Abstract: HomeRadiologyVol. 291, No. 2 PreviousNext Reviews and CommentaryFree AccessEditorialIs Percutaneous Bone Cryoablation Safe?Jack W. Jennings Jack W. Jennings Author AffiliationsFrom the Mallinckrodt Institute of Radiology, Washington University School of Medicine, Siteman Cancer Center, 510 S Kingshighway Blvd, St Louis, MO 63110.Address correspondence to the author (e-mail: [email protected]).Jack W. Jennings Published Online:Feb 26 2019https://doi.org/10.1148/radiol.2019190212MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Auloge et al in this issue.IntroductionBone is the third most common metastatic site from cancer, after lungs and liver. Prostate, breast, lung, kidney, and thyroid malignancies account for approximately 80% of skeletal metastases. Nearly 85% of patients have bone metastases at the time of death. Of the patients who develop skeletal metastases, approximately 50% will develop poorly controlled pain during the course of their disease (1).With the advances of systemic and immunotherapy, cancer patients are living longer and pain management for those with osseous metastatic disease is problematic. Traditional local and systemic therapies may be exhausted, including radiation, surgery, opioid and nonsteroidal analgesics, and chemotherapy. While radiation therapy remains the standard of care for palliation of painful osseous metastatic disease, it does have certain limitations. These include radiation-resistant histologies (eg, renal cell carcinoma, melanoma, and sarcoma), cumulative dose tolerance to adjacent radiosensitive organs (eg, spinal cord and bowel), and the need for systemic or immunotherapy during treatment.Over the last decade, minimally invasive, image-guided thermal ablation has emerged as an integral component of the multidisciplinary treatment algorithm of osseous metastatic disease. Ablation of osseous disease can offer a palliative, local treatment alternative to conventional therapies. Percutaneous cryoablation and radiofrequency ablation (RFA) are the two most published modalities for bone tumor ablation; studies with both modalities demonstrate significant pain improvement after treatment.Cryoablation with CT guidance is able to identify the ablation zone as a low-attenuation ice ball extending beyond the ablated tissue, utilizes multiple probes in variable configurations to sculpt tailored, additive ablation zones, and has shown to have decreased intra- and postprocedural pain relative to RFA (2). The ability to visualize the ablation zone allows the operator to know with confidence the anatomic structures susceptible to thermal injury. Ablation of weight-bearing bones (eg, spine, supra-acetabular ilium, and long bones) can increase the risk of postprocedural fractures. Consideration needs to include concurrent, prophylactic vertebral augmentation, cementoplasty, percutaneous screw fixation (osteosynthesis), or orthopedic nailing or fixation.Musculoskeletal tumors are often in the proximity of vital adjacent structures, including the spinal cord, peripheral nerves, vessels, and bowel. Often the greatest risk of the cryoablation procedure is collateral damage to these structures. Many of the critical neural structures are often not visible with conventional imaging techniques used for guidance in ablation procedures, including fluoroscopy, CT, and US. This requires the interventional radiologist to be familiar with the expected and variant anatomic location of these nerves, often with evaluation of preprocedural MRI and use of appropriate thermal protective techniques to prevent or at least minimize thermal injury. In cryoablation, the nerve motor functions are the first affected, and to a greater degree than sensory functions. Injury begins when temperatures decrease below 10°C, and total motor and sensory loss occurs between 0°C and 5°C (3).In this issue of Radiology, Auloge and colleagues (4) present the largest retrospective case series of percutaneous cryoablation, including 320 bone lesions in 239 patients, for pain palliation and/or local tumor control. They demonstrate that it is a very safe procedure, with an overall complication rate of 9.1% and a major complication rate of 2.5%. In four of the largest bone cryoablation studies previously reported (5–8), a total of 250 lesions were treated. The overall major complication rate was 3.2% (eight of 250), with a range of 0%–7.4%. This is in concordance with this current, larger series analysis. The major complications in the four studies included hemothorax, foot drop, osteomyelitis, femur fractures, and neuropathies. In the case series by Auloge et al (4), 50% of the major complications were postablation fractures of the acetabulum (despite concurrent cementoplasty), iliac wing, and scapula. The remaining complications included tumor seeding, infection, arterial bleeding, and severe hypotension. No major neural injuries occurred.A limitation of this study is that it is unclear how many lesions were treated with the aid of either passive or active thermoprotective techniques; however, such measures were described and utilized as indicated. In heat-based ablation, patient biofeedback (ie, painful response under conscious sedation) is very beneficial; however, it is less helpful in cryoablation, likely because it is a much less painful procedure due to the “numbing effect.” Because there is often no painful response from the patient during cryoablation, which would often require additional thermoprotective precautions, permanent nerve injury may result.Passive thermoprotection includes use of motor- and somatosensory-evoked potentials, electrostimulation, and thermocouples. Active thermoprotection includes soft-tissue displacement or nerve insulation with carbon dioxide insufflation, hydrodissection with saline, warming, and myelography or epidurography in spine lesions. These techniques become very crucial when treating spine lesions or lesions in the pelvis adjacent to neural structures. The senior author (A.G.) published an article about the use and benefits of carbon dioxide dissection and temperature monitoring to prevent nontarget ablation of adjacent vital structures in 37 ablations, with no complications or resultant nerve injury (3). Likewise, this same group of authors demonstrated their experience with peripheral motor nerve stimulation in 12 cases of percutaneous thermal ablation, which resulted in significant reduction of muscle response to electrostimulation during the ablation. This necessitated the use of active thermal protective measures in two cases and termination in one, with no postprocedural motor deficits (9). In a retrospective series of 64 musculoskeletal tumor ablations, Kurup et al (10) demonstrated the benefit of intraprocedural motor-evoked potentials and the correlation of persistent decreases in the potentials with sustained postprocedural motor deficits.The low rate of major complications in the Auloge et al large series of percutaneous ablation of musculoskeletal lesions and the use of thermoprotective techniques can be applied to other ablative modalities and dovetails with more recent growth of musculoskeletal interventional oncology procedures on a global scale. This study population included 68 (21%) spinal tumors without any major complication and only 1.8% having transient nerve injury (4), demonstrating that cryoablation can be safely performed adjacent to the spinal cord and major nerve roots using the appropriate thermoprotective techniques to prevent injury. The role of percutaneous spine ablation in the multidisciplinary treatment algorithm of spine metastatic disease is an area that is ripe for future research, as there continues to be much morbidity related to spine metastatic disease. Is there a role for combined radiation therapy and spine ablation to achieve more durable local tumor control and pain palliation, especially in patients for whom surgery is not an option? Both modalities have demonstrated good safety profiles. Can these be replicated in combined therapy? Multimodality local therapy may especially prove beneficial in those histologies that prove to be more radiation-resistant.In conclusion, percutaneous cryoablation of bone metastasis is safe, with a very low major complication rate. These results in conjunction with those of other recent studies may advance the role of minimally invasive ablation in the treatment of osseous metastatic disease for both palliative and local tumor control purposes. This study supports that consideration needs to be taken in older patients, those with low performance status, lesions requiring multiple cryoprobes, or lesions involving the long bones to minimize complication risks. Further, the study by Auloge et al (4) may lead to a broader and increased adoption by both interventional radiologists and referring physicians, allowing more patients to benefit from this procedure.Disclosures of Conflicts of Interest: J.W.J. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: disclosed payment received from Merit Medical, Galil/BTG, Medtronic, and Bard for consultancy and payment from Merit Medical for lectures, including service on speakers’ bureaus. Other relationships: disclosed no relevant relationships.References1. Nielsen OS, Munro AJ, Tannock IF. Bone metastases: pathophysiology and management policy. J Clin Oncol 1991;9(3):509–524. Crossref, Medline, Google Scholar2. Thacker PG, Callstrom MR, Curry TB, et al. Palliation of painful metastatic disease involving bone with imaging-guided treatment: comparison of patients’ immediate response to radiofrequency ablation and cryoablation. AJR Am J Roentgenol 2011;197(2):510–515. Crossref, Medline, Google Scholar3. Buy X, Tok CH, Szwarc D, Bierry G, Gangi A. Thermal protection during percutaneous thermal ablation procedures: interest of carbon dioxide dissection and temperature monitoring. Cardiovasc Intervent Radiol 2009;32(3):529–534. Crossref, Medline, Google Scholar4. Auloge P, Cazzatto RL, Rousseau C, et al. Complications of percutaneous bone tumor cryoablation: a 10-year experience. Radiology 2019;291:521–528. Link, Google Scholar5. Wallace AN, McWilliams SR, Connolly SE, et al. Percutaneous image-guided cryoablation of musculoskeletal metastases: pain palliation and local tumor control. J Vasc Interv Radiol 2016;27(12):1788–1796. Crossref, Medline, Google Scholar6. Tomasian A, Wallace A, Northrup B, Hillen TJ, Jennings JW. Spine cryoablation: pain palliation and local tumor control for vertebral metastases. AJNR Am J Neuroradiol 2016;37(1):189–195. Crossref, Medline, Google Scholar7. Callstrom MR, Dupuy DE, Solomon SB, et al. Percutaneous image-guided cryoablation of painful metastases involving bone: multicenter trial. Cancer 2013;119(5):1033–1041. Crossref, Medline, Google Scholar8. Prologo JD, Passalacqua M, Patel I, Bohnert N, Corn DJ. Image-guided cryoablation for the treatment of painful musculoskeletal metastatic disease: a single-center experience. Skeletal Radiol 2014;43(11):1551–1559. Crossref, Medline, Google Scholar9. Tsoumakidou G, Garnon J, Ramamurthy N, Buy X, Gangi A. Interest of electrostimulation of peripheral motor nerves during percutaneous thermal ablation. Cardiovasc Intervent Radiol 2013;36(6):1624–1628. Crossref, Medline, Google Scholar10. Kurup AN, Morris JM, Boon AJ, et al. Motor evoked potential monitoring during cryoablation of musculoskeletal tumors. J Vasc Interv Radiol 2014;25(11):1657–1664. Crossref, Medline, Google ScholarArticle HistoryReceived: Jan 28 2019Revision requested: Feb 1 2019Revision received: Feb 3 2019Accepted: Feb 5 2019Published online: Feb 26 2019Published in print: May 2019 FiguresReferencesRelatedDetailsCited ByVertebral Primary Bone Lesions: Review of Management OptionsAnjalikaChalamgari, DaisyValle, XubanPalau Villarreal, MarcoForeman, AnnikaLiu, AashayPatel, AkankshaDave, BrandonLucke-Wold2023 | Current Oncology, Vol. 30, No. 3Thermoprotection of Neural Structures During Musculoskeletal AblationAhmadParvinian, Jonathan M.Morris, Benjamin A.Johnson-Tesch, A. 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