|Bone: Surgery, RFA and Cryoablation
written and compiled by doctordee
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|Surgery of Long Bones|
SURGICAL INTERVENTION -- LONG BONES
The chance of developing a fracture increases with the duration and extent of tumor growth in the bone. The development of a fracture is devastating. It is vital that patients are routinely assessed by a specialist orthopedic and/or spinal surgeon to advise on preventive surgery. "A pathological long-bone fracture in a patient with known metastatic bone disease is really a reflection of inadequate clinical management." Orthopedic management should enable intervention prior to fracture, enabling a simpler and safer operation.
"Fractures are common through lytic metastases and weight bearing bones, the proximal femora being the most commonly affected sites... Although controversial, several radiological features have been identified which may predict imminent fracture. These include pain, the anatomical site of a lesion, its radiological characteristics, and its size. Although the intensity of bone pain is not directly associated with fracture risk, pain that is exacerbated by movement does appear to be an important factor, which predicts impending fracture. Radiographic assessment gives information on the size of a lesion and the extent to which the bone is destroyed. When less than one-third of the diameter of a long bone is affected, pathological fracture is relatively unusual, but above this amount and especially when more than 50% of the cortex is destroyed, the fracture rate increases markedly to approximately 80%. A practical scoring system incorporating the above factors has been described to give valuable guidance in the selection of patients for prophylactic fixation." 
Prior to surgery, bone isotope scans, Xrays of the entire affected bone, and possibly also MRI scans of the area, should be done. Other bony lesions will be seen, stabilized, and included in the field of irradiation. A pathologic fracture from a second metastasis at the edge of a plate or nail fixation of the first metastasis, is much more difficult to treat. "Providing the lesion is irradiated, there is no evidence to suggest that surgery increases the risk of disseminating tumor cells either locally or into the circulation. If the patient is not fit for surgery, then radiotherapy and nonweight-bearing is indicated." 
A fracture because of a bony metastasis [pathologic fracture] does not necessarily mean the patient is terminally ill. But untreated pathologic fractures rarely heal: large areas of bone destruction may not leave enough tissue for repair, and radiotherapy also inhibits fracture healing. So primary internal stabilization followed by radiotherapy is usually the treatment of choice, and the most likely path to restore mobility as well as relieve pain. [5.87]
"Coincident with improved overall cancer palliation during the past 2 decades has been an increasing incidence of clinically apparent bone metastases, and from these metastases subsequent pathologic fractures of the long bones, spine, and pelvis. Current techniques for surgical management of these fractures are extremely effective in alleviating pain and allowing patients to resume an ambulatory status, often without the need of external support. This, in turn, has significantly improved the quality of the remaining months or years of these individuals' lives. In fact, the long term survival of patients after their first long bone pathologic fracture from malignancy has more than tripled for the most common cancers (breast carcinoma, prostate carcinoma, lymphomas, and myelomas) during the past 25 years. Surgical techniques for stabilizing pathologic or impending fractures must be individualized for the area of involvement, the particular qualities of the bone involved, and the potential for involvement of adjacent soft tissue structures. Long bone fractures most commonly occur in the femur and humerus and are typically internally fixed by intramedullary devices that control impaction, distraction, and torquing stresses by the use of proximal and distal interlocking fixation. Such fixation must be able to withstand weight-bearing stresses on lower extremity long bones. Upper extremity pathologic fractures are often subjected to distractive forces inherent in lifting and pulling, but they are also subjected to heavy compressive forces, particularly in patients who require crutches or other devices to assist them in walking. Fixation of upper or lower extremity long bone fractures ordinarily may be accomplished with minimal blood loss or morbidity. In contrast, fractures or impending fractures involving the acetabulum necessitate extensive joint reconstruction, with inherent increased potential for morbidity and complications. For this reason, the anticipated prognosis for survival and mobility should be greater preoperatively for patients with acetabular fractures than for patients with fractures of either upper or lower extremity long bones. ... Ninety-six percent of patients experience good or excellent relief of pain after internal fixation of pathologic malignant long bone fractures. Eighty-four percent of patients with acetabular fractures experience good or excellent relief of pain after joint reconstruction. ... Patients with pathologic fractures from metastatic carcinoma of the breast had a mean survival of 24.6 months after surgical management of their fractures. There was a similarly encouraging improvement in the survival statistics for patients with other primary tumor types. Most malignant pathologic fractures of the pelvis, long bones, or spine are amenable to effective stabilization by the techniques described in this article. These techniques allow resumption of weight-bearing ambulation in all but a few patients, good or excellent relief of pain in the vast majority, and an enhanced anticipation of survival and improvement in quality of life." 
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For more information, search Pubmed for Surgery and Long Bone Metastases
|Surgery of Vertebrae|
SURGICAL INTERVENTION -- VERTEBRAL METASTASES
The spine is the commonest site for skeletal metastases. Sometimes the vertebrae are invaded by direct extension of a nearby tumor in the lung, neck, or abdomen. Sometimes the metastases arrive at the vertebrae by means of blood-borne spread, from the primary, through the lung circulation, to the peripheral circulation. The tumor might possibly also spread to the vertebrae via a "third circulation", the Batson plexus, a network of deep pelvic veins with rich anastomoses [connections] to the vertebral plexus [another network of veins]. [1, 2]
Metastatic tumors destroy vertebrae so that they spontaneously fracture [called a "pathologic" fracture]. If the vertebral pieces move out of alignment, they can cause major damage to the spinal cord, resulting in paralysis of the lower body [paraplegia] or all four limbs [quadriplegia], depending upon where the fracture is. Metastases in the spine can also cause symptoms from tumors growing into the spinal canal and pressing upon the spinal cord. Due to advances in spinal surgery, effective help often can be provided to these patients. The extent and type of surgical intervention, however, must be carefully considered in each individual case. [3, 4]
"The development of back pain in a patient with cancer, associated with an abnormality on a plain spinal radiograph, should serve as a warning for the possible development of spinal cord compression. In this situation more than 60% of patients will have myelographic abnormalities or evidence of epidural disease on magnetic resonance imaging. The key to successful rehabilitation is early diagnosis, high-dose corticosteroids, rapid assessment, and urgent referral for both decompression and spinal stabilization or radiotherapy. Neurological recovery is unlikely if the spinal compression is not relieved within 24-48 h." 
Article in The Oncologist
"Spinal instability is a cause of back pain in approximately 10% of patients with metastatic bone disease. This can cause excruciating pain, which is mechanical in origin. The patient is only comfortable when lying absolutely still and any movement reproduces severe pain. Consequently, the patient may not be able to sit, stand or walk even with the use of a spinal support. Because the pain is due to the instability, radiotherapy or systemic treatment will not relieve the pain. As with a pathological long-bone fracture, stabilization is required for pain relief. This involves major surgery, which may be associated with significant morbidity and mortality. There are several methods of spinal stabilization, but the posterior approach is technically easier and allows stabilization of a longer length of the spine. With careful selection of patients, excellent results can be obtained 
Criteria for impending vertebral collapse have been described as: "50-60% involvement of the vertebral body with no destruction of other structures, or 25-30% involvement with costovertebral joint destruction in the thoracic spine; and 35-40% involvement of vertebral body, or 20-25% involvement with posterior elements destruction in thoracolumbar and lumbar spine. ... With respect to the timing and occurrence of vertebral collapse, there is a distinct discrepancy between the thoracic and thoracolumbar or lumbar spine. When a prophylactic treatment is required, the optimum timing and method of treatment should be selected according to the level and extent of the metastatic vertebral involvement. "
Surgical intervention is the treatment of choice for unstable vertebrae or neurologic deficit, with the excision of the tumorous bone and stabilization of the spine. "Coincident with improved overall cancer palliation during the past 2 decades has been an increasing incidence of clinically apparent bone metastases, and from these metastases subsequent pathologic fractures of the long bones, spine, and pelvis. Current techniques for surgical management of these fractures are extremely effective in alleviating pain and allowing patients to resume an ambulatory status, often without the need of external support. This, in turn, has significantly improved the quality of the remaining months or years of these individuals' lives. In fact, the long term survival of patients after their first long bone pathologic fracture from malignancy has more than tripled for the most common cancers (breast carcinoma, prostate carcinoma, lymphomas, and myelomas) during the past 25 years." 
Generally, surgery is recommended, with tumor excision, and removal of tumorous parts or the entire vertebra. It is recommended that surgery be done BEFORE there is major neurological deficit, as the results are much better. "Surgical indications must be made at the first sign of deficit, regardless of the degree of compression present in the radiologic documentation, in order to avoid the transformation of reversible functional medullary changes into irreversible structural lesions." 
Results of surgical excision of metastatic neoplastic disease and stabilization of the spine seem to be overwhelmingly positive. Surgical intervention does prevent paraplegia, quadriplegia, and other neurologic deficit, as well as managing pain. The surgical techniques are well developed, and hospitalizations are not long, but complications can occur, and hemorrhage is one of them. Techniques vary, and can vary also with site of the tumor.
Excisions dealing with LMS lesions should always be en bloc if it is at all possible. That means that the tumor and its environs are removed in one resected piece, with wide margins. There is no cutting into the tumor, or removing the tumor piecemeal. [21, 30, 80, 111, 139]
"Embolization of vertebral metastases is a safe treatment prior to surgical resection. With appropriate monitoring, complications can be eliminated. The resulting devascularization allows for an aggressive resection of pathologic tissue." As well as decreasing hemorrhagic complications. 
"The spine is the commonest site for skeletal metastases. The majority of patients with spinal metastases can be managed conservatively, at least initially, but a significant number will develop complications, either neurological or mechanical, requiring surgical intervention. This paper emphasizes the need for a spinal surgeon to be involved early in the care of these patients...Post-operatively pain improved in 38 of the 42 patients (90%), the neurological deficit in 20 of the 29 patients with a deficit (69%) and the ambulatory ability in 25 of the 32 patients (78%) with very restricted mobility...: Identification of the cause of a patient's symptoms allows appropriate surgical intervention with favorable results." 
"Most spinal metastases can be managed conservatively. Those requiring surgical intervention present with progressive neurologic compromise, which requires decompression, or spinal instability, which requires stabilization. Constructs for internal stabilization of the spine must not be adversely affected by local postoperative irradiation. ... Eighty-two percent of patients with neurologic compromise secondary to vertebral malignancy improve at least one functional grade after decompression and stabilization, and 88% experience good or excellent relief of spinal pain with restoration of walking ability. Thirty-two percent survived for more than 2 years after spinal decompression and stabilization. Patients with pathologic fractures from metastatic carcinoma of the breast had a mean survival of 24.6 months after surgical management of their fractures. There was a similarly encouraging improvement in the survival statistics for patients with other primary tumor types. Most malignant pathologic fractures of the pelvis, long bones, or spine are amenable to effective stabilization by the techniques described in this article. These techniques allow resumption of weight-bearing ambulation in all but a few patients, good or excellent relief of pain in the vast majority, and an enhanced anticipation of survival and improvement in quality of life "
Twenty-one patients between 39-71 years underwent reconstructive surgery for destructive spinal tumors. Tissue was removed with autogenous bone grafting with or without vertebral prosthesis resulting in early ambulation, relief of pain, and neurological recovery reported in all. There were no complications from surgery. Surgical intervention is recommended where "reasonable longevity" is expected. 
Surgical Complications: In one study "90 patients underwent minimally invasive spinal surgery by thoracoscopic assistance as treatment for their anterior spinal lesions. A total of 30 complications were noted in 22 patients (24.4%). Two fatal complications occurred, resulting from massive blood transfusion in one case and postoperative pneumonia in another. Other nonfatal complications included four cases of transient intercostal neuralgia, three superficial wound infections, three cases of pharyngeal pain, two cases of lung atelectasis, two cases of residual pneumothorax, two cases of subcutaneous emphysema, one inadvertent pericardial penetration due to adhesion, one chylothorax that resolved after conservative management, one vertebral screw malposition, and one graft dislodgement that needed late revision surgery. Three patients required ventilatory support for longer than 72 hours. Five patients with spinal metastases had an estimated intraoperative blood loss of more than 2,000 ml. No injury to the internal organs or spinal cord was observed. There were four conversions to open procedures due to two cases of severe pleural adhesions and two poorly tolerated one-lung ventilation. At the latest follow-up, nine patients had died as a result of cancer dissemination. CONCLUSIONS: (a) Well-selected patients and attention to details are essential to optimizing surgical results. (b) A refined technique for less invasive tumor surgery has been developed. (c) Surgeons had better experience with the standard anterior spinal approach and showed no hesitation in converting to an open procedure when necessary. A procedure failure does not mean a treatment failure." 
Children with vertebral metastases who are treated with chemo, radiation and laminectomy, and who survive longer than 2 months, will probably develop spinal deformity if spinal stabilization is not carried out. [155 ]
Go To References
For more information, Search Pubmed for Surgery and Vertebral Metastases
|Radio Frequency Ablation|
Radiofrequency thermal ablation (RFA) is a new minimally invasive treatment for localized cancer, which can be done percutaneously [through the skin, without opening up a large incision.] "Minimally invasive surgical options require less resources, time, recovery, and cost, and often offer reduced morbidity and mortality, compared with more invasive methods " It is safe, simple, and effective. [8, 1, 2, 6, 7] RFA can ablate inoperable painful metastatic spinal tumors, and relieve pain, relieve or prevent neurologic deficit, and ablate the tumor so there is no further tumor growth. 
"Image-guided, local cancer treatment relies on the assumption that local disease control may improve survival. Recent developments in ablative techniques are being applied to patients with inoperable, small, or solitary liver tumors, recurrent ... renal cell carcinoma, and neoplasms in the bone, lung, breast, and adrenal gland. ... Recent refinements in ablation technology enable large tumor volumes to be treated with image-guided needle placement, either percutaneously, laparoscopically, or with open surgery. Local disease control potentially could result in improved survival, or enhanced operability." 
Consensus indications for use of RFA in oncology are currently ill-defined, despite widespread use of the technique. "More rigorous scientific review, long-term follow-up, and randomized prospective trials are needed to help define the role of RFA in oncology." 
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Search Pubmed for Radio Frequency Ablation on Bone
1: Radiology 1992 Apr;183(1):29-33 Ablation of osteoid osteomas with a percutaneously placed electrode: a new procedure. Rosenthal DI, Alexander A, Rosenberg AE, Springfield D.
Fetch PMID: 1549690
2: J Bone Joint Surg Br 2001 Apr;83(3):391-6 Percutaneous radiofrequency ablation in osteoid osteoma. Lindner NJ, Ozaki T, Roedl R, Gosheger G, Winkelmann W, Wortler K.
Fetch PMID: 11341426
3: Radiol Med (Torino) 2001 Nov-Dec;102(5-6):329-34 [Percutaneous radio-frequency ablation of osteoid osteoma: technique and preliminary results] [Article in Italian] Gallazzi MB, Arborio G, Garbagna PG, Perrucchini G, Daolio PA.
Fetch PMID: 11779979
4: Radiology 2001 Nov;221(2):463-8 Primary treatment of chondroblastoma with percutaneous radio-frequency heat ablation: report of three cases.Erickson JK, Rosenthal DI, Zaleske DJ, Gebhardt MC, Cates JM.
Fetch PMID: 11687691
5: J Bone Joint Surg Am 1998 Jun;80(6):815-21 Percutaneous radiofrequency coagulation of osteoid osteoma compared with operative treatment. Rosenthal DI, Hornicek FJ, Wolfe MW, Jennings LC, Gebhardt MC, Mankin HJ.
Fetch PMID: 9655099
6: Eur Spine J 1998;7(5):422-5 High-frequency radio-wave ablation of osteoid osteoma in the lumbar spine. Osti OL, Sebben R.
Fetch PMID: 9840478
7: Radiology 1995 Nov;197(2):451-4 Osteoid osteoma: percutaneous radio-frequency ablation. Rosenthal DI, Springfield DS, Gebhardt MC, Rosenberg AE, Mankin HJ.
Fetch PMID: 7480692
8. Cancer 2002 Jan 15;94(2):443-51 Percutaneous tumor ablation with radiofrequency. Wood BJ, Ramkaransingh JR, Fojo T, Walther MM, Libutti SK.
Diagnostic Radiology Department, Special Procedures Division, National Institutes of Health Clinical Center, Bethesda, Maryland 20892, USA. firstname.lastname@example.org
Fetch PMID: 11900230
9. Dietrich H.W. Gronemeyer,M.D. et.al The Cancer Journal Vol.8, No.1, Institute of MicroTherapy and the Department of Radiology and Microtherapy, University of Witten/Herdecke, Germany. EFMT Development and Research Center for Microtherapy in Bochum, Germany.
"The technological advances which have caused renewed interest in cryosurgery are the development of intraoperative ultrasound to monitor the therapeutic process and the development of new cryosurgical equipment designed to use supercooled liquid nitrogen. The thin, highly efficient probes, available in several sizes, can be placed in diseased sites via endoscopy or percutaneously in minimally invasive procedures. The manner of use is to place the probe in the desired location in the diseased tissue with ultrasound guidance. If required by the size or location of the tumor, as many as five probes can be inserted and cooled to -195 degrees C simultaneously. The process of freezing is monitored by ultrasound which displays a hypoechoic (dark) image when the tissue if frozen. Rapid freezing, slow thawing, and repetition of the freeze/thaw cycle are standard features of technique." 
"The cases selected for cryosurgery are generally those for which no conventional treatment is possible. ... Diverse tumors [in sites] such as the brain, bronchus, bone, pancreas, kidney, and uterus, have ... been treated in small numbers by cryosurgery. Judging from this experience, further expansion in the use of cryosurgical techniques seems certain." 
1. Cryobiology 1997 Jun;34(4):373-84
Minimally invasive cryosurgery--technological advances.
Baust J, Gage AA, Ma H, Zhang CM.
Center for Cryobiological Research State University of New York, Binghamton 13902, USA.
Fetch PMID: 9200822
For more information:
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Search Pubmed for Cryoablation and Bone Metastases
compiled/written by doctordee
with thanks to Lynette and Laura
updated December 2003
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