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Chapter24:Image-guided ablation in thethorax
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44. Ahrar K, Staord RJ, Tinkey PT, etal. Evaluation of cerebral
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48. Dupuy DE, Zagoria RJ, Akerley W, etal. Percutaneous
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52. Kashima M, Yamakado K, Takaki H, etal. Complications aer
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53. Palussiere J, Marcet B, Descat E, etal. Lung tumors treated with
percutaneous radiofrequency ablation:computer tomography
imaging follow-up. Cardiovasc Intervent Radiol 2011; 34
(5):989–997.
54. Okuma T, Matsuoka T, Yamamoto A, etal. Determinants
of local progression aer computer tomography-guided
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tumors:9year experience in a single institution. Cardiovasc
Intevent Radiol 2010; 33:787–793.
55. Singnurkar A, Solomon SM, Gonen M, Larson SM, Schoder
H. 18F-FDG PET/CT for the prediction and detection of local
recurrence aer radiofrequency ablation of malignant lung
lesions. J Nucl Med 2010; 51 (12):1833–1840.
56. Chua TC, Sarkir A, Saxena A, et al. Long-term outcome of
image-guided percutaneous radiofrequency ablation of lung
metastases:an open-labeled prospective trial of 148 patients.
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57. Chua TC, ornbury K, Saxena A, etal. Radiofrequency
ablation as an adjunct to systemic chemotherapy for colorectal
pulmonary metastases. Cancer 2010; 116 (9):2106–2114.
58. Pennathur A, Abbas G, Gooding WE, etal. Image-guided
radiofrequency ablation of lung neoplasm in 100 consecutive
patients by a thoracic surgical service. Ann orac Surg 2009; 88
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59. Yamakado K, Inoue Y, Takao M, etal. Long-term results of
radiofrequency ablation in colorectal lung metastases:single
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60. Nour-Eldin NE, Naguib NN, Saeed AS, etal. Risk factors
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61. Yoshimatsu R, Yamagami T, Terayama K, et al. Delayed and
recurrent pneumothorax aer radiofrequency ablation of lung
tumors. Chest 2009; 135 (4):1002–1009.
62. Zhu JC, Yan TD, Glenn D, Morris DL. Radiofrequency ablation
of lung tumors:feasibility and safety. Ann orac Surg 2009; 87
(4):1023–1028.
63. Lencioni R, Crocetti L, Cioni R. Response to radiofrequency
ablation of pulmonary tumors:a prospective, intention-to-treat,
multicentre clinical trial (the RAPTURE study). Lancet Oncol
2008; 9 (7):621–628.
64. Nomura M, Yamakado K, Nomoto Y, etal. Complications
aer lung radiofrequency ablation:risk factors for lung
inammation. Br J Radiol 2008; 81 (963):244–249.
65. Sano Y, Kanazawa S, Gibara H, etal. Feasibility of percutaneous
radiofrequency ablation for intrathoracic malignancies:a large
single-center experience. Cancer 2007; 109 (7):1397–1405.
66. Simon CJ, Dupuy DE, DiPetrillo TA, etal. Pulmonary
radiofrequency ablation:Long-term safety and ecacy in 153
patients. Radiology 2007; 243 (1):268–275.
67. Hiraki T, Sakurai J, Tsuda T, etal. Risk factors for local
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lung tumors:evaluation based on a preliminary review of 342
tumors. Cancer 2006; 107 (12):2873–2880.
68. Yan TD, King J, Sjarif A, Glenn D, et al. Learning curve for
percutaneous radiofrequency ablation of pulmonary metastases
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69. Gadaleta C, Catino A, Mattiolo V. Radiofrequency thermal
ablation in the treatment of lung malignancies. In Vivo 2006; 20
(6A):765–767.
70. Yan T, King J, Sjarif A, et al. Percutaneous radiofrequency of
pulmonary metastases from colorectal carcinoma:prognostic
determinants for survival. Ann Surg Oncol 2006; 13
(11):1529–1537.
71. Hiraki T, Tajiri N, Mimura H, etal. Pneumothorax, pleural
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of lung tumors:incidence and risk factors. Radiology 2006; 241
(1):275–283.
72. Ambrogi MC, Lucchi M, Dini P, etal. Percutaneous
radiofrequency of lung tumors:results in the midterm. Eur J
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73. Kang S, Luo R, Liao W, et al. Single group study to evaluate
the feasibility and complications of RFA and usefulness of
post-treatment positron emission tomography in lung tumors.
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74. Vogl TJ, Worst TS, Naguib NN, et al. Factors inuencing local
tumor control in patients with neoplastic pulmonary nodules
treated with microwave ablation:a risk-factor analysis. AJR Am
J Roentgenol 2013; 200 (3):665–672.
75. Belore G, Ronza F, Belore MP, et al. Patient’s survival in lung
malignancies treated by microwave ablation:our experience on
56 patients. Eur J Radiol 2013; 82 (1):177–181.
76. Lu Q, Cao W, Huang L, etal. CT-guided percutaneous
microwave ablation of pulmonary malignancies:results in 69
cases. Wolrd J Surg Oncol 2012; 7 (10):80.
77. Yashiro H, Nakatsuka S, Inoue M, etal. Factors aecting local
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78. Wang H, Littrup PJ, Duan Y, et al. oracic masses treated with
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79. Alexander ES, Hankins CA, Machan JT, Healey TT, Dupuy DE.
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80. Nour-Eldin NE, Naguib NN, Tawk AM, et al. Outcomes of
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81. Grieco CA, Simon CJ, Mayo-Smith WW, etal. Percutaneous
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82. Yasui K, Kanazawa S, Sano Y, etal. oracic tumors treated
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83. Belore G, Moggio G, Tedeschi E, etal. CT-guided
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84. erasse P, Arbuck SG, Eisenhauer EA, etal. New guidelines
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240
Chapter24:Image-guided ablation in thethorax
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91. Patti JW, Neeman Z, Wood BJ. Radiofrequency ablation for
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93. Simon CJ, Dupuy DE. Image-guided ablative techniques in
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94. Simon CJ, Dupuy DE. Percutaneous minimally invasive
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95. Grieco CA, Simon CJ, Mayo-Smith WW, et al. Percutaneous
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96. Callstrom MR, Charboneau JW. Image-guided palliation of
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cancer-associated pain. J Pain 2002; 3 (6):471–473.
241
Section VIII
Chapter
Organ-specific cancers – musculoskeletal
Percutaneous ablation of painful metastases
involvingbone
25
Matthew R. Callstrom and A. NicholasKurup
Introduction
Skeletal metastases are common in patients with cancer and
oen impact a patient’s quality of life due to focal pain, frequent
fractures, and resultant decreased mobility. Approximately
70% of the 1million people who die in the United States each
year have breast, lung, or prostate cancer and approximately
one-half of these, or 350,000 people, will die with bone metastases.1 Although bone metastases indicate a poor prognosis,
with a median survival of 3years or less, 5–40% of patients are
alive at 5years dependent on tumor histology and burden.
Bone-related cancer pain is oen undertreated, with nearly
80% of patients experiencing severe pain before a sucient palliative treatment plan is initiated.
4
Management of patients with painful skeletal metastases
is most eective through a multidisciplinary team that can
oer optimal analgesic therapy, radiation therapy, surgery,
hormonal and chemotherapies, and focal image-guided ablation therapies. e standard of care for treatment of painful
metastatic skeletal disease is external-beam radiation therapy
(EBRT). is treatment is eective for 50–80% of patients and
there is complete pain response in 50–60%.5 Although a majority of patients experience complete or partial relief of pain following radiation therapy, median relief of pain is achieved in
3–7weeks and pain relief response is transient in greater than
one-half of the patients.6 While radiation therapy results in an
initial reduction in pain for the majority of patients, at least
for a period of weeks, 20–30% of patients do not experience
pain relief.
7,8,9,10,11,12
Retreatment is possible for many patients
but for patients who experience minimal or transient relief of
pain following EBRT, further treatment is typically not oered
or further radiation therapy may not be oered secondary to
limitations in normal tissue tolerance.
Other treatment options for patients with painful skeletal metastases include surgery, which is generally reserved
for lesions at great risk for fracture or for spinal metastases
causing neurologic compromise, systemic therapies including
chemotherapy, hormonal therapy, radiopharmaceuticals, and
bisphosphonates in combination with opioid and non-steroidal
analgesics. For most patients, pain due to metastatic skeletal disease is oen refractory to standard chemotherapy or
hormonal therapy. Radiopharmaceuticals, which have known
benet in patients with diuse painful bony metastases, are not
considered standard of care for patients with isolated, painful
lesions. As a result, for many patients with painful metastatic
disease who have failed EBRT, analgesics remain the only alternative treatment option. However, many patients limit their use
of these medications due to signicant side eects such as constipation, nausea, and sedation.
Several minimally invasive, percutaneous thermal abla-
tion techniques have proven eective to provide palliation for
2,3
patients with limited skeletal metastases. ese methods are
based on using image-guided methods to deliver tissue ablative
energy or devices into focal metastatic tumors. ese include
the use of radiofrequency ablation (RFA), cryoablation, laser
ablation, microwave ablation, and magnetic resonance-guided
focused ultrasound. In addition, patients at risk for fracture
due to metastases in axially loaded locations (such as vertebral
bodies and periacetabular region) may benet from percutaneous cementoplasty. Of these minimally invasive methods, RFA
and cryoablation have been the most studied.
Indications for treatment
Patient selection is an important consideration when considering possible ablation therapy for painful metastatic disease.
Appropriate patients report moderate or severe pain, typically
≥4/10 for worst pain in a 24-hour period. Treatment of patients
with lower pain scores is usually not oered as it is dicult to
improve on mild pain and also because this type of pain can
usually be adequately managed by oral analgesics. In addition,
pain should be limited to one or two sites and correlates with a
corresponding abnormality evident with cross-sectional imaging. Patients with numerous painful tumors are not treated with
these techniques because this type of pain is better treated with
a systemic, rather than focal, approach. In addition, pain due to
multiple tumors is dicult to adequately localize for directed
therapy. Tumors that are well suited to ablative therapy are most
typically osteolytic or mixed osteolytic/osteoblastic in nature or
otherwise composed of so tissue. Osteoblastic lesions may be
treated, although they are frequently diuse when present and
device deployment requires the use of bone access devices or
Interventional Oncology, Second Edition, ed. Jean-François H.Geschwind and Michael C.Soulen. Published by Cambridge University Press.
©Cambridge University Press2016
243
Section VIII:Musculoskeletal
percutaneous approach. Active infection is a strong relative
contraindication, given the potential to seed necrotic, ablated
tissue with circulating microorganisms. Additional relative
contraindications include widespread skeletal metastases, for
which a systemic approach would be more appropriate; mildly
painful metastases, which are more suitable for analgesic medication and inconsistently respond to ablation; and tumors near
critical normal structures, which cannot be displaced or monitored adequately to allow safe ablation.
RFA technique
RFA is the most commonly used percutaneous thermal tumor
ablation method. RFA can be performed with either general
Figure 25.1 Patients are physically examined prior to the cryoablation
procedure for careful identification of the area of focal pain. The area is marked
on the skin and correlated with imaging findings prior to the cryoablation
procedure.
anesthesia or moderate conscious sedation. Ageneral anesthetic
is more commonly used because the level of local pain during
the RFA treatment can be greater than most patients can tolerate,
even with moderate conscious sedation, and because the procedures can be long, lasting over an hour depending on the size of
the target lesion. In addition, the use of general anesthesia allows
drills for access to the target tumor. Target tumors should be
remote or separable, using uid or other displacement maneuvers, from normal critical structures. Typically, a 1-cm margin
between the target tumor and nearest critical structure is preferred. Patients at risk for fracture or progression of fracture
due to skeletal metastatic disease should be considered for
surgery. If the tumor in question is in an axially loading location, augmentation with cement following ablation may also
be helpful.
Preprocedural imaging
Preprocedural imaging is important to characterize the target
tumors and correlate with the patient’s symptoms (Figure25.1).
Preprocedural imaging allows careful consideration of the
potential risks versus the benets of ablation and planning for
adjunctive maneuvers or additional monitoring that may be
of benet during the procedure. Computed tomography (CT),
positron emission tomography (PET)/CT, or magnetic resonance imaging (MRI) may all be helpful in patient and tumor
assessment. As a CT study is frequently used to guide and monitor the ablation procedure, it is useful to demonstrate the target
tumor and adjacent structures in treatment planning. PET/CT
oers the added benet of demonstrating metabolic activity,
which can add value for targeting tumors that have ill-dened
borders on CT or previously treated/irradiated tumors that
show surrounding bony changes (sclerosis or lucency) related
to treatment eect rather than tumor inltration. MRI oen
depicts the extent of bone involvement for skeletal metastases
and provides additional information regarding adjacent neural
structures, which are typically poorly demonstrated with other
imaging and should be avoided when possible.
13
Contraindications to ablation treatment
Percutaneous tumor ablation has few absolute contraindications. ese include uncorrectable bleeding diatheses, patient
inability to tolerate the level of anesthesia required to perform
the procedure, and inaccessibility of the target tumor from a
the procedure to be performed without the additional necessity
of providing supportive care for the patient as is required with
conscious sedation. Less complex lesions (i.e., supercial, small,
easily accessible, predominantly osteolytic or so-tissue lesions
remote from normal vital structures) may be treated with patients
under moderate sedation. Epidural spinal anesthesia or focal
nerve blocks are oen helpful to ease the pain during the immediate postablation period. If an epidural catheter is employed,
the duration of use is typically for a 12–24-hour period following
the RFA treatment. Prior to removal of the catheter, the medication delivery is halted for a trial period. If the patient’s pain has
returned to the pretreatment level or improved, the catheter is
removed. As a result, patients are oen observed overnight in
the hospital to provide adequate pain control or to allow transition and modication of oral analgesic medication dosage. e
patient is usually discharged with oral opioid analgesics for mild
to moderate discomfort orpain.
Intravenous conscious sedation permits intraprocedural
focused neurologic physical examination as a means of monitoring vulnerable neural structures. Alternatively, use of intravenous moderate sedation allows evoked potential monitoring
for nerve monitoring with cases adjacent to motor nerves or
the spinal cord.13 Following ablation, instillation of long-acting
local anesthetic medication along the periosteum may diminish postproceduralpain.
RFA procedures should be performed under appropriate
cross-sectional imaging guidance. Fluoroscopy may be useful
for portions of the procedure, but cross-sectional imaging is
usually needed to monitor ablation zones and avoid critical
structures. Ultrasound may be used for supercial, predominantly so-tissue lesions, particularly in ribs or extremities. CT
is the most commonly used modality for guidance, given its
availability and excellent delineation of the target tumor and
surrounding structures. MRI provides superior tumor depiction in bone; however, the MRI suite is a dicult environment
for most procedures, and MRI-compatible devices remain limited. Treatment of tumors involving bone or tumors adjacent
to bone require percutaneous placement of RFA electrodes
244
Chapter25:Percutaneous ablation of bone metastases
A
are oen used to reduce the risk of collateral thermal damage to adjacent normal structures. is can be accomplished
through patient positioning or displacement by uid (hydrodisplacement), balloons, or gas. For example, sterile water
(usually D5W with the use of RFA to prevent the risk of conduction of energy with buered uids) can be injected through
a needle to displace loops of bowel away from a target lesion
(Figure25.3). ermal monitoring provides feedback during
an RFA procedure with placement of a temperature-sensing
probe adjacent to a critical structure (Figure25.4). Because
the margin of the RF ablation cannot be accurately visualized
with CT or ultrasound imaging (MRI may allow visualization), this thermal monitoring avoids unexpected elevations
of temperature and potential injury to adjacent normal
structures.
B
RFA pain palliation outcomes
RFA has been studied in two prospective clinical trials for palliation of painful metastatic disease.
14,15,16
ese trials involved
similar cohorts of patients and both studies found that RFA
provides signicant and durable pain relief for patients who
have failed conventional therapies (Table25.1). e cohort of
patients in these prior RFA trials is similar, although the measure of treatment response was dierent, with the Goetz etal.
study14 using the Brief Pain Inventory (BPI: a visual analog
scale of 0–10), whereas the Dupuy etal. study16 used a modied Memorial pain assessment card (a visual analog scale of
0–100%).
In the rst reported study, 62 patients at ve centers in the
United States and Europe with painful metastatic lesions who
had failed or refused conventional radiation treatment were
Figure 25.2 Radiofrequency ablation bone interface.
treated, using primarily general anesthesia, with RF ablation
using a multitined electrode.
14,17
Patients who were included
in this study had moderate to severe pain (≥4/10 worst pain
into the target tumor. RFA electrodes may be placed directly
into so-tissue metastases or osteolytic skeletal metastases
with destroyed or thin overlying cortex. To penetrate osteoblastic metastases or to access tumors deep to intact cortical
bone, bone access devices may be required. ese include bone
biopsy needles or powered bone drills.
e targeted area of ablation includes the bone–tumor
interface, rather than targeting the central portions of the
mass, in order to achieve destruction of likely sites of origin
of the pain, including nerve endings and involved periosteum
(Figure 25.2). Either multitined electrodes or cool-tip electrodes can be used, depending on physician preference and
experience. Asingle ablation is typically performed for lesions
less than 3cm in diameter and the time of ablation is typically 5–10minutes at the target temperature of 100°C or until
tissue impedance limits energy delivery to the target tissue
(Figure25.2). For larger lesions, overlapping ablations are performed with the goal of treating the entire bone–tumor interface, with the time of ablation again typically 5–10minutes at
the target temperature of 100°C or until tissue impedance limits energy delivery to the target tissue.
e target lesion should be separated suciently from
adjacent critical structures to avoid injury. Multiple methods
over a 24-hour period) from ≤ 2 painful sites of metastasis
with tumors measuring 6.3cm on average and ranging from 1
to 18cm in diameter. is trial found 59 of 62 (95%) patients
experienced a clinically signicant decrease in pain (≥2-point
drop in worst pain in a 24-hour period). Pain scores for worst
pain using the BPI were 7.9/10 prior to treatment and 1, 4, 8,
and 24 weeks following RFA treatment were reduced to 5.8,
4.5, 3.0, and 1.4/10, respectively. Similar improvements in pain
and quality of life were observed with measures of the BPI
(Figure 25.5). Complications developed in six patients, with
three patients experiencing exacerbation of pre-existing tumor
cutaneous stulae in the pelvis within 1–2weeks of the procedure due to generation of a large volume of necrotic tissue following RFA. One patient each developed transient bowel and
bladder incontinence following treatment of a previously irradiated leiomyosarcoma metastasis involving the upper sacrum,
an acetabular fracture 6weeks following RFA of a breast cancer
metastasis with signicant involvement of the ileum, ischium,
and acetabulum, and a second-degree skin burn at the grounding padsite.
In a similar study involving six centers, utilizing the
American College of Radiology Imaging Network (ACRIN),
55 patients with a single painful (>50 on a 1–100-point scale)
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Section VIII:Musculoskeletal
A
A
B
B
C
Figure 25.4 Use of a thermocouple to monitor elevation in tissue
temperature from radiofrequency ablation (RFA) treatment of a painful
melanoma metastasis to the spine. (A) Photograph demonstrates
thermocouple adjacent to RFA probe. (B) Prone computed tomography image
demonstrates osteolytic destruction of the pedicle of a thoracic vertebral body
Figure 25.3 Radiofrequency ablation of painful metastatic carcinoid tumor
to sacrum. Water displaces bowel and prevents injury. (A) Prone computed
tomography (CT) demonstrates a 4-cm soft-tissue mass with associated
destruction of the sacrum. A gas-filled loop of rectum is adjacent to the mass.
(B) CT image shows needle in soft tissues; water (W) displaces rectum away
from the tumor. (C) CT image shows radiofrequency electrode within tumor.
and adjacent rib, RFA probe in place and thermocouple (arrow) between the
RFA electrode and the spinal canal.
osseous metastasis were treated using a single 17-gauge or
cluster cool-tip RF electrode with conscious sedation.16 e
mean treated tumor size was 5.2cm in diameter, ranging in
size from 2.0 to 8.0cm. Prior to treatment, patients reported
a mean pain score of 54/100 with a range of 51–91/100. ese
patients reported an average decrease in pain at the 1-month
follow-up of 27/100 points, and at the 3-month follow-up, a
decrease of 14/100 points. Immediately following RFA, 27%
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Chapter25:Percutaneous ablation of bone metastases
Table 25.1 Characteristics of patients treated with radiofrequency
ablation in two prospective multicenter trials
Trial Goetz etal.
14,15
Dupuy etal.
Number of patients 62 55
Female 22 (35%) 26 (47%)
Male 40 (65%) 29 (53%)
Age (years), mean (range) 64 (range 28–88) 62 (range 34–85)
Tumor type (number)
Renal carcinoma 14 10
Colorectal carcinoma 12 10
Lung carcinoma 4 17
Breast 4 4
Other 28 14
Tumor size (longest
diameter; cm)
6.3 cm (range
1.0–18.0 cm)
5.2 cm (range
2.0–8.0 cm)
Tumor location
Pelvis 31 22
Chest wall 6 20
Vertebrae 4 8
Other 21 5
of patients reported pain greater than the baseline pain score.
is study was conducted using conscious sedation, rather than
16
general anesthesia, in order to use sensorimotor testing during
the procedure. Notably, 27/55 patients had tumors that were
treated within 3cm of a major neurovascular bundle. With this
safeguard, one patient suered a motor nerve decit and three
other patients developed neuropathic pain, developing as late
as 35days post-RFA. Grade 3 toxicities were reported in 3/55
(5.4%), including one case of foot drop, one with increased
pain, and one with neuropathicpain.
Although prior studies found a benet from both EBRT
and RFA, this trial did not nd a benet from prior RT for a
reduction in pain intensity.18 e degree of pain relief following
treatment in this study was not as great as reported by Goetz
and colleagues,14 most notably at the 3-month time point, with
a reduction in pain of 14/100 in the ACRIN study16 and a corresponding reduction of 28/100 in the Goetz etal. study, although
this is likely within statistical error of the studies. e durability
of pain relief was not assessed beyond the 3-month time point in
the ACRIN study16; however, continued decreases in pain scores
were reported by patients in the Goetz etal. study, with reductions in pain of 53/100 at the week-24 follow-up evaluation.
Several patient eligibility criteria and procedural dierences
between these two studies may explain the relatively decreased
A B
10
8
6
4
Worst pain
2
0
0Week
1234 6810 12 14 16 18 20 22 24
N= 62 60 58 57 57 50 42 25 34 18 30 16 21 12 16
C D
10
8
6
4
Pain interference
2
10
8
6
4
Average pain
2
0
0Week
1 234 6810 12 14 16 18 20 22 24
N= 62 60 57 56 57 50 42 25 34 18 30 17 21 13 17
100
80
60
40
Pain relief (%)
20
0
0Week
1234 6810 12 14 16 18 20 22 24
N= 62 60 57 56 57 50 42 25 34 19 31 17 21 13 15
0
0Week
1 234 6810 12 14 16 18 20 22 24
N= 60 60 57 56 56 47 38 23 30 17 28 17 19 12 15
Figure 25.5 Mean Brief Pain Inventory (BPI) pain scores over time for patients treated with radiofrequency ablation (RFA). (A) Worst pain; (B) average pain;
(C) interference of pain in daily activities; (D) pain relief from RFA and medications. Error bars represent the 95% confidence intervals. N = the number of
patients completing BPI at each time point. (Reproduced from Callstrom MR, Charboneau JW, Goetz MP, et al. Image-guided ablation of painful metastatic bone
tumors: A new and effective approach to a difficult problem. Skeletal Radiol 2006; 35: 1–15, with permission of Springer Science and Business Media.)
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Section VIII:Musculoskeletal
pain relief realized in the ACRIN study.16 Patients in the Goetz
etal. trial had mostly exhausted conventional treatments, with
74% receiving radiotherapy prior to treatment with RF ablation
while, in the ACRIN study, 24% had received RT prior to treatment. However, neither study found that prior treatment with
radiotherapy had an impact on the pain response, although
combination therapy did help a subset of patients treated with
metastatic disease involving the chest wall masses.18 It is possible that dierences in response were due to the RF electrode
utilized, as the Goetz etal. trial used an expandable RF electrode (RITA Medical Systems, Angiodynamics, Latham, NY)
and the ACRIN trial used a cool-tip electrode (Radionics,
Covidien, Boulder,CO).
Management of procedural pain with the Goetz etal. trial
was accomplished with general anesthesia, while the ACRIN
trial utilized conscious sedation for a majority of cases. e
impact of the type of anesthesia is dicult to evaluate, although
it is possible that the total volume of tissue destruction could
be dierent between the two studies due to procedural pain
limiting the aggressiveness of tumor destruction. Finally, it is
possible that the dierence in response could be partially due
to dierences in types of tumors treated; however, the majority of tumor histology and location of tumors were the same
in both studies, including lung, colon, and renal metastases,
and no dierence in pain response was observed for tumor
type. Although a comparative trial of these two methods could
be conducted to determine a possible dierence in patient
response to these treatments, the dierences, if present, would
likely be small and of doubtful clinical signicance.
Cryoablation technique
Cryoablation has also recently emerged as an exceptional treatment method for the treatment of painful metastatic disease
involving bone and so tissue outside of liver and lung.
Cryoablation has the longest history of successful treatment of
neoplasms in various locations in the body, including prostate, kidney, liver, and lung. Cryoablation probes were initially
based on liquid nitrogen systems for tissue cooling. However,
these designs only allowed intraoperative use because the probe
shas were not insulated and were of relatively large diameter
to reduce the risk of vapor lock with evaporation of the liquid
nitrogen as it passed through the probes. With the advent of segmentally well-insulated probes and the use of Joule–ompson
ports utilizing room-temperature argon gas as a cooling source,
percutaneous systems became possible.
e expansion of the argon gas as it passes from approximately 3,000 psi to atmospheric pressure within each cryoprobe leads to rapid cooling about the tip to less than–100°C.
As intracellular and extracellular uid freezes, tissue destruction results from cell membrane disruption by ice crystals, cellular dehydration, and vascular thrombosis at temperatures
below– 20°C to– 40°C. ese current generation systems can
generate an ice ball, using a single probe, of approximately
3.5cm diameter. Active thawing is achieved by infusing helium
gas into the cryoprobes instead of argon gas. Multiple cryoprobes are used simultaneously to generate large conuent
ice balls limited by the number of cryoprobes utilized, readily
17,19,20,21,22,23
achieving > 8cm diameter. e shape of the ablation zone can
be controlled through varied geometry of probe placement.
Although a freeze–thaw–freeze cycle is necessary to ensure
complete cell death, decreased procedure times are possible for
the treatment of large or complex tumors by avoiding the need
to perform time-consuming overlapping ablations needed with
other ablation techniques. Importantly, synchronous ablation
with several cryoprobes eliminates residual disease at the ablation interfaces that can result from performing overlapping
sequential ablations.24 Cell death from cryoablation occurs
within about 3mm internal to the ice-ball margin.
21
An important rationale for using cryoablation for the treatment of painful metastatic disease is that the technology has
inherent technical advantages to eectively treat oen-complex
metastatic disease while preserving adjacent normal critical
tissue. Acritical distinction of cryoablation relative to other
ablation technologies is that ice generated in the body is well
visualized with non-contrast CT imaging. e edge of the ice
ball corresponds to 0°C and tissue outside this boundary is not
at risk for injury.25 e CT environment is readily available
for intervention in most practices and wide-bore systems are
also becoming more common, allowing placement of ablation
devices while retaining the ability to image patients without
great diculty. While it is possible to image thermal changes
with MRI, the challenges of performing ablation procedures in
this environment are considerable and not widely available in
many practices.
Two cryoablation systems are available for use: the
Endocare Cryocare system and the Galil Medical SeedNet system. e Endocare system uses two dierent sizes of insulated
cryoprobes measuring 2.4mm (13 gauge/7.2F; Perc-24) and
1.7 mm (16 gauge/5.1F; Perc-17R and Perc-17) in diameter.
e Galil system employs 1.5-mm (17 gauge/4.4F; insulated
IceRod+ and uninsulated IceSphere and IceSeed) cryoprobes
(similar MR-compatible cryoprobes are available) as well as
2.4-mm IceEdge cryoprobes. e Endocare system has eight
separately controlled channels (eight total) while the Galil system has 10 separately controlled channels with two ports on
each channel (20 total). ese systems generate ice balls of various geometries; for example, the Endocare Perc-24 produces an
ice ball up to 3.7cm in diameter and 5.7cm in length along the
probesha.
Following sterile preparation, one or more cryoprobes are
introduced through a skin nick under CT, ultrasound, or MR
guidance. In general, cryoprobes are placed into the targeted
tumor, with probes placed within 1cm of the tumor margin
and at a spacing of 2cm, with the goal of generating suciently
low temperatures in the ice ball for tissue destruction. Asingle freeze–thaw–freeze cycle is performed for each lesion, with
typical times for these cycles of 10 minutes–8 minutes–10 minutes, respectively. Shorter or longer times are oen used for
the freezing portions of the cycle depending on the adequacy
of coverage of the lesion and the proximity of adjacent critical
structures. Most commonly, non-contrast CT imaging is performed approximately every 2minutes throughout the freezing portions of the cycle, with body window and level settings
(W400, L40), to monitor the growth of the iceball.
248