Minimally Invasive Interventional Procedures for Metastatic Bone Disease: A Comprehensive Review

Autrusseau P., Schneegans O., Koch G., Weiss J., Caudrelier J., Dalili D., Perolat R., Auloge P., Cazzato R.L., Gangi A., Garnon J.

AbstractPurpose To determine the oncologic outcomes and safety profile of image-guided percutaneous cryoablation (PCA) for extraspinal thyroid cancer bone metastases with curative intent. Materials and Methods Between January 2010 and January 2020, 16 consecutive patients (8 men, 8 women; mean age, 61 years ± 19; range, 30–84 years) with 18 bone metastases (median bone tumor size, 19 mm; interquartile range [IQR], 12–29 mm; range, 7–58 mm) underwent PCA of oligometastatic extraspinal bone metastases. Thirteen (81%) patients were radioiodine therapy resistant. Two patients underwent 2 bone tumor ablations in a single session. Procedural data, oncologic outcomes, follow-up (with magnetic resonance imaging and positron emission tomography–computed tomography), and adverse events were retrospectively investigated. Local tumor progression-free survival, disease-free survival, and overall survival were estimated using the Kaplan-Meier method. Results A median of 2 cryoprobes (IQR, 1.25–3 cryoprobes; range, 1–7 cryoprobes) were used, with 2 freezing cycles; the median length of freezing was 20 minutes (IQR, 17–20 minutes; range, 10–20 minutes). The technical success was 100% (18/18), and the primary technical efficacy was 94.4% (17/18). The median follow-up was 68 months (IQR, 38–93 months). During follow-up, 3 of 17 (17.6%) tumors demonstrated local progression at 7, 13, and 27 months. Consequently, the 1-, 2-, 3-, 4-, and 5-year local tumor progression-free survivals were 93.3%, 84.6%, 76.9%, 75%, and 72.7%, respectively. Two of 16 (12.5%) patients died during follow-up at 43 and 88 months. The major adverse event rate was 5.5% (1/18) with 1 postablative acromion fracture. Conclusions PCA for extraspinal thyroid cancer bone metastases demonstrated high local tumor control rates with a safe profile at long-term follow-up.

Gumusay O., Huppert L.A., Behr S.C., Rugo H.S.

Patients with metastatic breast cancer are at high risk for developing vertebral compression fractures due to underlying bone metastases and bone density loss. Vertebral augmentation techniques including percutaneous vertebroplasty and percutaneous balloon kyphoplasty are techniques used to stabilize compression fractures and improve pain. However, rare complications from these interventions have been observed, including spinal cord compression, nerve root compression, venous cement embolism, and pulmonary cement embolism. These complications pose unique potential challenges for patients with cancer who may already have decreased lung function and potential for venous thromboembolism. In this review, we first describe the role of percutaneous vertebral augmentations in patients with metastatic cancer, with a particular focus on patients with breast cancer. Then, we describe complications of vertebral augmentation in two patients with metastatic breast cancer including long-term symptomatic and radiographic follow-up.

Bongiovanni A., Foca F., Oboldi D., Diano D., Bazzocchi A., Fabbri L., Mercatali L., Vanni S., Maltoni M., Bianchini D., Casadei C., Matteucci F., Nanni O., Rossi B., Sintuzzi E., et. al.

Bone metastases (BM) are still the main cause of morbidity and mortality in cancer patients, not only because of their complications, defined as skeletal-related events (SREs), but also because of the negative impact bone pain has on quality of life (QoL) and survival, especially when opioid analgesics and locoregional treatments fail. A single-center prospective study was carried out on 12 patients with symptomatic BM treated with MRI-guided focused ultrasound (MR-HIFU). The primary endpoint was the effectiveness of MR-HIFU in reducing current and breakthrough cancer pain (BTCP) scores. The main secondary aims were the evaluation of circulating markers at different time-points and their relation to pain and procedure efficacy. Other secondary objectives included temporal evolution of pain response, evaluation of QoL, and side effects of the treatment. Descriptive statistics were used to evaluate primary and secondary endpoints. Questionnaires on pain and QoL completed at baseline and at 30 days were compared using appropriate statistical tests with exploratory intent. MR-HIFU was successfully completed in all 12 patients enrolled between September 2015 and December 2018. On day 30, 6 (50.0%) patients showed a complete response of current pain and 6 a partial response, while 5 (41.7%) obtained a complete BTCP response. A partial response of BM evaluated by MD Anderson criteria was obtained in 9 (81.8%) patients. Only one patient progressed in the target lesion after MR-HIFU. No treatment-related adverse events were recorded. Bone turnover markers CTX/RANK-L (P) do not demonstrate any significant change with the pain or BM response. In our patients, targeted therapy of painful BM with MRI-guided focused ultrasound ablation was safe and showed encouraging early-onset and functional results.

Bucknor M.D., Baal J.D., McGill K.C., Infosino A., Link T.M.

AbstractMagnetic resonance-guided focused ultrasound (MRgFUS) is a novel noninvasive therapy that uses focused sound energy to thermally ablate focal pathology within the body. In the United States, MRgFUS is approved by the Food and Drug Administration for the treatment of uterine fibroids, palliation of painful bone metastases, and thalamotomy for the treatment of essential tremor. However, it has also demonstrated utility for the treatment of a wide range of additional musculoskeletal (MSK) conditions that currently are treated as off-label indications. Advantages of the technology include the lack of ionizing radiation, the completely noninvasive technique, and the precise targeting that offer unprecedented control of the delivery of the thermal dose, as well as real-time monitoring capability with MR thermometry. In this review, we describe the most common MSK applications of MRgFUS: palliation of bone metastases, treatment of osteoid osteomas, desmoid tumors, facet arthropathy, and other developing indications.

Arrigoni F., Bianchi G., Formiconi F., Palumbo P., Zugaro L., Gravina G.L., Barile A., Masciocchi C.

Thermal ablation techniques are procedures of growing interest for management of bone metastases. Among these, cryoablation is probably the most advanced. It allows treatment of large and irregular volumes of pathological tissue, real-time evaluation of the area of ablation and appears less painful than heat-based ablative techniques like radiofrequency and microwaves. Literature shows the effectiveness of cryoablation in the management of bone metastases in terms of pain palliation, but also its employment with curative intent is recommended. We reviewed the outcomes of cryoablation procedures performed in our radiology department over the last seven years, confirming the results in terms of pain palliation and local control of disease. We retrospectively evaluated results of 28 procedures of cryoablation, of which 17 treated with palliative and 11 with curative intent. In a 3-month follow-up study, we recorded an overall reduction of pain (evaluated using a VAS 0–10 scale) between pre- and post-treatment. The mean values dropped from 6.9 (SD: ± 1.3) to 3.5 (SD ± 2.6) (p < 0.0001). In the group of patients treated for local tumor control (follow-up: 22.4 months), we recorded a stability and/or reduction in volume of the lesion in 10 out 11 patients. No major complications were recorded.

Çelebioğlu E.C., Bilgiç S., Merter A., Karaca M.O., Başarır K., Yıldız H.Y.

Colak C., Forney M.C., Simpfendorfer C.S., Mesko N.W., Ilaslan H.

Abstract 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.

Kim W., Kim K.

Campanacci L., Bianchi G., Cevolani L., Errani C., Ciani G., Facchini G., Spinnato P., Tognù A., Massari L., Cornelis F.H., Mosconi M., Screpis D., Benazzo F., Rossi B., Bonicoli E., et. al.

Bone metastases are frequent in patients with cancer. Electrochemotherapy (ECT) is a minimally invasive treatment. Preclinical and clinical studies supported the use of ECT in patients with metastatic bone disease (MBD). The purposes of this multicentre study are to confirm the safety and efficacy of ECT, and to identify appropriate operating procedures in different MBD conditions.102 patients were treated in 11 Centres and recorded in the REINBONE registry (a shared database protected by security passwords): clinical and radiological information, ECT session, adverse events, response, quality of life indicators and duration of follow-up were registered.105 ECT sessions were performed (one ECT session in 99 patients, two ECT sessions in 3 patients). 24 patients (23.5%) received a programmed intramedullary nail after ECT, during the same surgical procedure. Mean follow-up was 5.9 ± 5.1 months (range 1.5-52). The response to treatment by RECIST criteria was 40.4% objective responses, 50.6% stable disease and 9% progressive disease. According to PERCIST criteria the response was: 31.4% OR; 51.7% SD, 16.9% PD with no significant differences between the 2 criteria. Diagnosis of breast cancer and ECOG values 0-1 were significantly associated to objective response. A significant decrease in pain intensity and significant better quality of life was observed after ECT session at follow-up.The results are encouraging on pain and tumour local control. ECT proved to be an effective and safe treatment for MBD and it should be considered as an alternative treatment as well as in combination with radiation therapy.

Yang Y., Ren B., Bian X., Li D., Xu C., Shi F., Zhao J., Tao M., Liang R.

Background Bone is among the most common metastasis sites in patients with advanced cancer. Approximately two-thirds of bone metastasis results in pain, the majority of which is moderate to unbearable pain, which seriously affects the quality of life of patients. With the development of ablation techniques, microwave ablation (MWA) has great potential to eliminate the pain caused by bone metastasis. This study aimed to evaluate the efficacy and safety of image-guided (computed tomography-guided) percutaneous MWA for metastatic osseous pain. Methods This is a retrospective study involving 18 patients with cancer-related pain caused by osseous or soft tissue metastasis in the First Affiliated Hospital of Soochow University from June 2015 to October 2020. All patients (14 men and 4 women; mean age 60.2 years) underwent image-guided percutaneous palliative MWA. A paired-sample t-test was used to compare the changes in Numeric Rating Scale (NRS) score and dosage of morphine preoperatively and postoperatively (at 24 h, 3 days, and 14 days after MWA). In addition, we assessed the level of pain relief according to the patients' subjective feelings. Results The paired-samples t-test showed that the NRS score (6.83±0.92 vs. 1.67±0.97, P Conclusions Image-guided (Computed Tomography-guided) percutaneous MWA can effectively relieve pain, thus improving the quality of life in patients with osseous metastasis. MWA is a feasible, safe, and effective treatment for pain caused by bone metastasis.

Park J.W., Lim H., Kang H.G., Kim J.H., Kim H.

In advanced cancer patients, pelvic bone metastasis often causes pain and gait disturbance. The use of percutaneous bone cement [polymethylmethacrylate (PMMA)] injection for pain management and strengthening in pelvic bone metastasis has rarely been reported. To evaluate this method, we aimed to determine surgical outcomes and complications over a long-term follow-up period using a large patient group. We retrospectively collected data from 178 patients who underwent percutaneous cementoplasty for pelvic metastatic lesions, 201 in total. Surgical outcomes evaluated included pain reduction and improvement of ambulation. Mortality within 1 month after procedure and pulmonary embolism caused by thrombus, fat, tumor emboli, or bone cement were investigated as surgical complications. For long-term survivors, pain relapse and mechanical failure were analyzed. The mean follow-up period was 12.6 months, and there were 159 fatalities at last follow-up. The mean regional pain numerical rating scale scores decreased from 6.1 preoperatively to 2.4 1 month after procedure (p < 0.01). Gait function was maintained, worsened, and uncheckable in 68%, 24%, and 8% of patients, respectively, 1 month after procedure. Of long-term survivors followed up for > 12 months (n = 53), there were no significant changes in serial plain radiographs, and regional pain aggravation was observed in 9%. Pulmonary cement embolism and bone cement implantation syndrome was observed in 11% and 10%, respectively. However, all patients with these complications were asymptomatic. Percutaneous cement injection into the pelvis is a feasible and safe palliative surgical option for patients with advanced malignancy in terms of pain reduction and maintenance of ambulatory function under regional anesthesia.

Han X., Huang R., Meng T., Yin H., Song D.

ObjectiveCancer pain, the most common skeleton-related event of bone metastases, significantly disturbs patients’ life. MRI-guided focused ultrasound (MRgFUS) is a therapeutic option to relieve pain; however, its efficacy and safety have not been fully explored. Therefore, we aim to conduct a meta-analysis on studies reporting MRgFUS for patients with bone metastases.MethodsRandomized controlled trials (RCT) and non-RCTs on MRgFUS treatment for patients with bone metastases were collected using PubMed, MEDLINE In-Process (US National Library of Medicine), National Institutes of Health (US National Library of Medicine), Embase (Elsevier), Web of Science, CINAHL, and the Cochrane Library between August 2007 and September 2019. Data on quantitative pain assessment before/after MRgFUS, response rate, and complication were extracted and analyzed.ResultsFifteen eligible studies with 362 patients were selected in this meta-analysis. The average pain score was 6.74 (95% CI: 6.30–7.18) at baseline, 4.15 (95% CI: 3.31–4.99) at 0–1 week, 3.09 (95% CI: 2.46–3.72) at 1–5 weeks, and 2.28 (95% CI: 1.37–3.19) at 5–14 weeks. Compared with baseline, the pain improvement at 0–1 week was 2.54 (95% CI: 1.92–3.16, p &lt; 0.01), at 1–5 weeks was 3.56 (95% CI: 3.11–4.02, p &lt; 0.01), and at 5–14 weeks was 4.22 (95% CI: 3.68–4.76, p &lt; 0.01). Change from baseline in OMEDD at 2 weeks after treatment was −15.11 (95% CI: −34.73, 4.50), at 1 month after treatment was −10.87 (95% CI: −26.32, 4.58), and at 3 months after treatment was −5.53 (95% CI: −20.44, 9.38). The overall CR rate was 0.36 (95% CI: 0.24–0.48), PR rate was 0.47 (95% CI: 0.36–0.58), and NR rate was 0.23 (95% CI: 0.13–0.34). Among 14 studies including 352 patients, 93 (26.4%) patients with minor complications and 5 (1.42%) patients with major complications were recorded.ConclusionThis meta-analysis identifies MRgFUS as a reliable therapeutic option to relieve cancer pain for patients with metastatic bone tumors with controllable related complications.

Chen-Xu S., Martel-Villagrán J., Bueno-Horcajadas Á.

La radiología intervencionista tiene un papel cada vez más importante en el tratamiento local, generalmente con intención paliativa, de las metástasis óseas, aunque en pacientes seleccionados puede realizarse con intención curativa. Disponemos de dos grupos de técnicas principales, de las cuales unas se centran en la consolidación del hueso: la osteoplastia/vertebroplastia, que consiste en la inyección de polimetilmetacrilato para reforzar el hueso y mejorar el dolor, y la osteosíntesis percutánea, que consiste en la fijación mediante tornillos de las fracturas mínimamente/no desplazadas para su consolidación. Por otro lado, tenemos la ablación tumoral, que nos permitirá la destrucción tumoral, ya sea por instilación de alcohol o a través de la termoablación. La termoablación es la preferida en musculoesquelético, ya que es una ablación más controlada. Dentro de este grupo tenemos: la radiofrecuencia, que aplica una onda de alta frecuencia alternante (450-600 Hz) en la interfase tumor-hueso que alcanza altas temperaturas y necrosis coagulativa; la ablación por microondas, que aplica ondas electromagnéticas (aproximadamente 900 y 2450 MHz) a través de una antena que se coloca directamente en el seno del tumor, produciendo agitación molecular y calor que provoca una necrosis coagulativa; la crioablación, que consiste en la aplicación de un frío extremo para destruir tumores, y, por último, la MRgFUS ( Magnetic Resonance-guided focused ultrasound surgery ), técnica no invasiva que funciona como un haz de ultrasonidos generado por el transductor colocado sobre la piel del paciente, concentrándose en la lesión diana donde la energía mecánica se convierte en energía térmica (65-85 ° C ). El plan terapéutico ha de ser determinado por un equipo multidisciplinar, y puede tener intención paliativa o curativa. Una vez seleccionado el paciente, se realizará un estudio preprocedimiento y se decidirá cuál será la técnica más adecuada en función de una serie de factores. Durante el procedimiento se tomarán medidas de protección y monitorizacióny finalmente se realizará un seguimiento posprocedimiento. Interventional radiology is playing an increasingly important role in the local treatment of bone metastases; this treatment is usually done with palliative intent, although in selected patients it can be done with curative intent. Two main groups of techniques are available. The first group, centered on bone consolidation, includes osteoplasty / vertebroplasty, in which polymethyl methacrylate (PMMA) is injected to reinforce the bone and relieve pain, and percutaneous osteosynthesis, in which fractures with nondisplaced or minimally bone fragments are fixed in place with screws. The second group centers on tumor ablation. Tumor ablation refers to the destruction of tumor tissue by the instillation of alcohol or by other means. Thermoablation is the preferred technique in musculoskeletal tumors because it allows for greater control of ablation. Thermoablation can be done with radiofrequency, in which the application of a high frequency (450 Hz–600 Hz) alternating wave to the tumor-bone interface achieves high temperatures, resulting in coagulative necrosis. Another thermoablation technique uses microwaves, applying electromagnetic waves in an approximate range of 900 MHz to 2450 MHz through an antenna that is placed directly in the core of the tumor, stimulating the movement of molecules to generate heat and thus resulting in coagulative necrosis. Cryoablation destroys tumor tissue by applying extreme cold. A more recent, noninvasive technique, magnetic resonance-guided focused ultrasound surgery (MRgFUS), focuses an ultrasound beam from a transducer placed on the patient's skin on the target lesion, where the waves’ mechanical energy is converted into thermal energy (65 °C–85 °C). Treatment should be planned by a multidisciplinary team. Treatment can be done with curative or palliative intent. Once the patient is selected, a preprocedural workup should be done to determine the most appropriate technique based on a series of factors. During the procedure, protective measures must be taken and the patient must be closely monitored. After the procedure, patients must be followed up.

di Biase L., Falato E., Caminiti M.L., Pecoraro P.M., Narducci F., Di Lazzaro V.

Chronic pain is one of the leading causes of disability and disease burden worldwide, accounting for a prevalence between 6.9% and 10% in the general population. Pharmacotherapy alone results ineffective in about 70-60% of patients in terms of a satisfactory degree of pain relief. Focused ultrasound is a promising tool for chronic pain management, being approved for thalamotomy in chronic neuropathic pain and for bone metastases-related pain treatment. FUS is a noninvasive technique for neuromodulation and for tissue ablation that can be applied to several tissues. Transcranial FUS (tFUS) can lead to opposite biological effects, depending on stimulation parameters: from reversible neural activity facilitation or suppression (low-intensity, low-frequency ultrasound, LILFUS) to irreversible tissue ablation (high-intensity focused ultrasounds, HIFU). HIFU is approved for thalamotomy in neuropathic pain at the central nervous system level and for the treatment of facet joint osteoarthritis at the peripheral level. Potential applications include HIFU at the spinal cord level for selected cases of refractory chronic neuropathic pain, knee osteoarthritis, sacroiliac joint disease, intervertebral disc nucleolysis, phantom limb, and ablation of peripheral nerves. FUS at nonablative dosage, LILFUS, has potential reversible and tissue-selective effects. FUS applications at nonablative doses currently are at a research stage. The main potential applications include targeted drug and gene delivery through the Blood-Brain Barrier, assessment of pain thresholds and study of pain, and reversible peripheral nerve conduction block. The aim of the present review is to describe the approved and potential applications of the focused ultrasound technology in the field of chronic pain management.

Cazzato R.L., De Marini P., Leonard-Lorant I., Dalili D., Koch G., Autrusseau P.A., Mayer T., Weiss J., Auloge P., Garnon J., Gangi A.

Gabriel B., Hoang H., Chang E., Chan J.P.

Guan J., Qi F., Liang H., Liu X., Zhao Z., Chen L., Zhang R., Yang R.Y., Goker B., Singh S., Hoang B.H., Geller D.S., Wang J., Yang R.

This review aims to summarize the evolution of surgical techniques for periacetabular metastatic cancer, assess their strengths and limitations, and clarify the corresponding indications. We conducted a comprehensive literature review on periacetabular metastatic cancer, summarizing surgical techniques involving both open and minimally invasive approaches. Additionally, we evaluated the indications for different minimally invasive techniques and proposed potential combinations of these techniques. Our review underscores the benefits of minimally invasive surgery, including reduced surgical trauma, improved patient mobility, lower complication rates, and expedited recovery times, facilitating earlier initiation of systemic cancer therapies. These techniques show substantial potential for broader application in the future. Despite the historical reliance on open surgery as the standard treatment, minimally invasive approaches are emerging as a promising alternative, particularly for managing osteolytic metastases around the acetabulum. This review provides insights into the optimal integration of these techniques, aiming to support evidence-based clinical decision-making and improve patient outcomes.

Ahmed N.T., Obaya H.E., Abd Elhadi A.A., Saad A.E., Abdelaziz A.

INTRODUCTION. The double chin is an excessive accumulation of fat in the pre- and post-platysma that can manifest in various forms and sizes. Thin individuals might manifest a double chin, similar to those who are afflicted by obesity. It may result in a reduction in the definition of the mandible and give the perception of obesity or aging. AIM. To evaluate any effect of High-Intensity Focused Ultrasound (HIFU) on sleep quality measures in obese women with a double chin. MATERIALS AND METHODS. Typically, 60 women aged 35–50 years were selected from AL Qasr-Alaini Hospital and were equally divided at random into groups A and B (n = 30). Group A (HIFU with exercise) received 3 HIFU sessions, a session/month/three months with adouble chin exercise (daily). Group B (Exercise group) received daily double chin exercises for only three months. Pre- and post-intervention, we assessed body mass index (BMI), hormonal changes (cortisol level), submental fat, and sleep apnea Apnea-Hypopnea Index. RESULTS AND DISCUSSION. The results revealed no significant effect in age, weight, and height in both groups (p 0.05). Post-three-month intervention, group A demonstrated a statistically significant decrease in the predetermined assessed outcomes compared to group B (p 0.001). CONCLUSION. There was established a significant impact of HIFU on measurements of sleep quality in obese doubled chin women.

de Sá Pires C.G., Marques M.A., Fonseca E.M., Oliveira V.C.

Bone metastases occur when cancer cells from the primary tumor spread to the bones. The incidence of bone metastases is increasing due to the longer survival of patients with primary tumors, driven by advances in cancer treatments. In patients with multiple bone metastases, care is primarily palliative, aiming to improve their quality of life through pain relief. Bone metastases are strongly associated with pathological fractures, particularly in the femur. In these cases, minimally invasive treatments such as percutaneous cementoplasty and internal fixation with intramedullary nails are growing in popularity. Methods: This manuscript focuses on studying these two therapies by developing virtual models using ANSYS® software. Thermal and thermomechanical analyses were conducted to evaluate the heat effect resulting from the polymerization of different types of bone cement and to assess the benefits of combining it with internal fixation using intramedullary nails made of different materials. Results: The results highlight the advantages of combining these two techniques compared to cementoplasty alone. Furthermore, the use of Gentamicin Bone Cement (CMW 3®) with an intramedullary nail made of either material has been shown to provide a more significant functional improvement. Conclusions: The combination of cementoplasty with internal fixation is more effective than cementoplasty alone. The use of CMW 3® cement with an intramedullary nail made of either material provides greater control over the growth of the metastatic lesion. The chosen injection angle results in an excessive volume of cement, causing a high degree of thermal necrosis.

Kwan W.C., Zuckerman S.L., Fisher C.G., Laufer I., Chou D., O'Toole J.E., Schultheiss M., Weber M.H., Sciubba D.M., Pahuta M., Shin J.H., Fehlings M.G., Versteeg A., Goodwin M.L., Boriani S., et. al.

Study Design Systematic review. Objective In patients with extradural metastatic spine disease, we sought to systematically review the outcomes and complications of patients with intermediate Spinal Instability Neoplastic Score (SINS) lesions undergoing radiation therapy, percutaneous interventions, minimally invasive surgeries, or open spinal surgeries. Methods Following PRISMA guidelines for systematic reviews, MEDLINE, EMBASE, Web of Science, the Cochrane Database of Systematic Reviews and the Cochrane Center Register of Controlled Trials were queried for studies that reported on SINS intermediate patients who underwent: 1) radiotherapy, 2) percutaneous intervention, 3) minimally invasive, or 4) open surgery. Dates of publication were between 2013-22. Patients with low- or high-grade SINS were excluded. Outcome measures were pain score, functional status, neurological outcome, ambulation, survival, and perioperative complications. Results Thirty-nine studies (n = 4554) were included that analyzed outcomes in the SINS intermediate cohort. Radiotherapy appeared to provide temporary improvement in pain score; however, recurrent pain led to surgery in 15%–20% of patients. Percutaneous vertebral augmentation provided improvement in pain. Minimally invasive surgery and open surgery offered improvement in pain, quality of life, neurological, and ambulatory outcomes. Open surgery may be associated with more complications. There was limited evidence for radiofrequency ablation. Conclusion In the SINS intermediate group, radiotherapy was associated with temporary improvement of pain but may require subsequent surgery. Both minimally invasive surgery and open spinal surgery achieved improvements in pain, quality of life, and neurological outcomes for patients with spine metastases. Open surgery may be associated with more complications.

Papalexis N., Peta G., Carta M., Quarchioni S., Di Carlo M., Miceli M., Facchini G.

Background: Arterial embolization is a minimally invasive treatment that occludes blood vessels supplying pathological tissue. Developed to control bleeding without surgery, it has evolved over decades and is now applied in musculoskeletal oncology as a preoperative treatment, palliative care, or standalone therapy for select tumors. Recently, its use has expanded globally in treating chronic pain syndromes and osteoarthritis. Materials and Methods: We reviewed the literature on arterial embolization in various musculoskeletal conditions. The focus was on established oncologic indications for primary and metastatic bone or soft tissue tumors, and emerging evidence on degenerative diseases like osteoarthritis, inflammatory musculoskeletal pathology, and intractable pain. Emphasis was placed on leading studies regarding efficacy, complications, and recurrence rates. Discussion: Arterial embolization has progressed from bleeding control to a versatile therapeutic option in musculoskeletal medicine. It offers symptom relief, reduces tumor size, and improves quality of life. Applications include oncologic interventions and management of degenerative and inflammatory conditions. Despite its benefits, variations in complications and recurrence rates highlight the need for standardized protocols and further research. Conclusions: Arterial embolization is a safe and effective minimally invasive tool in the multidisciplinary management of a wide range of musculoskeletal pathologies. Ongoing research is crucial to understand long-term efficacy, optimize protocols, and broaden its applications.

Ganse B.

Bone regeneration is a complex pathophysiological process determined by molecular, cellular, and biomechanical factors, including immune cells and growth factors. Fracture healing usually takes several weeks to months, during which patients are frequently immobilized and unable to work. As immobilization is associated with negative health and socioeconomic effects, it would be desirable if fracture healing could be accelerated and the healing time shortened. However, interventions for this purpose are not yet part of current clinical treatment guidelines, and there has never been a comprehensive review specifically on this topic. Therefore, this narrative review provides an overview of the available clinical evidence on methods that accelerate fracture healing, with a focus on clinical applicability in healthy patients without bone disease. The most promising methods identified are the application of axial micromovement, electromagnetic stimulation with electromagnetic fields and direct electric currents, as well as the administration of growth factors and parathyroid hormone. Some interventions have been shown to reduce the healing time by up to 20 to 30%, potentially equivalent to several weeks. As a combination of methods could decrease the healing time even further than one method alone, especially if their mechanisms of action differ, clinical studies in human patients are needed to assess the individual and combined effects on healing progress. Studies are also necessary to determine the ideal settings for the interventions, i.e., optimal frequencies, intensities, and exposure times throughout the separate healing phases. More clinical research is also desirable to create an evidence base for clinical guidelines. To make it easier to conduct these investigations, the development of new methods that allow better quantification of fracture-healing progress and speed in human patients is needed.

Cheung B.H., Co M.T.

Breast cancer, the most prevalent malignancy in women, has witnessed a paradigm shift in its management over the years. From the historically predominant mastectomies, which often led to significant physical and psychological morbidity, the focus has shifted to breast-conserving surgery and minimally invasive ablative techniques. This chapter provides a comprehensive review of the various ablative modalities available for breast cancer management, emphasizing their mechanisms, indications, efficacy, and potential complications. Ablative techniques characterized by their minimally invasive nature aim to obliterate tumor cells while preserving breast tissue aesthetics. These techniques, including cryoablation, radiofrequency ablation (RFA), high-intensity focused ultrasound (HIFU), microwave ablation (MWA), and laser therapy, aim to obliterate tumor cells while maximizing breast tissue preservation and aesthetic outcomes. Moreover, due to the minimally invasive nature, they are particularly beneficial for patients unfit for traditional surgeries, as most of them can be performed without general anesthesia. However, the non-excisional nature of these procedures raises concerns about the completeness of ablation and oncological safety. Accurate imaging guidance, primarily ultrasound and magnetic resonance imaging (MRI), is paramount for the precision of these techniques. The chapter also delves into the role of ablative surgery in palliative settings, highlighting its potential in symptom alleviation and prevention of disease-related complications. As the field of breast cancer surgery continues to evolve, these ablative techniques, backed by technological advancements and interdisciplinary research, promise to play an increasingly significant role in personalized patient care.

Papalexis N., Peta G., Gasbarrini A., Miceli M., Spinnato P., Facchini G.

Background The artery of Adamkiewicz (AKA) is vital for spinal cord blood supply. Its role in embolization procedures for bone metastases can cause serious complications. We explored its prevalence, anatomical variation, and effect on spinal embolization using N-butyl cyanoacrylate (NBCA) in patients with bone metastases. Purpose To understand the impact and variability of AKA in spinal embolizations in cases of bone metastases to reduce complications and improve patient outcomes. Material and Methods We examined data from 454 patients who underwent spinal embolization with NBCA between 2009 and 2018. The presence, anastomoses, and tumor features of AKA were assessed via pre-procedure imaging and angiography. Complications were classified per the CIRSE Classification System. Results AKA was found in 22.8% of patients, predominantly left-sided and originating from T8 to L1. Direct and indirect anastomoses were present in 66.6% and 33.4% of patients, respectively. Extra-compartmental invasion was linked with direct anastomosis ( P = 0.004). High-grade complications were rare but included one instance of bilateral lower limb paralysis. Partial embolization was necessary in 22.8% of cases due to AKA. Conclusion The study underscores the need for rigorous preoperative evaluation of AKA origin and anastomoses in patients undergoing spinal embolization for bone metastases. Given the significant presence of AKA and related anastomoses, especially with renal extra-compartmental tumors, caution is advised to reduce complications and optimize patient outcomes. Further research is required for best practice guidelines involving bone metastases and AKA.

Papalexis N., Savarese L.G., Peta G., Errani C., Tuzzato G., Spinnato P., Ponti F., Miceli M., Facchini G.

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.

Papalexis N., Peta G., Vara G., Spinnato P., Errani C., Martella C., Miceli M., Facchini G.

To investigate the safety and efficacy of palliative arterial embolization for metastases of the sternum. This study included 10 consecutive patients (5 M, 5 F; mean age 58.1; range 37–70) with metastases of the sternum from different primary tumors, treated with palliative arterial embolization using NBCA-Lipiodol between January 2007 and June 2022. Four patients received a second embolization at the same site, for a total of 14 embolizations. Data on technical and clinical success, as well as changes in tumor size, were collected. All embolization-related complications were evaluated according to the CIRSE classification system for complications. Post-embolization angiography showed occlusion of more than 90% of the pathological feeding vessels in all procedures. Pain score and analgesic drug consumption were reduced by 50% in all 10 patients (100%, p < 0.05). The mean duration of pain relief was 9.5 months (range 8 to 12 months, p < 0.05). Metastatic tumor size was reduced from a mean of 71.5 cm3 (range 41.6 to 90.3 cm3) pre-embolization to a mean of 67.9 cm3 (range 38.5 to 86.1 cm3) at the 12-month follow-up (p < 0.05). None of the patients experienced embolization-related complications. Arterial embolization is safe and effective as a palliative treatment for patients with metastases of the sternum who did not benefit from radiation therapy or experienced recurrence in symptoms.

Iezzi R., Gangi A., Posa A., Pua U., Liang P., Santos E., Kurup A.N., Tanzilli A., Tenore L., De Leoni D., Filippiadis D., Giuliante F., Valentini V., Gasbarrini A., Goldberg S.N., et. al.

Interventional oncology (IO) employs image-guided techniques to perform minimally invasive procedures, providing lower-risk alternatives to many traditional medical and surgical therapies for cancer patients. Since its advent, due to rapidly evolving research development, its role has expanded to encompass the diagnosis and treatment of diseases across multiple body systems. In detail, interventional oncology is expanding its role across a wide spectrum of disease sites, offering a potential cure, control, or palliative care for many types of cancer patients. Due to its widespread use, a comprehensive review of the new indications for locoregional procedures is mandatory. This article summarizes the expert discussion and report from the “MIOLive Meet SIO” (Society of Interventional Oncology) session during the last MIOLive 2022 (Mediterranean Interventional Oncology Live) congress held in Rome, Italy, integrating evidence-reported literature and experience-based perceptions. The aim of this paper is to provide an updated review of the new techniques and devices available for innovative indications not only to residents and fellows but also to colleagues approaching locoregional treatments.

Wang B., Zhang K., Zhang X., Yang S., Hu M., Li P., Yang W., Fan J., Xing C., Yuan Q.

The spine is the most frequently affected part of the skeletal system to metastatic tumors. External radiotherapy is considered the first-line standard of care for these patients with spine metastases. Recurrent spinal metastases after radiotherapy cannot be treated with further radiotherapy within a short period of time, making treatment difficult. We aimed to evaluate the effectiveness and safety of MWA combined with cementoplasty in the treatment of spinal metastases after radiotherapy under real-time temperature monitoring. In this retrospective study, 82 patients with 115 spinal metastatic lesions were treated with MWA and cementoplasty under real-time temperature monitoring. Changes in visual analog scale (VAS) scores, daily morphine consumption, and Oswestry Disability Index (ODI) scores were noted. A paired Student’s t-test was used to assess these parameters. Complications during the procedure were graded using the CTCAE version 5.0. Technical success was attained in all patients. The mean VAS score was 6.3 ± 2.0 (range, 4–10) before operation, and remarkable decline was noted in one month (1.7 ± 1.0 [P < .001]), three months (1.4 ± 0.8 [P < .001]), and six months (1.3 ± 0.8 [P < .001]) after the operation. Significant reductions in daily morphine consumption and ODI scores were also observed (P < .05). Cement leakage was found in 27.8% (32/115) of lesions, with no obvious associated symptoms. MWA combined with cementoplasty under real-time temperature monitoring is an effective and safe method for recurrent spinal metastases after radiotherapy.

Errani C.

The incidence of metastatic bone disease is increasing, as patients with cancer are living longer [...]