Jack W. Jennings

Treatment of Metastatic Posterior Vertebral Body Osseous Tumors by Using a Targeted Bipolar Radiofrequency Ablation Device: Technical Note

PURPOSE To evaluate the feasibility of use and safety of a targeted radiofrequency ablation (RFA) device for metastatic posterior vertebral body tumors. MATERIALS AND METHODS This retrospective study was institutional review board approved and HIPAA compliant. Consent was waived for retrospective participation. Fluoroscopic or computed tomography-guided targeted RFA was performed in 26 patients (47 tumors) with painful metastatic posterior vertebral body tumors, some of which were radiation therapy resistant, by using a newly developed spinal tumor ablation system that contains an articulating bipolar extensible electrode. In 14 women and 12 men aged 44-85 years (mean age, 62 years), the most common primary tumor was lung cancer in seven patients (27%) and renal cell carcinoma and sarcoma in five patients each (19%). Other tumors included breast cancer and melanoma in two patients each (8%) and colon cancer, multiple myeloma, neuroendocrine tumor, head and neck squamous cell carcinoma, and unknown primary tumor in one patient each (4%). Ablation was performed with device thermocouples that permitted real-time monitoring of the periphery of the ablation zones to determine ablation size. Sequential postprocedural pain scores were obtained. Thirteen patients underwent follow-up imaging, and one underwent subsequent biopsy of a treated area. A paired two-tailed Student t test was used to evaluate significance of postoperative visual analog scale scores of pain at 1 week and 1 month. RESULTS Four of 26 patients developed transient radicular symptoms after ablation, which resolved with transforaminal blocks. No permanent neurologic injuries resulted from the procedure. Intraprocedural imaging demonstrated that the articulating bipolar instrument could be navigated into the posterior vertebral body tumors with a transpedicular approach. Postablation imaging confirmed necrosis within the ablation zone. Three patients showed progression of disease at the treated levels at follow-up. Systemic therapy was not interrupted to perform the procedures. CONCLUSION Targeted RFA with a newly developed articulating device is both feasible and safe for the treatment of painful posterior vertebral body metastatic tumors.

The metastatic spine disease multidisciplinary working group algorithms

The Metastatic Spine Disease Multidisciplinary Working Group consists of medical and radiation oncologists, surgeons, and interventional radiologists from multiple comprehensive cancer centers who have developed evidence- and expert opinion-based algorithms for managing metastatic spine disease. The purpose of these algorithms is to facilitate interdisciplinary referrals by providing physicians with straightforward recommendations regarding the use of available treatment options, including emerging modalities such as stereotactic body radiation therapy and percutaneous tumor ablation. This consensus document details the evidence supporting the Working Group algorithms and includes illustrative cases to demonstrate how the algorithms may be applied.

Use of Imaging in the Management of Metastatic Spine Disease With Percutaneous Ablation and Vertebral Augmentation

OBJECTIVE The purpose of this article is to describe the role of imaging in the management of metastatic spine disease with percutaneous ablation and vertebral augmentation. Topics include the imaging diagnosis of spinal metastases, imaging factors related to patient selection and procedural planning, intraprocedural imaging guidance, and posttreatment imaging assessment. CONCLUSION Radiologists should be familiar with pertinent imaging findings related to the percutaneous management of metastatic spine disease.

Radiographic Local Control of Spinal Metastases with Percutaneous Radiofrequency Ablation and Vertebral Augmentation

BACKGROUND AND PURPOSE: Combination radiofrequency ablation and vertebral augmentation is an emerging minimally invasive therapy for patients with metastatic spine disease who have not responded to or have contraindications to radiation therapy. The purpose of this study was to evaluate the rate of radiographic local control of spinal metastases treated with combination radiofrequency ablation and vertebral augmentation. MATERIALS AND METHODS: We retrospectively reviewed our tumor ablation database for all patients who underwent radiofrequency ablation and vertebral augmentation of spinal metastases between April 2012 and July 2014. Tumors treated in conjunction with radiation therapy were excluded. Tumor characteristics, procedural details, and complications were recorded. Posttreatment imaging was reviewed for radiographic evidence of tumor progression. RESULTS: Fifty-five tumors met study inclusion criteria. Radiographic local tumor control rates were 89% (41/46) at 3 months, 74% (26/35) at 6 months, and 70% (21/30) at 1 year after treatment. Clinical follow-up was available in 93% (51/55) of cases. The median duration of clinical follow-up was 34 weeks (interquartile range, 15–89 weeks), during which no complications were reported and no patients had clinical evidence of metastatic spinal cord compression at the treated levels. CONCLUSIONS: Combination radiofrequency ablation and vertebral augmentation appears to be an effective treatment for achieving local control of spinal metastases. A prospective clinical trial is now needed to replicate these results.

Hip Chondrolysis and Femoral Head Osteonecrosis: A Complication of Periacetabular Cryoablation

PURPOSE To describe a new complication and retrospectively identify the incidence and risk factors for hip chondrolysis and femoral head osteonecrosis associated with percutaneous cryoablation of periacetabular malignancies. MATERIALS AND METHODS In this retrospective study, 45 patients with a total of 113 musculoskeletal lesions were treated by percutaneous image-guided cryoablation between May 2008 and June 2013. Included in the treated population were 10 patients with a total of 12 periacetabular lesions. Clinical and imaging follow-up of at least 2 months was reviewed for evidence of femoral head osteonecrosis or hip chondrolysis. Parametric and nonparametric statistical methods were used to assess patient demographics and treatment technique and parameters on the development of hip chondrolysis/femoral head osteonecrosis. RESULTS Hip chondrolysis/femoral head osteonecrosis developed in 40% of patients (four of 10) and in 33% of treated periacetabular lesions (four of 12). All patients in whom chondrolysis/osteonecrosis developed were women. Needle proximity to the acetabulum (< 5 mm) was a significant predictor of chondrolysis/osteonecrosis development (P = .01). Three of the four patients in whom chondrolysis/osteonecrosis developed have undergone total joint replacement. CONCLUSIONS Periacetabular cryoablation can result in transarticular extension of the ablation zone, which may result in the development of hip chondrolysis and femoral head osteonecrosis. The proximity of the cryoablation probe to the acetabulum is a significant risk factor in the development of this complication.

Benign Spine Lesions: Advances in Techniques for Minimally Invasive Percutaneous Treatment

SUMMARY: Minimally invasive percutaneous imaging-guided techniques have been shown to be safe and effective for the treatment of benign tumors of the spine. Techniques available include a variety of tumor ablation technologies, including radiofrequency ablation, cryoablation, microwave ablation, alcohol ablation, and laser photocoagulation. Vertebral augmentation may be performed after ablation as part of the same procedure for fracture stabilization or prevention. Typically, the treatment goal in benign spine lesions is definitive cure. Painful benign spine lesions commonly encountered in daily practice include osteoid osteoma, osteoblastoma, vertebral hemangioma, aneurysmal bone cyst, Paget disease, and subacute/chronic Schmorl node. This review discusses the most recent advancement and use of minimally invasive percutaneous therapeutic options for the management of benign spine lesions.

Percutaneous Image-Guided Cryoablation of Musculoskeletal Metastases: Pain Palliation and Local Tumor Control.

PURPOSE To evaluate the safety and effectiveness of cryoablation of musculoskeletal metastases in terms of achieving pain palliation and local tumor control. MATERIALS AND METHODS A retrospective review was performed of 92 musculoskeletal metastases in 56 patients treated with percutaneous image-guided cryoablation. Mean age of the cohort was 53.9 y ± 15.1, and cohort included 48% (27/56) men. Median tumor volume was 13.0 cm3 (range, 0.5-577.2 cm3). Indications for treatment included pain palliation (41%; 38/92), local tumor control (15%; 14/92), or both (43%; 40/92). Concurrent cementoplasty was performed after 28% (26/92) of treatments. RESULTS In 78 tumors treated for pain palliation, median pain score before treatment was 8.0. Decreased median pain scores were reported 1 day (6.0; P < .001, n = 62), 1 week (5.0; P < .001, n = 70), 1 month (5.0; P < .001, n = 63), and 3 months (4.5; P = .01, n = 28) after treatment. The median pain score at 6-month follow-up was 7.5 (P = .33, n = 11). Radiographic local tumor control rates were 90% (37/41) at 3 months, 86% (32/37) at 6 months, and 79% (26/33) at 12 months after treatment. The procedural complication rate was 4.3% (4/92). The 3 major complications included 2 cases of hemothorax and 1 transient foot drop. CONCLUSIONS Cryoablation is an effective treatment for palliating painful musculoskeletal metastases and achieving local tumor control.

Image-guided biopsy and treatment of musculoskeletal tumors.

This article reviews the basics of image-guided intervention of musculoskeletal neoplasms. Image-guided procedures are playing an ever-increasing role in the diagnosis, staging, and treatment of musculoskeletal tumors. The successful handling of these lesions necessitates a multidisciplinary approach, with the radiologist working closely with the orthopedic oncologic surgeon, medical oncologist, radiation oncologist, and pathologist to ensure that the procedure is performed in a way that maximizes the chance of definitive diagnosis and/or the treatment effect while minimizing potential complications. To accomplish these goals, the radiologist must be familiar with the indications and contraindications for any biopsy or treatment, effective procedure planning (e.g., selection of biopsy path, type of imaging guidance and biopsy needle, etc.), proper specimen handling, and potential treatment options such as thermal ablation or cement augmentation. Continued involvement after the procedure-including follow-up to ensure that pathology is concordant with imaging-is also crucial.

Drill-Assisted Biopsy of the Axial and Appendicular Skeleton: Safety, Technical Success, and Diagnostic Efficacy

The purpose of this study was to evaluate the safety, technical success rate, and diagnostic efficacy of drill-assisted axial and appendicular bone biopsies. During a 3-y period, 703 drill-assisted biopsies were performed. The cohort included 54.2% men, with a mean age of 57.6 y ± 17.1. Median lesion volume was 10.9 mL (interquartile range, 3.4-30.2 mL). Lesions were lytic (31.7%), sclerotic (21.2%), mixed lytic and sclerotic (27.7%), or normal radiographic bone quality (19.3%). No complications were reported. The technical biopsy success rate was 99.9%. Crush artifact was present in 5.8% of specimens submitted for surgical pathologic examination, and 2.1% of specimens were inadequate for histologic evaluation.

Delayed vertebral body collapse after stereotactic radiosurgery and radiofrequency ablation: Case report with histopathologic-MRI correlation.

Stereotactic radiosurgery and percutaneous radiofrequency ablation are emerging therapies for pain palliation and local control of spinal metastases. However, the post-treatment imaging findings are not well characterized and the risk of long-term complications is unknown. We present the case of a 46-year-old woman with delayed vertebral body collapse after stereotactic radiosurgery and radiofrequency ablation of a painful lumbar metastasis. Histopathologic-MRI correlation confirmed osteonecrosis as the underlying etiology and demonstrated that treatment-induced vascular fibrosis and tumor progression can have identical imaging appearances.