Musculoskeletal Interventional Oncology: A Contemporary Review.

Musculoskeletal interventional oncology is an emerging field that addresses the limitations of conventional therapies for bone and soft-tissue tumors. The field's growth has been driven by evolving treatment paradigms, expanding society guidelines, mounting supportive literature, technologic advances, and cross-specialty collaboration with medical, surgical, and radiation oncology. Safe, effective, and durable pain palliation, local control, and stabilization of musculoskeletal tumors are increasingly achieved through an expanding array of contemporary minimally invasive percutaneous image-guided treatments, including ablation, osteoplasty, vertebral augmentation (with or without mechanical reinforcement via implants), osseous consolidation via percutaneous screw fixation (with or without osteoplasty), tumor embolization, and neurolysis. These interventions may be used for curative or palliative indications and can be readily combined with systemic therapies. Therapeutic approaches include the combination of different interventional oncology techniques as well as the sequential application of such techniques with other local treatments, including surgery or radiation. This article reviews the current practice of interventional oncology treatments for the management of patients with bone and soft-tissue tumors with a focus on emerging technologies and techniques.

Cone-Beam CT With Enhanced Needle Guidance and Augmented Fluoroscopy Overlay: Applications in Interventional Radiology.

Digital flat-panel detector cone-beam CT (CBCT), introduced in the early 2000s, was historically used in interventional radiology primarily for liver-directed therapies. However, contemporary advanced imaging applications, including enhanced needle guidance and augmented fluoroscopy overlay, have evolved substantially over the prior decade and now work synergistically with CBCT guidance to overcome limitations encountered with other imaging modalities. CBCT with advanced imaging applications has become increasingly used to facilitate a broad range of minimally invasive procedures, particularly relating to pain and musculoskeletal interventions. Potential advantages of CBCT with advanced imaging applications include greater accuracy for complex needle paths, improved targeting in the presence of metal artifact, enhanced visualization during injection of contrast medium or cement, increased ease when space in the gantry is limited, and reduced radiation doses versus conventional CT guidance. Nonetheless, CBCT guidance remains underutilized, partly relating to lack of familiarity with the technique. This article describes the practical implementation of CBCT with enhanced needle guidance and augmented fluoroscopy overlay and depicts the technique's application for an array of interventional radiology procedures, including epidural steroid injections, celiac plexus block and neurolysis, pudendal block, spine ablation, percutaneous osseous ablation fixation and osteoplasty, biliary recanalization, and transcaval type II endoleak repair.

Image guidance in osteoplasty and fixation.

Oncology patients, particularly those with breast, colorectal, prostate, renal and pancreatic cancers, are living longer due to advances in detection, and treatment. Unfortunately, this has come with a commensurate increase in the prevalence of osseous metastases and skeletal related events approaching 100,000 new patients each year. Patients are now experiencing serious morbidity and mortality due to pathologic fractures, altered structural mechanics, and cancer related bone pain. This patient population poses challenges for conventional open surgical and/or medical management often due to disease extent, location, and, in general, poor surgical candidacy. Percutaneous techniques may also be challenging under image guidance due to limited ability to use traditional orthopedic corridors, loss of cortical landmarks with destructive lesions, and need for live image guidance. Modern angiography suites with cone beam computed tomography (CBCT) and advanced imaging applications including needle guidance, 3D fusion, tumor segmentation, and angio-CT have facilitated the development of novel minimally invasive techniques for pain palliation and stabilization. The interventional radiologist is uniquely positioned to harness these advanced imaging applications and offer effective, safe, minimally invasive treatment options to patients with neoplastic disease within the axial, and appendicular skeletons. The focus of this article is to address the technical aspects of patient preparation, positioning, advanced imaging system capabilities, guidance strategies, and pitfalls during osteoplasty and fixation procedures.

Vertebroplasty, Kyphoplasty, and Implant-Based Mechanical Vertebral Augmentation.

Vertebral compression fractures are a global public health issue with a quantifiable negative impact on patient morbidity and mortality. The contemporary approach to the treatment of osteoporotic fragility fractures has moved beyond first-line nonsurgical management. An improved understanding of biomechanical forces, consequential morbidity and mortality, and the drive to reduce opioid use has resulted in multidisciplinary treatment algorithms and significant advances in augmentation techniques. This review will inform musculoskeletal radiologists, interventionalists, and minimally invasive spine surgeons on the proper work-up of patients, imaging features differentiating benign and malignant pathologic fractures, high-risk fracture morphologies, and new mechanical augmentation device options, and it describes the appropriate selection of devices, complications, outcomes, and future trends.

Advanced Interventional Pain Management Approach to Neoplastic Disease Outside the Spine.

Neoplastic disease of the musculoskeletal system may result in serious morbidity and mortality secondary to cancer related bone pain, pathologic fracture, altered structural mechanics, and involvement of adjacent structures.1 Recent advances in cancer detection and treatment have allowed more patients to live longer. The prevalence of osseous metastatic disease has increased to 100,000 new patients developing bone metastases each year.2 These patients are seeing long-term exposure to chemotherapy and radiation leading to increased skeletal events, morbidity, and a negative impact on quality of life. Bone metastases in conjunction with poor bone quality often prevent surgical therapy. Utilization of thermal ablation in this patient population is supported by contemporary literature and offers a minimally invasive approach to pain palliation, local tumor control, and decreased morbidity with unique advantages compared to surgery or radiation.3 In addition to spine disease, interventional radiologists are able to meaningfully impact pelvic, shoulder girdle, and long bone metastases. Adding to ablation we have in our repertoire the ability to provide structural support utilizing cement and/or screw fixation as an adjunct for both pain palliation and mechanical stabilization.4-6 These novel therapies have allowed more patients with metastatic disease to be treated. The focus of this chapter is to highlight importance of patient selection, ablative modality selection, integration of cementoplasty (also described as osteoplasty) and osseous fixation, and procedural techniques/strategy in the pelvis and other common sites of bone metastases outside the spine.