Integrated CT-Fluoroscopy Equipment: Improving the Interventional Radiology Approach and Patient Experience for Treatment of Musculoskeletal Malignancies

Abstract

Integrated CT-fluoroscopy equipment augments the comprehensive approach to the treatment of musculoskeletal (MSK) malignancy by interventional radiology techniques. As the role of minimally invasive treatment expands to meet the highly variable presentation of MSK malignancy, creative solutions to treatment challenges are required to improve locoregional tumor control and durability of pain palliation. Challenges to effective treatment can often be attributed to a combination of aggressive tumor biology, large size, forbidding location, and adverse vascularity. In these cases, a tailored treatment approach may necessitate the application of multiple interventional radiology (IR) techniques that require different image guidance capabilities. Integrated CT-fluoroscopy equipment provides the means to leverage both imaging modalities within the same procedural setting to facilitate the simultaneous application of multiple synergistic treatments and protective measures. This article examines the potential role of hybrid units in the IR treatment of challenging MSK malignancies as a means to empower a paradigm transition for a more comprehensive and patient-tailored approach.

Keywords: hybrid; integrated; interventional radiology; malignancy; musculoskeletal.

Fig. 1

Integrated CT–fluoroscopy equipment (hybrid unit). Note the floor tracks extending from the moveable CT to the procedure table, the ceiling tracks for the moveable suspended fluoroscopy c-arm, and rails for the moveable table.

Fig. 2

Metastatic renal cell carcinoma to the left fifth rib measured 5.7 × 3.4 × 3.4 cm ( a and b ). Given the size and vascularity, embolization of fourth to fifth intercostal arteries was performed via radial access ( c and d ), followed immediately by CT-guided cryoablation ( e ) with protective carbon dioxide iatrogenic pneumothorax ( f ).

Fig. 3

Two pathologic fractures of the iliac bone from metastatic breast adenocarcinoma ( a ) treated for pain palliation. Weight-bearing fracture ( a —yellow arrows) treated by percutaneous screw fixation using fluoroscopic guidance to facilitate screw placement and cement injection via a posterior approach ( b and c ). Painful iliac crest fracture ( a and d —red arrows) treated using CT guidance to facilitate fracture reduction ( e ) before percutaneous screw fixation ( f ).

Fig. 4

Metastatic lung adenocarcinoma of the sixth vertebra and paraspinal tissues measured 3.1 × 3.6 × 3.3 cm ( a and b ) with epidural encroachment. Treatment performed for pain palliation and prevention of skeletal-related event from potential further extension into the spinal canal. Given size, vascularity, and proximity of intercostal artery ( c ), embolization was performed with particle and coil deployment ( d ), followed immediately by CT-guided cryoablation ( e —yellow arrows delineate cryoablation margins) after protective insufflation of carbon dioxide ( e —red arrows). Posttreatment imaging demonstrates marked reduction in viable tumor ( f —postcontrast MRI; g —PET/CT).

Fig. 5

Recurrent retroperitoneal liposarcoma status postsurgical resection measured 3.1 × 3.2 × 4.4 cm ( a ) treated for locoregional cure. Proximity to multiple critical structures requiring extensive isolation using both fluoroscopy and CT-guided techniques: coil embolization of the adjacent lumbar artery ( b ), fluoroscopic placement of a wire within the adjacent ureter ( c —arrows), hydrodissection of ureter marked by this wire ( d —arrow head), hydrodissection of kidney ( d —arrow), and carbon dioxide insufflation at adjacent lumbar nerve root ( e —arrows) before CT-guided cryoablation ( f —arrows delineate ice ball margins).

Fig. 6

Metastatic renal cell carcinoma to the acetabulum measured 3.8 × 5.5 × 9.2 cm ( a and b —arrows) treated for pain palliation and prevention of skeletal-related event. Given size and vascularity, particle embolization ( c ) was followed immediately by CT-guided cryoablation ( d and e , arrows delineate ice ball margins) and cementoplasty of superior and posterior aspects of acetabulum ( f and g ).

Fig. 7

Metastatic renal cell carcinoma to the left iliac bone measured 4.5 × 2.6 × 1.9 cm ( a ) with surrounding bone edema on MRI ( b and c ) treated for pain palliation and prevention of impending pathologic fracture. Given size and vascularity, particle and coil embolization ( d ) was followed immediately by CT-guided cryoablation ( e and f , arrows delineate ice ball margins) and stabilization with percutaneous screw fixation ( g ).