The Hopeless Case? Palliative Cryoablation and Cementoplasty Procedures for Palliation of Large Pelvic Bone Metastases

Abstract

Background: Metastases to the bone are common in cancer patients, and it has been estimated that up to 50% of patients with pelvic bone metastases will not achieve adequate pain control with medications alone. This has led to a paradigm shift over recent years towards the use and development of minimally invasive image-guided treatment options for palliation of bony metastases. Despite these developments, large metastatic lesions are still often considered to be “hopeless cases” that would garner little to no benefit from image-guided intervention. This study is the first large series to describe the novel use of combination percutaneous cryoablation and cementoplasty for palliation of such large metastases to the pelvis. Objectives: We aim to evaluate the efficacy and safety of image-guided percutaneous cryoablation and cementoplasty for palliation of large pelvic bone metastases. Study Design: This retrospective analysis was approved by our institutional review board. This study was conducted from January 2013 to December 2016, where consecutive patients referred for pain management of large pelvic bone metastases underwent combination percutaneous cryoablation and cementoplasty. Setting: This study took place at a tertiary care center after patients were referred following formal review from a multidisciplinary conference, which was comprised of interventional radiologists, pain management and palliative care physicians, radiation and medical oncologists, and when available, anesthesiologists. Methods: Forty-eight patients (36 men and 12 women) with a mean cohort age of 77.5 years (range: 52 – 89 years) were referred from the multidisciplinary conference for palliation of pelvic bone metastases. The inclusion criteria included patients with metastases greater or equal to 5.0 cm and significant pain refractory to conventional pain management regimens. All of the patients were deemed not to be surgical candidates. Mean pain scores were collected at numerous time-points along with procedural technical success rates and complication rates. Results: Combination cryoablation and cementoplasty was performed on 48 consecutively referred patients with a 100% technical success rate and no immediate complications. The pain levels demonstrated a significant decrease (P < 0.001) following intervention, with mean pain scores of 7.9 (range: 5 – 10) and 1.2 (range: 0 – 7) throughout the week prior to intervention and at 24 hours postintervention, respectively. The post-intervention pain scores remained stable at 1 to 9 weeks followup (mean: 4.1 weeks). Three patents (6.3%) reported no change in pain following the intervention; however, no patients reported worsened pain. Limitations: The limitations of this study include its retrospective nature and the length of follow-up, which was often restricted given the life expectancy of our patient cohort. Conclusion: Combination cryoablation and cementoplasty is a novel and efficacious treatment option for palliation of large pelvic bone metastases. Marked improvements in pain, as well as mobility and quality of life, are often attainable. Key words: Pain, palliative care, palliation, percutaneous, cryoablation, cementoplasty, metastases, pelvis, interventional radiology, thermal ablation

Percutaneous Cryoablation of Large Tumors: Safety, Feasibility, and Technical Considerations

“…The complication rate reported herein contrasts with Coupal and colleagues, who reported a series of 48 patients undergoing cryoablation and cementoplasty for palliation of painful pelvic metastases greater than 5 cm in size. [6] While technical success in their series was 100%, with significant and sustained improvement in pain scores following ablation, there were no major complications in their series. The lack of major complications in that series may be related to relative aggressiveness of treatment and patient and tumor selection factors.…”

“…As technology and operator experience have advanced over the past two decades, the role of cryoablation has expanded to encompass a variety of clinical needs, ranging from established indications in the treatment of solid renal masses and painful skeletal metastases to emerging uses in disease processes such as abdominal wall endometriosis, vascular malformations, and extra-abdominal desmoid tumors [1][2][3][4][5]. Cryoablation is increasingly used to treat large tumors that may be unsuitable for surgical cure or other local therapies due to their size, prior non-ablative treatment failure, or coexisting disease burden [6].…”

“…While the general safety and efficacy of cryoablation have been well documented, these data predominantly reflect treatment of relatively small tumors [8][9][10]. Few series specifically evaluate large tumor cryoablation or address the considerable technical and logistical challenges inherent to such cases [6,11]. This single-center retrospective study was conducted to assess the safety and efficacy of percutaneous image-guided cryoablation of large tumors and, in order to help guide others in such treatment, highlight the key technical considerations and risk mitigation strategies that support successful treatment.…”

Joint-sparing reconstruction for extensive periacetabular metastases: Literature review and a novel minimally invasive surgical technique

“…Interventional techniques like percutaneous cementoplasty and thermal ablation have been typically useful in patients with metastatic acetabular lesions without impending fractures or instability, who experience refractory pain to radiation therapy and medical management, and/or are non-surgical candidates [1] , [13] , [18] . With the addition of screws to the percutaneous osteoplasty technique, some surgeons have extended this indication to include impending fractures, minimally displaced fractures and unstable lesions involving the posterior or anterior column [8] , [10] , [11] , [14] , [17] , [19] .…”

Biomechanics of the Osseous Pelvis and Its Implication for Consolidative Treatments in Interventional Oncology

“…If the patient is not a surgical candidate, percutaneous cementoplasty +/-screw fixation and thermal ablation might be used for palliation with reserved expectations for stabilization outcomes (fig. 9) [2,49].…”