Metastatic Osseous Pain Control: Bone Ablation and Cementoplasty

Abstract

Nociceptive and/or neuropathic pain can be present in all phases of cancer (early and metastatic) and are not adequately treated in 56 to 82.3% of patients. In these patients, radiotherapy achieves overall pain responses (complete and partial responses combined) up to 60 and 61%. On the other hand, nowadays, ablation is included in clinical guidelines for bone metastases and the technique is governed by level I evidence. Depending on the location of the lesion in the peripheral skeleton, either the Mirels scoring or the Harrington (alternatively the Levy) grading system can be used for prophylactic fixation recommendation. As minimally invasive treatment options may be considered in patients with poor clinical status or limited life expectancy, the aim of this review is to detail the techniques proposed so far in the literature and to report the results in terms of safety and efficacy of ablation and cementoplasty (with or without fixation) for bone metastases. Percutaneous image-guided treatments appear as an interesting alternative for localized metastatic lesions of the peripheral skeleton.

Keywords: ablation; bone metastasis; cementoplasty; interventional radiology; pain.

Fig. 1

Female patient with ovarian cancer and manubrium metastasis treated with cryoablation. ( a ) Positron emission tomography/computed tomography (PET/CT) scan illustrating an FDG avid sternal lesion. ( b , c ) CT axial and coronal reconstruction during the cryoablation session with two cryoprobes placed within the lesion.

Fig. 2

Male patient with bronchogenic carcinoma and soft-tissue metastasis at the chest wall infiltrating the posterior rib at T11 and T12 level. Computed tomography axial scan illustrating the microwave antenna in the center of the metastatic lesion. Notice the presence of a sterile glove on the skin surface, filled with cold saline to avoid thermal injury.

Fig. 3

Male patient with sacral sarcoma and secondary painful fracture postsurgery and radiotherapy. ( a ) Computed tomographic (CT) axial scan (patient is placed in lateral decubitus position) illustrating the wide fracture line at sacral midline and the lytic lesion at the right sacral wing. ( b ) CT axial scan illustrating cement at the lesion location and two cannulated screws percutaneously placed bridging the fracture line.

Fig. 4

Female patient with renal cell carcinoma and oligometastatic disease (two lesions, one in femoral bone and one in the scapula)—fluoroscopy anteroposterior views. ( a ) Bone access needle was inserted along the femoral neck. ( b ) Microwave antenna was coaxially inserted and ablation session was performed. ( c ) A second bone access needle was inserted with cranio-caudal direction. ( d , e ) Metallic micro-needles (22 G) were coaxially introduced through both the access needles to create a mesh (REBAR concept). ( f ) PMMA was injected covering the whole extent of the lesion and the metallic mesh and bridging the construct to normal bone.

Fig. 5

Preventive stabilization. Fluoroscopy anteroposterior view illustrating the Y-STRUT implant inside the femoral bone along with cement to increase the surface contact between the bone and the device and to anchor the device in the proximal femur.