Quality improvement guidelines for bone tumour management.

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CIRSE GUIDELINES
Quality Improvement Guidelines for Bone Tumour Management
A. Gangi•G. Tsoumakidou•X. Buy•
E. Quoix
Received: 5 October 2009/Accepted: 5 October 2009/Published online: 12 February 2010
? Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2010
Introduction
Different image-guided percutaneous techniques can be
used for treatment or pain palliation in patients with pri-
mary or secondary bone tumours. Curative ablation can be
applied for the treatment of specific benign or in selected
cases of malignant localized bone tumours [1]. Pain palli-
ation therapy of primary and secondary bone tumours [2, 3]
can be achieved with safe, fast, effective, and tolerable
percutaneous methods [4]. Ablation (chemical, thermal,
mechanical), cavitation (radiofrequency ionization), and
consolidation (cementoplasty) techniques can be used
separately or in combination. Each technique has its indi-
cations as well as its own advantages and drawbacks.
Definitions
•
Curative treatment The therapeutic goal of curative
treatment is to completely and definitively ablate the
tumour.
Palliative treatment The therapeutic goal of palliative
treatment is not to completely ablate the tumour but to
achieve pain palliation.
•
Consolidation Techniques
•
Cementoplasty Percutaneous injection of methylmeth-
acrylate provides bone strengthening and pain relief
[5, 6]. Cementoplasty is a symptomatic and not a
curative treatment [7, 8].
Ablation Techniques
•
Chemical ablation Injection of ethanol is used to ablate
osteolytic bone tumours as well as achieve pain man-
agement (neurolysis) [9].
Thermal ablation procedures consist of the following:
•
1.
Laser photocoagulation Thermoablation is pro-
duced with near-infrared wavelength lasers (neo-
dymium yttrium aluminum garnet [Nd:YAG] diode
laser 800–1000 nm).
Radiofrequency ablation Thermoablation is pro-
duced by altering the electric current at the tip of
the electrode, thus causing local ionic agitation and
subsequent frictional heat.
Cryoablation The application of extreme cold aims
to destroy cells by causing both direct cellular and
vascular injury [10, 11].
2.
3.
•
Radiofrequency ionisation (decompression ablation
technique) consists of the following:
1.Low-temperaturebipolartechnique:Thisproducesa
plasmafieldatthetipoftheelectrodethatbreaksthe
intermolecular bonds, thus creating a cavity inside
the tissue, which leads in turn to decompression.
Treatment Strategy
The management of patients with bone tumours requires
consideration of the following:
A. Gangi (&) ? G. Tsoumakidou ? X. Buy ? E. Quoix
Non-Vascular Interventional Radiology Department, Strasbourg
University Hospital, 67091 Strasbourg, Cedex, France
e-mail: gangi@rad6.u-strasbg.fr
123
Cardiovasc Intervent Radiol (2010) 33:706–713
DOI 10.1007/s00270-009-9738-9

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•
histology of the tumour with differentiation of benign
and malignant tumours;
careful evaluation of the patient’s general condition;
understanding of the disease process;
appreciation ofthedegree
(consolidation);
thorough working knowledge of available treatment
options and multidisciplinary decision making; and
precisionofthetreatmentgoal,i.e.,curativeorpalliative.
•
•
•
of bonedestruction
•
•
Tumour Biopsy
Percutaneous image-guided biopsy of the tumour should be
obtained when needed. Specific benign bone tumours have
characteristic imaging findings (e.g., osteoid osteoma) and
thus usually do not require a pretreatment biopsy specimen.
For the rest, i.e., benign and primary malignant neoplasms,
histologic confirmation is necessary. For chondroblastoma,
a biopsy should always be performed to differentiate it
from clear cell chondrosarcoma.
Secondary metastatic tumours usually do not require a
biopsy specimen. Biopsy should be performed only in
cases of unknown primary tumour or multiple primary
neoplasms or when there is doubt if the lesion is a sec-
ondary localization of the known primary neoplasm.
Curative Percutaneous Bone Tumour Management
Indications
•
Benign lesions
1.
2.
Osteoid osteoma;
osteoblastoma (when the maximum diameter is
\3cm); and
chondroblastoma. 3.
•
Malignant lesions (primary or secondary in nonsurgical
patients) are made by multidisciplinary decision.
Treatement is reserved for slow-growing cancers with
the following typical features:
1.
2.
with\3 proven locations, and
measuring\3 cm in diameter.
Palliative Percutaneous Bone Tumour Management
Indications
In the palliative treatment of painful bone tumours (pri-
mary or secondary), the therapeutic goal is not complete
ablation of the tumour but rather:
•
•
•
•
pain palliation;
tumour reduction;
prevention of impending pathologic fractures; and/or
decompression and debulking of bone tumours (espe-
cially for tumours bulging into the spinal canal).
Procedure Set-Up and Sedation
General Considerations
Coagulation studies (prothrombin time, activated partial
prothrombin time, international normalized ratio) as well
as platelet and white blood counts should be normal. All
infections located remotely from the surgical site should be
identified and resolved before the intervention is per-
formed. Informed written consent should be obtained
before the procedure.
Procedure Set-Up
Dealing with bone tumours requires strict sterile condi-
tions. Antibiotics can be administered intravenously on the
day of the procedure to prevent infection.
Sedation
Bone tumour management is usually painful and requires
sedation and analgesia. Tumour ablation usually needs
deeper sedation, such a general anaesthesia, nerve root
blocks, or spinal anaesthesia. For single-level cementopl-
asty, general anaesthesia is not mandatory; conscious
sedation is usually sufficient.
Types of Image Guidance
•
Fluoroscopy is the most commonly used imaging
modality for skeletal interventions, especially when
real-time imaging is needed (e.g., cement injection
during cementoplasty).
Ultrasound can be used in superficial lytic tumours, i.e.,
those with a soft-tissue component.
Computed axial tomography (CAT) guidance provides
high-resolution images that are useful for tumour
ablation (three-dimensional [3-D] imaging is necessary)
and help decrease the complication rate.
Magnetic resonance imaging (MRI) guidance is prom-
ising for its thermal-monitoring capacity. It also offers
the possibility of 3-D imaging, which is necessary for
tumour ablation.
•
•
•
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•
Flat-panel cone-beam CAT is becoming more accurate,
faster, and therefore very promising.
Multimodality imaging, which is associated with fluo-
roscopy and CAT scan, allows faster, safer, and more
accurate procedures and is particularly useful for
complex cases (e.g., spine).
•
Review of Techniques
Cementoplasty
Patient Selection and Technique
Osteolytic tumours (e.g., metastasis, multiple myeloma,
lymphoma) that are located near the vertebral body, ace-
tabulum, and condyles and that cause local pain, disability,
and a risk of compression fracture are excellent indications
for cementoplasty.
Cementoplasty can be performed with the patient under
sedation or general anaesthesia (especially for multilevel
vertebroplasty) [12, 13] using fluoroscopic or/and CAT
guidance. For vertebroplasty, a 10- or 15-gauge beveled
needle (for thoracic/lumbar and cervical level, respec-
tively) should be used. Cement injection should be per-
formed under real-time imaging (fluoroscopic-lateral view,
multislice fluoro-CAT).
Patient Outcome
Significant pain relief ([50% decrease in narcotic analge-
sics used or[50% pain decrease per visual analogue scale)
has been reported in 75% to 85% of patients [8, 14–16].
Improved results have been obtained by combining thermal
ablation and cementoplasty in cases of paravertebral tumor
extension or soft-tissue extension [17].
Complications
Cement leakage has been reported to occur in 38% to
72.5% of patients [18]; lung embolism, infection, and
fracture in\1% of patients; and allergic reaction, puncture-
site bleeding, and acute increased pain or new areas of pain
in 14% of patients [16].
Chemical Ablation with Ethanol
Patient Selection and Technique
Palliative treatment can be offered to patients with osteo-
lytic painful bone tumours without risk of fracture [5]. The
procedure should be performed strictly with the patient
under deep sedation or general anaesthesia (due to the pain
induced during ethanol injection in bone and soft tissue)
and under CAT guidance. According to the size and
number of lesions and level of pain relief desired, alco-
holization using 3 to 25 ml sterile 95% ethanol is admin-
istered either as a multisession technique or as a one-shot
technique through a 22-gauge needle.
Nonionic iodinated contrast medium should be always
injected into the lesion before ethanol injection to predict
the distribution. In patients with large tumours, alcohol
should be selectively instilled into regions considered to be
responsible for pain (usually the periphery of the tumour
and osteolytic areas). The size and shape of the necrosis
induced with ethanol is not always reproducible and
depends on the degree of vascularization, necrosis, and
tissue consistency.
Patient Outcome
Pain relief has been reported in 74% of patients and usually
occurs within 24 hours. In 26% of cases, decreased tumour
size has been observed, whereas in 18.5% of cases tumour
size continues to increase. Duration of pain relief ranges
from 10 to 27 weeks. The best results are obtained in
patients with small lytic metastases (i.e., diameter ranging
from 3 to 6 cm) [9].
Complications
Minor complications include low-grade fever (17%),
hyperuricemia, and pain during the first 6 hours. Major
complications include infection and accidental leakage
causing damage to the contiguous neurologic structures
(\1.5%).
Laser Ablation
Patient Selection and Technique
Because of the small size of the ablation zone produced,
laser is mostly used for patients with small tumours or in
those with contraindications to radiofrequency ablation
(RFA) (e.g., metallic implants). Multiple fibres are required
for patients with larger tumours.
Osteoid Osteomas
The best indication is tumour size (\1 cm in diameter). The
procedure should always be performed with the patient
under general anaesthesia or regional block (severe pain is
typically experienced during penetration of the nidus). The
laser fibre (400–600 lm) is always inserted coaxially into
the tumour under CAT guidance through a spinal needle or
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drill needle when necessary. The choice of access route (all
neurovascular structures should be avoided) and diffusion
of heat should be taken into account to avoid complica-
tions. If required, additional insulation techniques and
thermal monitoring should be applied to protect adjacent
vulnerable structures. The positioning of the fibre exactly
in the centre of the nidus is the key to a successful pro-
cedure. Two-watt power is applied for 6–10 min depending
on tumour size. At the end of ablation, 5–10 ml rupivacaine
2 mg/ml is injected (strictly extravascularly) in contact
with the periosteum to decrease postprocedural pain.
Painful Bone Metastases
Painful bone metastases can be treated by inserting B8
simultaneously energized bare fibres into the tumour with
approximately 1.5-cm spacing.
Patient Outcome
The success rate for ablation of osteoid osteomas is similar
to that of RF, with a 95% success rate in a single session [1,
19, 20].
Major Complications
Major complications include neurologic damage of contigu-
ous structures and neurodystrophia (\0.5% of patients) [21].
Recurrence Rate
The recurrence rate for osteoid osteoma is approximately
5% (mainly in intra-articular lesions) [1].
RFA
Patient Selection and Technique
The indications for RFA in bone can be curative or palli-
ative [22].
Major Indications
Curative indications include patients with primary (e.g.,
osteoid osteoma, osteoblastoma, chondroblastoma) or sec-
ondary bone tumours with contraindications to surgery or
patient refusal of surgery (tumour size should be\5 cm in
diameter). Palliative indications include painful bone
metastases (pain not controlled by conventional therapies).
Ablation protocols vary according to lesion size and
generator used. The best guidance modality is CAT with or
withoutfluoroscopy[23].BoneRFArequiresregional block
or general anaesthesia. At the end of ablation, 5 to 10 ml
rupivacaine 2 mg/ml is injected (strictly extravascularly) in
contactwiththeperiosteumtodecrease postproceduralpain.
In osteoid osteoma, RFA technique is similar to that for
laser ablation. The small size of the nidus does not require
large ablation with expandable and multitined or perfusion
and internally cooled electrodes. A 1-cm active-tip elec-
trode is used to reach a temperature of 90?C within 6 to 10
minutes. If cortical bone must be passed through, a bone
biopsy needle must be used, and the electrode is coaxially
inserted into the lesion. Because the bone needle is not
insulated, it should not come into contact with the active
part of the RFA electrode. For tumours in close proximity
to neurologic structures or other organs, thermal protection
techniques are required [24]. RFA seems to be promising
for the treatment of chondroblastomas, although few pub-
lished data exist on outcomes exist [25–27].
For large volumes of ablation in tumours involving
weight-bearing bones, additional consolidation with ce-
mentoplasty or surgery should be considered to prevent the
risk of secondary fracture [28]. If cementoplasty is per-
formed in the same session with RFA, the injection should
be delayed until the tumour temperature has decreased to
normal levels to avoid setting the cement too quickly.
The major advantage of RFA compared with chemical
ablation (ethanol) is better delimitation of the ablation zone
without risk of leak. The difficulty in treating bone tumours
with RFA lies in thermal protection of vulnerable sur-
rounding structures (particularly nerve roots) and penetra-
tion of the lesion, which in some cases requires coaxial
introducer systems [2, 29].
Patient Outcome
For osteoid osteoma, the success rate of bone RFA is similar
tothatoflasertherapy([85%ofpatients),andtherecurrence
rate has been reported to be 5–10% [20, 30]. A 10–15%
recurrenceratehasbeennotedfortypicalosteoblastoma,and
a 50% rate has been reported for aggressive osteoblastoma.
An acute postablation inflammatory reaction can occur and
should be prevented with administration of anti-inflamma-
tory therapy. When using RFA for pain palliation in painful
malignant bone tumours, significant ([50%) and rapid pain
relief, including a subsequent substantial decrease in medi-
cation, has been reported in 70–95% of patients [4, 21, 31–
34]. Because of advanced disease, recurrence of pain in
relation to other metastases is common, but most patients
remain pain free at the ablated area.
Complications
Complications include thermal damage of contiguous
structures (insulation techniques and thermal monitoring
are mandatory to decrease theses risks) and infection.
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Cryoablation
Patient Selection and Technique
The indications and procedural technique are similar to
those for RFA. Cryoablation is efficient for both lytic and
sclerotic tumours. Procedure planning remains the same.
However, compared with RFA, B25 cryoprobes (17-gauge;
best gap between probes is 2 cm) can be inserted simul-
taneously [35].
The procedure is performed with the patient under
sedation or general anaesthesia using CAT or MRI guid-
ance (MRI-compatible cryoprobes exist on the market).
Percutaneous cryoablation appears to require less analgesia
than RFA [36]. Cryoablation of skeletal metastases is a
time-consuming procedure [37] because two 10-minute
freeze cycles, separated by an 8-min passive thaw, should
be performed per position. Monitoring of the ice ball (of
predictable geometry based on the length and diameter of
the expansion room at the tip of the probe) is necessary and
can be achieved with CAT imaging (e.g., hypodense ice
ball). For complete necrosis of the tumour, it is important
to extend the margins of the ice ball by a minimum 5-mm
distance beyond the tumour margins to ensure complete
cell death.
When thermal insulation is required, fluid should be avoi-
ded. For the best tissue insulation and protection of sur-
rounding organs, carbon dioxide (CO2) should be used [24].
For large volumes of ablation in tumours involving
weight-bearing bones, additional consolidation with ce-
mentoplasty or surgery should be considered to prevent the
risk of secondary fracture [28, 38]. If cementoplasty is
performed in the same session with cryoablation, injection
should be delayed until the temperature of the tumour has
increased to normal levels to avoid cement leakage.
Compared with other ablation techniques, cryotherapy
offers the major advantages of direct visualization of the
ice ball, simultaneous use of B25 probes, and less post-
procedural pain [37, 39].
Effective cryoablation tissue injury depends on four
criteria:
1.
2.
3.
4.
excellent monitoring of the process;
fast cooling to a lethal temperature;
slow thawing; and
repetition of the freeze–thaw cycle [35, 40–44].
Patient Outcome
Percutaneous cryoablation is a safe and effective method
for palliation of pain caused by metastatic disease and has
been reported to provide significant pain relief in B75% of
patients [37].
Complications
Complications include cryoshock phenomenon, a rare
syndrome that happens after large ablations, especially in
the liver, occurs in 1% to 3.8% of patients [45–47] as well
as thermal damage to contiguous neural structures (tem-
porary neuropraxia at –20?C and permanent neurologic
damage at B40?C) [48].
Radiofrequency Ionization
Patient Selection and Technique
The best candidates for this technique are (1) patients
having painful nonsurgical spinal tumours with intracana-
lar extension and (2) patients with rupture of the posterior
wall of the vertebral body and thus a high risk of cement
leakage or shift of the tumour in the canal, both of which
have neurologic consequences.
A bone trocar is used to allow tumoral access and
coaxial insertion of the RFA 16-gauge bipolar electrode.
A side-arm catheter is connected to the electrode to
slowly inject saline solution for activation of the plasma
field. The angled tip of the electrode allows the digging
of several channels inside the tumour by rotation of the
electrode on its axis. In spinal lesions after cavitation,
acrylic cement is injected into the cavity for consolida-
tion [21, 48].
Patient Outcome
Decreased neuralgia has been reported in B87% of patients
[48] (due to tumour decompression). Decreased cement
leakage, although reported, requires further evaluation.
Complications
Complications include accidental damage to nerve roots
and perforation of adjacent organs.
Thermal Insulation and Monitoring
Thermal insulation and monitoring is used to protect
important anatomic structures from thermal injury during
application of different thermal ablation techniques. Heat-
ing at C45?C has been shown to be neurotoxic to the spinal
cord and the peripheral nerves. Interposition of bone
increases the insulation but depends on the thickness of
bone lamella [2]. Precautionary measures should be taken
when no intact insulating cortex remains between the
tumour and the neurologic structures. The risk of thermal
damage increases with the size of the active tip of the
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electrode [29, 49]. Thermal insulation techniques and
thermal monitoring can be used alone or in combination, if
necessary, to decrease unintended thermal injury to non-
target structures.
Thermal Insulation
Thermal insulation consists of fluid, gas, or balloon
interposition between adjacent nontarget structures and
the ablation zone [1, 50–52]. Hydrodissection is one of
the most commonly used techniques. With aerodissec-
tion, CO2 is injected using a dedicated CO2 injection
syringe, which allows precise control of the volume of
gas insufflated in the desired zone under positive pres-
sure [24].
•
RFA Saline is not a suitable solution (because of its
high electrical conductivity), and dextrose in water 5%
has been advocated.
Cryoablation Carbon dioxide can be used to displace
the nontarget structures away from the treatment zone,
thus creating an excellent thermal insulator blanket.
Fluid is not suitable because it can freeze in contact
with the ice ball. In ultrasound-guided interventions,
CO2dissection cannot be used (the ring-down artifact
from gas deteriorates the image).
•
Thermal Monitoring
Thermal monitoring is achieved with thermocouples
inserted coaxially through an 18-gauge spinal needle [53].
Special care is needed with RFA because the tip of metal-
based thermocouple should never be placed too close to the
RFA electrode (this could result in arcing and electrical
conductivity).
Conclusion: Proposed Treatment Strategy
•
Precise clinical evaluation of the patient is mandatory
and should include origin and location of pain, previous
treatment, patient-tolerated
expectancy.
Whole-body 3-D imaging should be used to precisely
analyze the lesions and their relation to surrounding
structures.
Multidisciplinary decision making is required to choose
the most efficient and least disabling technique.
anaesthesia, andlife
•
•
1.For a painful tumour involving a flat weight-bearing
bone without invasion of surrounding tissues and
associated with risk of compression fracture, single
cementoplasty is the most appropriate technique.
For a painful bone tumour with extension into
surrounding soft tissues, thermal ablation is required
to control the pain caused by soft-tissue invasion.
However, if there is a risk of pathologic fracture, an
additional consolidation technique is required (cemen-
toplasty for flat bones or surgery for long bones).
For nonsurgical spinal tumours extending toward the
canal with rupture of the posterior wall and epidural
extension, percutaneous tumour decompression using
radiofrequency ionization is the best technique. After
tumour decompression, the cavity created can be filled
with cement (Algorithm 1).
2.
3.
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Tumour Management
Curative Palliative
No need for
Consolidation
LaserA
Tumour Ablation Need for
Consolidation
Thermal Ablation
RFACryoA Cavitation
Extension to the canal
or need for debunking
Thermal Ablation
Extension to
surrounding tissues
Cementoplasty Chemical or
Thermal Ablation
(+/-)
Need for Tumour
Size Reduction
Thermal Ablation
Algorithm 1 Tumour-
management therapeutic option
algorithm
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