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Combined Treatment of a Spinal Metastasis with Radiofrequency Heat Ablation and Vertebroplasty

¹ Abteilung Röntgendiagnostik, Universitätsklinikum Freiburg, Hugstetter Str. 55, D 79106 Freiburg, Germany.
² Department of Orthopedics and Traumatology, University Hospital of Freiburg, D 79106, Freiburg, Germany.

Received July 15, 2002; accepted after revision September 17, 2002.

 
Address correspondence to O. Schaefer.

Introduction

Top Introduction Subject and Methods Results Discussion References

 
Metastatic cancer is the most common malignant disease of the skeletal system. Many of the affected patients are receiving palliative care. The first goals should be the alleviation of pain and the prevention of complications such as pathologic fractures, which is especially important in patients with spinal metastasis to avoid instability and neurologic dysfunction. The standard treatments include radiation therapy, surgery, chemotherapy, hormone therapy, and, recently, therapy using systemic radiopharmaceuticals and biphosphonates; radiotherapy remains the treatment of choice. However, the long-term results of these treatments are not fully satisfying; an effective, minimally invasive local therapy that can be performed at a single outpatient setting would be beneficial [1].

We are aware of only four patients whose spinal metastases have been treated with a combination of radiofrequency heat ablation and vertebroplasty [2]. To our knowledge, ours is the first report on the successful use of combined radiofrequency heat ablation and vertebroplasty in a single session. The aim of performing radiofrequency heat ablation before vertebroplasty in this patient was to destroy tumor tissue and to thrombose the paravertebral and intravertebral venous plexus and thereby minimize procedure-related complications. The purpose of vertebroplasty was to then stabilize the vertebra.

Subject and Methods

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An 80-year-old man with suspected renal cell carcinoma and lower back pain was referred to our institutuion. Initial contrast-enhanced multidetector CT (Somatom Volume Zoom; Siemens, Erlangen, Germany) revealed a left renal cell carcinoma and a solitary osteolytic metastasis measuring 3 x 2 cm in the L3 vertebral body (Fig. 1A). Tumor nephrectomy was carried out, but the patient refused the standard treatment options for the vertebral metastasis. Because of the anterior location of the metastasis and the intact posterior cortex of the vertebral body, the decision was made to treat the tumor with percutaneous radiofrequency heat ablation in combination with vertebroplasty. The patient gave written informed consent.

View larger version (158K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —80-year-old man with renal cell carcinoma who presented with lower back pain. CT scan shows osteolytic metastasis of L3 vertebral body measuring 3 x 2 cm in diameter. Note intact posterior cortex of vertebra.

We administered general endotracheal anesthesia and placed the patient in a prone position on the CT table. A team of anesthesiologists, trauma surgeons, and radiologists were present in the CT room during the entire procedure. The whole procedure was performed under fluoroscopic and CT guidance. Before radiofrequency heat ablation, a biopsy was taken from the lesion. A small skin incision was made at the puncture site, and an 11-gauge bone marrow biopsy needle (OptiMed, Ettlingen, Germany) was inserted via a transpedicular approach into the tumor. Histopathologic examination confirmed a vertebral metastasis of the renal cell carcinoma. A 16-gauge LeVeen needle electrode (RadioTherapeutics, Sunnyvale, CA) was deployed through the inserted cannula into the central part of the lesion (Fig. 1B). After unsheathing the electrode tines, which opened to a diameter of 2.5 cm in the metastasis, we connected the needle with a radiofrequency generator (RF 3000; RadioTherapeutics).

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —80-year-old man with renal cell carcinoma who presented with lower back pain. CT scan shows inserted LeVeen needle electrode (RadioTherapeutics, Sunnyvale, CA) with unsheathed electrode tines in metastasis. Microbubble formation is detected after radiofrequency heat ablation, indicating tumor necrosis.

The radiofrequency heat ablation started at an energy level of 40 W. The deployed energy was increased by 10 W every 3 min (up to 80 W) until the initial electrical tissue impedance of 45 rose and further current flow was prevented (roll-off). The device was advanced to the ventral part of the metastasis to perform a second radiofrequency ablation cycle, ranging from 40 to 70 W. Control CT scans revealed microbubble formation in the treated area, indicating tumor necrosis. No complications occurred.

Before vertebroplasty, intraosseous venography was conducted by injecting iopentol (Imagopaque 300; Amersham Health, Braunschweig, Germany) through the trocar. To complete the procedure, 4 mL of polymethylmetacrylate was injected through the vertebroplasty needle. Control CT scans revealed a homogeneous distribution in the tumor necrosis with a small ventral leakage (Fig. 1C). After the intervention, the patient experienced no pain and was neurologically intact at sensorimotor physical examination. A control radiographic study of the thorax excluded pulmonary embolism of polymethylmetacrylate. After an overnight hospital stay, the patient was released from the clinic free of pain.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —80-year-old man with renal cell carcinoma who presented with lower back pain. Control CT scan acquired immediately after vertebroplasty shows homogeneous cement distribution in tumor necrosis with small ventral leakage.

Results

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The combination of radiofrequency ablation and vertebroplasty was feasible in our patient. Intraosseous venography performed after radiofrequency ablation revealed no venous drainage of the highly vascularized metastasis because of damaged tumor vessels. Vertebroplasty was performed successfully with a homogeneous distribution of the cement in the tumor necrosis. Control radiographs and CT scans acquired 3 months after the procedure revealed a stable vertebral body with no further tumor growth and an unchanged location of the instilled cement (Fig. 1D). The patient was still pain-free without medication and was experiencing no limitations in his activity.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D. —80-year-old man with renal cell carcinoma who presented with lower back pain. Control radiograph acquired 3 months after procedure reveals stable vertebral body with unchanged location of cement filling.

Discussion

Top Introduction Subject and Methods Results Discussion References

 
Radiofrequency heat ablation has proven to be an effective method for the treatment of malignant and benign tumors [3, 4]. This technique has been used in several organs and is receiving increasing attention for the treatment of musculoskeletal diseases, such as osteoid osteomas, chondroblastomas, epitheloid hemangioendotheliomas, and bone metastasis, including spinal lesions [2, 5, 6, 7]. Major benefits of radiofrequency heat ablation are the immediate cell death and the accurate control of lesion size with an imaging-guided procedure. Groenemeyer et al. [2] reported four cases of spinal metastasis that were treated using a combination of radiofrequency heat ablation and vertebroplasty. Vertebroplasty was performed 3–7 days after radiofrequency heat ablation. Inclusion criteria were previous ineffective standard treatments, pain despite analgesics, high risk of neurologic deficits, and increased risk of fractures. Exclusion criteria were osteoblastic tumors, paraplegia, and hemorrhagic diathesis.

Indications for minimally invasive cementoplasty are to provide pain control and to stabilize an osteolytic lesion. Potential complications due to needle positioning or cement leakage include mechanical or thermal damage to the adjacent soft tissue. Most often, treatment of vertebral compression fractures and metastases has been performed with excellent results regarding long-term pain relief and improvement in mobility [8, 9].

Until now, no data had been acquired from controlled clinical trials with long-term follow-up about the use of radiofrequency heat ablation before cementoplasty. We performed radiofrequency heat ablation before vertebroplasty in a single session to necrotize the metastasis and to thrombose the paravertebral and intravertebral venous plexus and thereby minimize procedure-related complications. We think that necrotizing tumor tissue by radiofrequency heat ablation may optimize cement distribution, which will be facilitated by changes in tumor consistency as a result of thermal alterations.

The thermal effects of radiofrequency heating on the adjacent soft and neural tissue must be considered before radiofrequency ablation is applied to spinal tumors [6]. Dupuy et al. [6] reported that a margin of safety will be provided in cases in which preserved cancellous or cortical bone is between the lesion and the spinal canal. The presence of cortical bone even serves as an insulator and potentially improves heat retention [1, 6]. Because of the anterior location of the metastasis in our patient, we estimated the potential risk of neural tissue heating and damaging to be low. The procedure was performed without complications, and reduction of tumor burden, stabilization, and pain relief were achieved.

The combination of percutaneous radiofrequency heat ablation and cementoplasty seems to be a promising, feasible, minimally invasive technique in the treatment of spinal metastasis. Further clinical experience and prospective studies are warranted to determine the longterm efficacy of this interventional approach.

References

Top Introduction Subject and Methods Results Discussion References

 

1. Dupuy DE, Goldberg SN. Image-guided radiofrequency tumor ablation: challenges and opportunities. II. J Vasc Interv Radiol 2001;12:1135 –1148[Medline]
2. Groenemeyer DH, Schirp S, Gevargez A. Imageguided radiofrequency ablation of spinal tumors: preliminary experience with an expandable array electrode. Cancer J 2002;8:33 –39[Medline]
3. Goldberg SN, Dupuy DE. Image-guided radiofrequency tumor ablation: challenges and opportunities. J Vasc Interv Radiol 2001;12:1021 –1032[Medline]
4. Gazelle GS, Goldberg SN, Solbiati L, Livraghi T. Tumor ablation with radio-frequency energy. Radiology 2000;217:633 –646[Abstract/Free Full Text]
5. Woertler K, Vestring T, Boettner F, Winkelmann W, Heindel W, Lindner N. Osteoid osteoma: CT-guided percutaneous radiofrequency ablation and follow-up in 47 patients. J Vasc Interv Radiol 2001;12:717 –722[Medline]
6. Dupuy DE, Hong R, Oliver B, Goldberg SN. Radiofrequency ablation of spinal tumors: temperature distribution in the spinal canal. AJR 2000;175:1263 –1266[Free Full Text]
7. Nour SG, Aschoff AJ, Mitchell IC, Emancipator SN, Duerk JL, Lewin JS. MR imaging-guided radio-frequency thermal ablation of the lumbar vertebrae in porcine models. Radiology 2002;224:452 –462[Abstract/Free Full Text]
8. Weill A, Chiras J, Simon JM, Rose M, Sola-Martinez T, Enkaoua E. Spinal metastases: indications for and results of percutaneous injection of acrylic surgical cement. Radiology 1996;199:241 –247[Abstract/Free Full Text]
9. Peh WC, Gilula LA, Peck DD. Percutaneous vertebroplasty for severe osteoporotic vertebral body compression fractures. Radiology 2002;223:121 –126[Abstract/Free Full Text]

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