Saline-Infused Bipolar Radiofrequency Ablation of High-Risk Spinal and Paraspinal Neoplasms
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1 Radiofreque ncy blation of Spinal Neoplasms Radiofrequency blation Technical Innovation M E D E N T U R I L I M G I N G JR 2006; 186:S322 S X/06/1865 S322 merican Roentgen Ray Society Y O Xavier uy 1 ntonio asile 1,2 Guillame ierry 1 Juan upelli 1 fshin Gangi 1 F uy X, asile, ierry G, upelli J, Gangi Keywords: oncology, radiofrequency ablation, spine, vertebroplasty DOI: /JR Received February 16, 2005; accepted after revision May 9, Department of Radiology, University Hospital of Strasbourg, Strasbourg, France. 2 Department of Radiology, Ospedale Ferrarotto, via itelli, atania 94125, Italy. ddress correspondence to. asile. Saline-Infused ipolar Radiofrequency blation of High-Risk Spinal and Paraspinal Neoplasms OJETIVE. We present three cases of symptomatic high-risk metastases involving the vertebral body treated using infused bipolar radiofrequency ablation either alone or in combination with vertebroplasty. ONLUSION. In our experience, the bipolar technique can reduce the risk of spinal cord damage in radiofrequency ablation of lesions within 1 cm of neural structures and involving paravertebral soft tissue. adiofrequency ablation, either R alone or in combination with cementoplasty, has been shown to be effective in the treatment of refractory pain from spinal neoplasms [1, 2]. In many series, because of the hyperthermic cytotoxicity risk of spinal cord injury, lesions within 1 cm of the spinal cord represent an exclusion criterion [1, 3, 4]. Furthermore, in many cases large lesions involve the cortex and soft tissue surrounding vertebral bone. In these cases, satisfactory ablation of the whole lesion requires that the radiofrequency needle be repositioned several times to obtain an overlap. Normal saline (0.9%) infusion has been shown to be effective in enlarging the area of necrosis during radiofrequency ablation, acting as a liquid electrode with conductivity 3 5 times greater than that of blood and times greater than that of soft tissues; furthermore, electrical conductivity is increased even more using a highly concentrated Nal solution (6 36%) [5, 6]. Use of a hypertonic saline infusion in combination with bipolar technique has been attempted in animal liver and resulted in faster and more extensive ablation and less heat loss than did monopolar technique. ipolar technique was first reported in 2003 in explanted and in vivo livers [7 9]. It uses one electrode thermally shielded by the opposing second electrode, which also actively heats nearby tissue. Thus, the heat is trapped between the two electrodes, obviating diversion of current from the ablation site in any direction [8, 10, 11]. The aim of this article is to present three cases of potentially high-risk lesions of the spine (< 1 cm from the spinal cord, with cortical or pedicle invasion) treated with saline-infused bipolar radiofrequency ablation with or without vertebroplasty. ase Report ase 1 49-year-old man with renal cell carcinoma of the left kidney was referred for palliative treatment of a refractory painful metastasis in L3. T showed the lesion to be in the right half of the vertebral body, involving either the posterior wall or the ipsilateral pedicle (Fig. 1). Invasion of soft tissue around the vertebral body was also noted. The lesion contacted the spinal cord and dural sac without interposition of the cortex. Once the patient had given informed consent, we treated the lesion with bipolar technique through a posterior approach while the patient was prone. Two open, perfused 18-gauge radiofrequency needles (erchtold, Medizinelektronik) were inserted (Fig. 1). The more medial needle was less than 1 cm from the spinal cord. While energy was delivered, hypertonic saline (5.85%) was infused at a rate of 70 ml/hr through the delivery needle, in accord with our standard protocol. The delivery needle was the more peripheral needle from the spinal cord, thus obviating delivery of current to the spine. The radiofrequency power was set at 60 W, and the lesion was treated for 10 min, in accord with our standard protocol and suggestions in the literature (Fig. 1) [8, 11]. On the basis of the rief Pain Inventory (PI, short form), the patient s symptoms were determined to have improved within 24 hr after the procedure (from 7 degrees before S322 JR:186, May 2006
2 Radiofrequency blation of Spinal Neoplasms the procedure to 2 degrees after the procedure). The patient did not experience radiating pain during the procedure and was neurologically intact when examined after the procedure. ase 2 65-year-old man who previously underwent surgery for prostatic cancer was referred with paresthesia for palliative treatment of a refractory painful metastasis in T10. Previous T had shown extensive involvement of both the vertebral body and the pedicles, with a right paravertebral mass involving the posterior arc of the ipsilateral rib (Fig. 2). Signs of medullary compression were observed at the MRI examination. Once the patient had given informed consent, we treated the lesion with bipolar technique through a posterior approach while the patient was prone. Two open, perfused 18-gauge radiofrequency needles (erchtold) were inserted into the paravertebral mass (Fig. 2). The more medial needle was less that 1.5 cm from the spinal cord. The delivery needle was the more peripheral needle from the spinal cord, thus obviating delivery of current to the spine. While energy was delivered, hypertonic saline (5.85%) was infused at a rate of 70 ml/hr through the delivery needle. The radiofrequency power was set at 60 W, and the lesion was treated for 10 min, in accord with our standard protocol. Subsequently a 10- gauge vertebroplasty needle was inserted into the vertebral body (Fig. 2). Through this needle, an infused 18-gauge radiofrequency needle was coaxially positioned to reach the middle of the vertebral body and was connected to Fig year-old man with renal cell carcinoma of left kidney who was referred for palliative treatment of refractory painful metastasis in L3. and, xial T scans show soft-tissue mass involving vertebral body, posterior wall, and ipsilateral pedicle () and same mass with two infused 18-gauge radiofrequency needles inserted ()., Posttreatment T control scan shows air bubbles within treated lesion, a sign of necrosis. the generator for another 10 min. Once the radiofrequency probe had been retrieved, a normal vertebroplasty was performed through the 10-gauge needle left in place. On the basis of the PI (short form), the patient s symptoms were determined to have improved within 24 hr after the procedure (from 8 degrees before the procedure to 2 degrees after the procedure). The neurologic examination immediately after the procedure had findings identical to those of the previous examination. ase 3 52-year-old man with a history of prostatic carcinoma previously treated by surgery was referred for palliative treatment of a refractory painful metastasis in T10. T showed the lesion to be in the left paravertebral space, with JR:186, May 2006 S323
3 Fig year-old man who previously underwent surgery for prostatic cancer and was referred with paresthesia for palliative treatment of refractory painful metastasis in T10., T scan shows extensive involvement of either vertebral body or pedicles, with right paravertebral mass involving posterior arc of ipsilateral rib., T scan shows two infused 18-gauge radiofrequency needles that were inserted into paravertebral mass under T and fluoroscopic guidance., T scan shows 10-gauge vertebroplasty needle that was placed into vertebral body between contralateral rib and pedicle under T and fluoroscopic guidance, and 18- gauge radiofrequency needle that was inserted through the 10-gauge needle (arrow). D, T and fluoroscopic control image after radiofrequency plus vertebroplasty shows oval paraspinal necrotic area, with cement in vertebral body. involvement of the left pedicle and the posterior arc of the ipsilateral rib (Fig. 3). The lesion was laterally contacting the spinal cord and dural sac, without interposition of the cortex or signs of compression. Once the patient had given informed consent, we treated the lesion with bipolar technique through a posterior approach while the patient was prone (Fig. 3). Two open, perfused 18-gauge radiofrequency needles (erchtold) were inserted. While energy was delivered, hypertonic saline (5.85%) was infused at a rate of 70 ml/hr through the delivery needle. The delivery needle was the more peripheral needle from the spinal cord, thus obviating delivery of current to the spine. The radiofrequency power was set at 60 W, and the lesion was treated for 10 min, in accord with our standard protocol (Figs. 3 and 3D). On the basis of the PI (short form), the patient s symptoms were determined to have improved within 24 hr after the procedure (from 8 degrees before the procedure to 3 degrees after the procedure). The patient did not experience radiating pain during the procedure and was neurologically intact when examined after the procedure. Discussion Saline infusion and bipolar technique represent two methods to increase the dimensions of radiofrequency-induced coagulation necrosis. The Nal injection increases energy conductivity, limiting tissue carbonization around the electrodes and thus reducing tissue impedance [11]. Furthermore, the use of a hypertonic saline infusion (5.85%) reduces the injected volume of about 40% (70 ml/hr), preventing the consequences of an unpredictable diffusion of hot saline (i.e., too great a decrease in impedance, lack of heating, need D S324 JR:186, May 2006
4 Radiofrequency blation of Spinal Neoplasms Fig year-old man with history of prostatic carcinoma previously treated by surgery who was referred for palliative treatment of refractory painful metastasis in T10., T scan shows left paraspinal soft-tissue lesion, with involvement of ipsilateral pedicle and posterior arc of ipsilateral rib., T scan shows two infused 18-gauge radiofrequency needles that were inserted through posterior approach with patient prone., Posttreatment T control scan shows air bubbles within treated lesion, a sign of necrosis. D, MR follow-up image shows round-shaped hypointense area corresponding to ablated tissue. for high power). Instillation of large amounts (600 ml/hr) of isotonic saline during hepatic radiofrequency ablation has been reported to produce unpredictable burns to distal organ such as stomach and small bowel, likely related to the diffusion of hot saline [7]. Use of a highly concentrated Nal solution (6 36%) [5] as a liquid electrode more effectively enlarges the area of necrosis during radiofrequency ablation, with conductivity greater than in blood and soft tissues. Radiofrequency ablation techniques using dual electrodes consist of the introduction of two probe needles applied in sequential, simultaneous, alternating, and bipolar modes [8]. In the last of these modes, energy is applied to one electrode and the other is used as the return electrode. In experimental studies, bipolar technique has been found to produce heat more efficiently at a given current [8], likely because the flow of current is concentrated between the electrodes [11]. Thus, the potential exists for a more concentrated flow of current between the two electrodes and a better-defined area of radiofrequency-induced coagulation necrosis, reducing heat loss and potential damage to adjacent structures. These well-defined oval lesions that result from bipolar radiofrequency ablation are in contrast to the two cylindric areas of tissue necrosis that result from the use of two electrodes in monopolar mode. There are few reports in the literature describing spinal neoplasms treated only with radiofrequency ablation; some other cases are found in large series of bone lesions treated in this way [5, 12]. mong these articles, 80 95% of patients undergoing radiofrequency ablation of bone metastases experienced a clinically significant decrease in pain, with the complication rate ranging from 0% to 6.9% [2, 12]. Other studies have advocated that radiofrequency ab- D JR:186, May 2006 S325
5 lation and vertebroplasty be combined for the management of bone metastases [13] due to the combination of the antitumoral effect of heat and the mechanical stabilization of the vertebral body by the cement injection. mong these studies, the largest series of spinal metastases treated with radiofrequency ablation was 17 cases [2]. In that article, Nakatsuka et al. [2] reported a high technical and clinical success rate of up to 100%, with 24% of patients with spinal metastases experiencing neurologic complications. This high complication rate was likely due to the fact that only three of 17 lesions were separated from the posterior cortex and pedicles by 3 mm or more [2]. In most series on either radiofrequency ablation or radiofrequency plus cementoplasty, lesions within 1 cm of the spinal cord were considered ineligible for treatment. Surely this exclusion criterion reduces the complication rate; however, it also reduces the use of radiofrequency ablation in the palliative treatment of patients with refractory pain that is due to spinal metastases. allstrom et al. [12] and Goetz et al. [4] reported that, respectively, three of 19 and eight of 94 patients could not be treated because their lesions were too close to the spinal cord or vital structures. With the technique that we are reporting, we noted no major complications related to hyperthermia toxicity of the spinal cord, even in cases with involvement of the posterior wall and of soft tissue around the vertebral body with destruction of the cortex. This lack of complications is probably due to the fact that, as previously described, the flow of current is limited to the region between the electrodes; thus, the electrode locations almost represent the limits of the heated tissue. Of course, we used this approach in patients in end-stage disease, to whom no other options could be offered to increase their quality of life. In conclusion, although larger series are needed to confirm our data, our findings suggest that bipolar technique, either alone or in combination with cementoplasty, reduces the risk of spinal cord damage in high-risk spinal or paraspinal lesions, increasing the safety of the procedure and the number of patients eligible to receive such palliative treatment. References 1. Gronemeyer DH, Schirp S, Gevargez. Imageguided radiofrequency ablation of spinal tumors: preliminary experience with an expandable array electrode. ancer J 2002; 8: Nakatsuka, Yamakado K, Maeda M, et al. Radiofrequency ablation combined with bone cement injection for the treatment of bone malignancies. J Vasc Interv Radiol 2004; 15: Yamada T, Tateishi, ho S, et al. The effects of hyperthermia on the spinal cord. Spine 1992; 17: Goetz MP, allstrom MR, harboneau JW, et al. Percutaneous image-guided radiofrequency ablation of painful metastases involving bone: a multicenter study. J lin Oncol 2004; 22: Miao Y, Ni Y, Yu, J, et al. n ex vivo study on radiofrequency tissue ablation: increased lesion size by using an expandable-wet electrode. Eur Radiol 2001; 11: Goldberg SN, hmed M, Gazelle GS, et al. Radiofrequency thermal ablation with Nal solution injection: effect of electrical conductivity on tissue heating, and coagulation phantom and porcine liver study. Radiology 2001; 219: urdio F, Guemes, urdio JM, et al. Large hepatic ablation with bipolar saline-enhanced radiofrequency: an experimental study in in vivo porcine liver with a novel approach. J Surg Res 2003; 110: Lee JM, Han JK, Kim SH, et al. comparative experimental study of the in-vitro efficiency of hypertonic saline-enhanced hepatic bipolar and monopolar radiofrequency ablation. Korean J Radiol 2003; 4: Gangi, Guth S, Imbert J. Interest of radiofrequency liver tissue ablation with a bipolar-wet electrode. Eur Radiol 2003; 133:477 (abstract) 10. Goldberg SN, Gazelle GS, Dawson SL, et al. Radiofrequency tissue ablation using multiple arrays: greater tissue destruction than multiple probes operating alone. cad Radiol 1995; 2: Lee Jr FT, Haemmerich D, Wright S, et al. Multiple probe radiofrequency ablation: pilot study in an animal model. J Vasc Interv Radiol 2003; 14: allstrom MR, harboneau JW, Goetz MP, et al. Painful metastases involving bone: feasibility of percutaneous T- and US-guided radio-frequency ablation. Radiology 2002; 224: Schaefer O, Lohrmann, Markmiller M, et al. ombined treatment of a spinal metastasis with radiofrequency heat ablation and vertebroplasty. JR 2003; 180: S326 JR:186, May 2006
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