Combined Ablation and Radiation Therapy of Spinal Metastases: A Novel Multimodality Treatment Approach.

BACKGROUND: Radiation therapy (RT) is the current gold standard for palliation of painful vertebral metastases. However, other percutaneous modalities such as radiofrequency ablation (RFA), cryoablation, and vertebral augmentation have also been shown to be effective in alleviating symptoms. Combined RT and ablation may be more effective than either therapy alone in palliating painful metastatic disease to the spine. OBJECTIVE: To evaluate the safety and efficacy of combined ablation, either RFA or cryoablation, and RT in the treatment of spinal metastases. STUDY DESIGN: Retrospective study. SETTING: This is a retrospective study at a single institution. METHODS: Medical records of all patients who underwent ablation of spine lesions at a single institution between March 2012 and June 2014 were reviewed; patients treated with both RT and either RFA or cryoablation concurrently were identified. Pain scores before and after RFA were measured with the numerical rating scale (NRS) (0-10 point scale) and compared. Procedural complications, changes in general activity level, and pain medication usage after ablation were also recorded. When available, follow-up imaging was evaluated for evidence of residual or recurrent disease. RESULTS: Twenty-one patients with 36 spine metastases were treated with RT and percutaneous ablation concurrently; either RFA (21/22) or cryoablation (1/22). One patient received 2 separate RFA treatments. Overall, mean worst pain score (8.0, SD = 2.3) significantly decreased at both one week (4.3, SD = 3.1; P < .02) and 4 weeks (2.9, SD = 3.3; P < .0003). Temporary post-procedural radicular pain occurred after one RFA treatment (4.5%; 1/22). Seven patients had radiation resistant tumors (renal cell, melanoma, or sarcoma). Post-procedural imaging (median 6 months; range 2-27 months) showed stable treated disease in 12/13 treatments at 3 months and 10/10 at 6 months. LIMITATIONS: The therapeutic effect of vertebral augmentation versus percutaneous ablation cannot be separated in this retrospective study. Radiation treatment protocols were variable and included both stereotactic body and conventional RT which may have different safety and efficacy profiles. CONCLUSION: Percutaneous ablation and concurrent RT is safe and effective in palliating painful spinal metastases and can be effective in those who have radiation resistant tumor histology.

CT Dose Optimization in Pediatric Radiology: A Multiyear Effort to Preserve the Benefits of Imaging While Reducing the Risks.

The marked increase in radiation exposure from medical imaging, especially in children, has caused considerable alarm and spurred efforts to preserve the benefits but reduce the risks of imaging. Applying the principles of the Image Gently campaign, data-driven process and quality improvement techniques such as process mapping and flowcharting, cause-and-effect diagrams, Pareto analysis, statistical process control (control charts), failure mode and effects analysis, "lean" or Six Sigma methodology, and closed feedback loops led to a multiyear program that has reduced overall computed tomographic (CT) examination volume by more than fourfold and concurrently decreased radiation exposure per CT study without compromising diagnostic utility. This systematic approach involving education, streamlining access to magnetic resonance imaging and ultrasonography, auditing with comparison with benchmarks, applying modern CT technology, and revising CT protocols has led to a more than twofold reduction in CT radiation exposure between 2005 and 2012 for patients at the authors' institution while maintaining diagnostic utility.

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.

Radiofrequency ablation and vertebral augmentation for palliation of painful spinal metastases.

Radiofrequency ablation (RFA) and vertebral augmentation is an emerging combination therapy for painful osseous metastases that cannot be or are incompletely palliated with radiation therapy. Herein, we report our experience performing RFA and vertebral augmentation of spinal metastases for pain palliation. Institutional review board approval was obtained to retrospectively review our tumor ablation database for all patients who underwent RFA of osseous metastases between April 2012 and July 2014. Patient demographics, lesion characteristics, concurrent palliative therapies, and complications were recorded. Pre- and post-procedure mean worst pain scores 1 and 4 weeks after treatment were measured using the Numeric Rating Scale (10-point scale) and compared. During the study period, 72 RFA treatments of 110 spinal metastases were performed. Eighty one percent (89/110) of metastases involved the posterior vertebral body and 45 % (49/110) involved the pedicles. Vertebral augmentation was performed after 95 % (105/110) of ablations. Mean and median pre-procedure pain scores were 8.0 ± 1.9 and 8.0, respectively. Patients reported clinically significant decreased pain scores at both 1-week (mean, 3.9 ± 3.0; median, 3.25; P < 0.0001) and 4-week (mean, 2.9 ± 3.0; median, 2.75; P < 0.0001) follow-up. No major complications occurred related to RFA and there were no instances of symptomatic cement extravasation. Combination RFA and vertebral augmentation is a safe and effective therapy for palliation of painful spinal metastases, including tumor involving the posterior vertebral body and/or pedicles.