery, radiation, chemotherapy, immunotherapy, and ablative therapies, to control their disease. The combination of cryoablation and immunotherapy may lead to an enhanced antitumor immune response via the abscopal effect. It is hypothesized that the combination of cryoablation and immunotherapy in patients with metastatic STS is safe and feasible.

MATERIALS AND METHODS

A single-center retrospective analysis was performed on patients with metastatic STS who underwent cryoablation. Sixteen patients were treated with 27 cryoablation procedures while receiving ipilimumab and nivolumab from April 2017 to July 2020. Response Evaluation Criteria in Solid Tumors, 1.1, were used to determine the outcomes of nontarget tumors. Progression-free survival (PFS) and overall survival (OS) were calculated from the date of the first cryoablation after initiating immunotherapy until progression or death.

RESULTS

Thirty-four tumors were cryoablated, 23 of which were intentionally subtotal. The most common tumor subtype was liposarcoma (n = 4). Thirteen (81%) patients had previously demonstrated disease progression on multiple lines of chemotherapy. All tumors cryoablated with a complete intention demonstrated a complete response. Seven patients had a clinical benefit, including 1 with a complete response, 1 with a partial response, and 5 with stable disease. The median OS was 14.1 months, with a median PFS of 2.3 months (95% confidence interval, 1.8-14.3). Five patients had pneumothoraces after cryoablation, 2 of whom required chest tube placement. Eleven patients experienced adverse events related to immunotherapy, 10 of whom experienced grade 1 or 2.

CONCLUSIONS

Cryoablation in patients with metastatic STS undergoing immunotherapy is feasible and safe.

GEIS-SEHOP clinical practice guidelines for the treatment of rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is the most frequent soft tissue sarcoma (STS) in children and adolescents. In Spain the annual incidence is 4.4 cases per million children < 14 years. It is an uncommon neoplasm in adults, but 40% of RMS are diagnosed in patients over 20 years of age, representing 1% of all STS in this age group. RMS can appear anywhere in the body, with some sites more frequently affected including head and neck, genitourinary system and limbs. Assessment of a patient with suspicion of RMS includes imaging studies (MRI, CT, PET-CT) and biopsy. All patients with RMS should receive chemotherapy, either at diagnosis in advanced or metastatic stages, or after initial resection in early local stages. Local control includes surgery and/or radiotherapy depending on site, stage, histology and response to chemotherapy. This guide provides recommendations for diagnosis, staging and treatment of this neoplasm.

Preoperative cryoablation of a hypervascular bone metastasis: A case of effective devascularization before preoperative embolization

Image-guided cryoablation has become a common approach for the palliative treatment of painful metastatic bone lesions, and indications for this procedure have expanded to include local control of bone metastases. We report a case in which cryoablation was performed on a large hypervascular renal cell carcinoma bone metastasis before surgical fixation of an impending fracture. In this case, cryoablation reduced the patient's pain but also appeared to result in devascularization of the tumor, thus obviating the need for preoperative embolization. This case raises the possibility that image-guided cryoablation may represent an alternative to preoperative embolization for vascular tumors while also serving a palliative function.

Image-guided Cryotherapy for Musculoskeletal Tumors

BACKGROUND

This article represents a review of the use of image-guided cryotherapy in the treatment of musculoskeletal tumor lesions. Cryotherapy is able to induce a lethal effect on cancer cells through direct and indirect mechanisms. In this manuscript, we combined our experience with that of other authors who have published on this topic in order to provide indications on when to use cryotherapy in musculoskeletal oncology.

DISCUSSION

Image-Guided percutaneous cryotherapy is a therapeutic method now widely accepted in the treatment of patients with musculoskeletal tumors. It can be used both for palliative treatments of metastatic bone lesions and for the curative treatment of benign bone tumors, such as osteoid osteoma or osteoblastoma. In the treatment of bone metastases, cryotherapy plays a major role in alleviating or resolving disease-related pain, but it has also been demonstrated that it can have a role in local disease control. In recent years, the use of cryotherapy has also expanded for the treatment of both benign and malignant soft tissue tumors.

CONCLUSION

Percutaneous cryotherapy can be considered a safe and effective technique in the treatment of benign and malignant musculoskeletal tumors. Cryotherapy can be considered the first option in benign tumor lesions, such as osteoid osteoma, and a valid alternative to radiofrequency ablation. In the treatment of painful bone metastases, it must be considered secondarily to other standard treatments (radiotherapy, bisphosphonate therapy, and chemotherapy) when they are no longer effective in controlling the disease or when they cannot be repeated (for example, radiotherapy).

Image-guided percutaneous cryoablation of unresectable sacrococcygeal chordoma: Feasibility and outcome in a selected group of patients with long term follow-up

BACKGROUND

Chordoma is a rare malignant tumor of the axial skeleton. Percutaneous cryoablation (PCA) is a minimally invasive technique that allows freezing of tumors under imaging control. The purpose of our retrospective study was to investigate the outcome of PCA in a selected cohort of patients with sacrococcygeal chordoma, with a minimum of 5 years follow-up.

MATERIALS AND METHODS

Four patients were treated in 10 sessions. The mean follow-up was 57.3 months. We evaluated the feasibility, the procedure-related complications, the impact on pain control and oncological outcomes.

RESULTS

Freezing of 100% of the tumor volume was possible in 60%. Pain control was not reliably evaluable. Local recurrence occurred in 90% of the treated lesions; the mean time to progression was 8.1 months (range 1.5-16). At last follow-up, one patient had died of the disease, one of another cause and one was receiving the best supportive care. The only patient alive without the disease had received additional carbon-ion radiotherapy. The 5-year survival rate after index PCA was 50%.

CONCLUSION

Complete freezing of the tumor was technically challenging, mainly due to the complex local anatomy. Recurrence occurred in 90% of the lesions treated. PCA should be considered with caution in the curative management of sacrococcygeal chordoma.

Acute Phase Response and Postprocedural Evaluation of Open and Laparoscopic Cryoablation Procedures in Porcine Pancreases

OBJECTIVES

Cryoablation is a potentially less invasive locoregional ablation modality. Although cryoablation has been used to treat malignancy in various organs, a limited application of this modality in the pancreas has been reported.

METHODS

Acute phase response assessments and postprocedural course evaluations of 2 experimental locoregional ablation methods were conducted. In one method, open and laparoscopic cryoablation of a porcine pancreas using an argon-helium gas-based cryoablation system and monitoring of tissue temperature during the procedure were performed. In the other method, open cryoablation of a porcine pancreas using liquid nitrogen was performed. The animals were evaluated postoperatively.

RESULTS

The size of the cryolesion was larger in the second treatment than in the first. Laparoscopic cryoablation was associated with the formation of an iceball, which possibly affected the surrounding structures. The ablated region was adequately cooled with 10 minutes of freeze/repeat cycles. The area cooled to a temperature of less than -40°C was approximately half the size of the cryolesion in diameter. The swine used for the evaluation of the postprocedural course survived 3 weeks after the procedure with a temporal elevation of the serum lipase level.

CONCLUSIONS

Cryoablation of the pancreas was experimentally practicable without severe complications under direct or laparoscopic vision.

Low-grade Fibromyxoid Sarcoma: Treatment Outcomes and Efficacy of Chemotherapy

BACKGROUND

Low-grade fibromyxoid sarcoma (LGFMS) is a rare sarcoma subtype with a generally indolent pattern of clinical behaviour, but treatments for advanced disease are limited.

PATIENTS AND METHODS

A retrospective search of a prospectively maintained institutional database identified 102 patients treated from December 1994 to August 2018. We evaluated the outcome of patients and the efficacy and safety of non-surgical therapies in LGFMS.

RESULTS

Ninety-four out of 102 (92.2%) underwent primary resection, seven (6.9%) were treated with systemic therapy and one (1.0%) is currently being treated with pre-operative radiotherapy. The RECIST 1.1 response rate to first-line chemotherapy was 0%, and median progression-free survival was 1.84 months (95% confidence intervaI=0.10-3.6 months).

CONCLUSION

Conventional systemic therapy has limited efficacy in advanced LGFMS.

Successful treatment with cryoablation in a patient with bone metastasis in the mid-shaft femur: a case report

Background: Treatment of metastatic bone tumors is challenging due to the morbidity associated with patients with metastasis. The present case report described a patient with successful treatment of bone metastasis using cryoablation with plate and cementation to prevent fracture for bone metastasis of leiomyosarcoma in the mid-shaft of the femur.

Case report: The metastatic tumor was located at intramedullary lesion of the femur. At first, cryoablation was performed under local anesthesia. After one week after cryoablation, curettage and fixation with plate and cementation were performed to prevent fracture. Tumor cells were not observed in the histopathological findings of the curettage tissue. Four years after cryoablation, there was no recurrence and the patient could walk without any support.

Conclusion: We suggest that a tumor with limited cancellous bone and of a small size may undergo cryoablation. The prevention of fracture after cryoablation should be considered.

Percutaneous image-guided cryoablation of painful bone metastases: A single institution experience

BACKGROUND

Bone metastases are frequently painful and may lead to various complications that can affect quality of life. While external beam radiation therapy is the standard first-line treatment, 20-30% of patients do not experience sufficient pain relief. Cryoablation is increasingly being used for the treatment of musculoskeletal metastases. The purpose of our retrospective study was to analyze pain relief and local disease control after percutaneous image-guided cryoablation (PCA) therapy of painful bone metastases.

MATERIALS AND METHODS

Sixteen patients treated with PCA for painful bone metastases (n=18) over a 5-year period (from June 2011 to June 2016) were retrospectively reviewed. Five patients also benefited from long bone fixation because of an impending fracture. We analyzed the impact of treatment on pain relief, using a numerical rating scale (NRS), and local disease control.

RESULTS

The mean follow-up period was 12 months (range, 1.5-39 months). At last oncological outpatient consultation, 75% (12/16) of patients had good pain relief, while 63% (10/16) had locally stable disease or no local recurrence of the treated bone metastases. The mean NRS score decreased significantly from 3.3 to 1.2 after PCA (p=0.0024). The five patients with concomitant long bone fixation all had satisfactory pain relief at the last follow-up visit.

CONCLUSION

PCA is a safe and valid treatment option for pain and local disease control in cases of painful bone metastases after failed standard first-line therapy. This technique can also be effectively associated to prophylactic long bone fixation and may allow for easier rehabilitation protocols when treating weight-bearing bones.

LEVEL OF EVIDENCE

IV, Retrospective case series.

Role of metastasis-directed treatment in kidney cancer

Despite the rapid elaboration of multiple, novel systemic agents introduced for metastatic renal cell carcinoma (mRCC) in recent years, a durable complete response remains elusive with systemic therapy alone. Definitive treatment of the metastatic deposit remains the sole potentially curative option and is a cornerstone of mRCC therapy, offering potential for both local control and palliation of tumor-related symptoms. In this review, the evidence supporting the definitive treatment of mRCC is examined and summarized, including the use of surgical metastasectomy, thermal ablation, radiotherapy, and other minimally invasive options. Multimodal approaches, including the combination of metastasectomy with novel systemic agents, are discussed. Finally, the authors review considerations for patient selection for this type of therapy and summarize available risk-stratification tools that may help guide shared decision making.

Immunotherapy Plus Cryotherapy: Potential Augmented Abscopal Effect for Advanced Cancers

Since the 1920s the gold standard for treating cancer has been surgery, which is typically preceded or followed with chemotherapy and/or radiation, a process that perhaps contributes to the destruction of a patient’s immune defense system. Cryosurgery ablation of a solid tumor is mechanistically similar to a vaccination where hundreds of unique antigens from a heterogeneous population of tumor cells derived from the invading cancer are released. However, releasing tumor-derived self-antigens into circulation may not be sufficient enough to overcome the checkpoint escape mechanisms some cancers have evolved to avoid immune responses. The potentiated immune response caused by blocking tumor checkpoints designed to prevent programmed cell death may be the optimal treatment method for the immune system to recognize these new circulating cryoablated self-antigens. Preclinical and clinical evidence exists for the complementary roles for Cytotoxic T-lymphocyte-associated protein (CTLA-4) and PD-1 antagonists in regulating adaptive immunity, demonstrating that combination immunotherapy followed by cryosurgery provides a more targeted immune response to distant lesions, a phenomenon known as the abscopal effect. We propose that when the host’s immune system has been “primed” with combined anti-CTLA-4 and anti-PD-1 adjuvants prior to cryosurgery, the preserved cryoablated tumor antigens will be presented and processed by the host’s immune system resulting in a robust cytotoxic CD8⁺ T-cell response. Based on recent investigations and well-described biochemical mechanisms presented herein, a polyvalent autoinoculation of many tumor-specific antigens, derived from a heterogeneous population of tumor cancer cells, would present to an unhindered yet pre-sensitized immune system yielding a superior advantage in locating, recognizing, and destroying tumor cells throughout the body.