Interventional Techniques for Bone and Musculoskeletal Soft Tissue Tumors: Current Practices and Future Directions - Part I. Ablation

Abstract

Musculoskeletal (MSK) image-guided oncologic intervention is an established field within radiology. Numerous studies have described its clinical benefits, safety, cost effectiveness, patient satisfaction, and improved quality of life, thereby establishing image-guided oncologic intervention as a preferred pathway in treating patients presenting with specific benign MSK tumors. But there is a paradigm shift on the horizon because these techniques may also support established pillars (surgery, systemic treatment, radiotherapy) in the treatment of malignant MSK tumors. Unlike benign tumors, where they are used as primary therapy lines with curative intent, such interventions can be selected for malignant tumors as adjuvant treatment in painful or unstable bone or soft tissue lesions or as more palliative therapy strategies. Using examples from our clinical practices, we elaborate on the benefits of applying a multidisciplinary approach (traditionally involving MSK radiologists, oncologists, orthopaedic surgeons, microbiologists, pathologists, physiotherapists, and pain management experts), ideally within a sarcoma treatment center to deliver a patient-specific therapy plan and illustrate methods to assess the benefits of this model of care.In this article, we review the current repertoire of ablation techniques, demonstrate why such procedures offer value-based alternatives to conventional treatments of specific tumors, and reflect on future directions. Additionally, we review the advantages and limitations of each technique and offer guidance to improve outcomes.

Interventional Radiology in the Management of Metastases and Bone Tumors

“…Embolization is performed for the treatment of bone lesions either alone or in combination with other techniques [ 2 , 3 , 7 ]. It reduces hypervascularization of the lesions by injection of embolic agents into the vessels, causing necrosis of the tumors.…”

“…It is defined “percutaneous” because the energy pass through the skin, the soft tissues and the bone using a needle or a needleless technique (magnetic resonance imaging-guided high-intensity focused ultrasound MRgFUS). The most used techniques include radiofrequency thermal ablation (RFA), cryoablation (CA), laser and microwaves thermal ablation (MWA) [ 7 ]. The main advantage is the possibility to create an ablation area of known and reproducible size.…”

“…Ethanol injection is a precursor of thermal ablation and is considered a technique of chemical ablation: through direct injection of alcohol into the lesion, it produces tumor necrosis directly through cellular dehydration and indirectly through vascular thrombosis and tissue ischaemia. This technique does not allow full control of the ablation, since the diffusion of ethanol is not fully predictable or reproducible [ 7 ].…”

“…In case of tumoral extension to neural structures, pain may be radicular (exacerbated by percussion or palpation) and/or mechanical (exacerbated by movement) [ 5 , 6 ]. In advanced stages of the disease, pain can become intolerable and refractory to conventional therapies, causing walking disability, psychological and functional impact, and significantly impairing quality of life [ 2 , 3 , 4 , 7 ]. The approach to the patient with BM must be strictly multidisciplinary with the involvement of all professional figures (oncologist, radiotherapist, orthopedic, and pain therapy specialist) to offer the patient the best treatments.…”

“…The approach to the patient with BM must be strictly multidisciplinary with the involvement of all professional figures (oncologist, radiotherapist, orthopedic, and pain therapy specialist) to offer the patient the best treatments. In the decision making for surgical and/or medical treatment, life expectancy of patients with metastatic bone disease is the most important factor; a short life expectancy suggests the use of less invasive procedures, that bring lower complication rates and shorter rehabilitation times [ 7 ]. In this context, interventional radiology procedures play an important primary or complementary role in the management of BMs [ 8 , 9 , 10 ], especially in terms of palliation of pain and treatment of fractures.…”