Nonsurgical Treatments for Metastatic Cancer in Bones - SIR http://www.sirweb.

org/patients/bone-cancer/

Nonsurgical Treatments for Metastatic Cancer in Bones

Interventional Radiologists Help Reduce Pain and Improve Quality of Life

Bones are the third most common location where cancer cells spread and metastasize. Each year, about
100,000 cases of bone metastasis are reported in the United States. Bone metastases occur when cancer
cells gain access to the blood stream, reach the bone marrow, begin to multiply and then grow new blood
vessels to obtain oxygen and food--which in turn causes the cancer cells to grow more and spread.

Some bone metastases become painful because the tumor eats away at the bone, creating holes that make
the bone thin and weak. As the bones are replaced with tumor, nerve endings in and around the bone send pain
signals to the brain. If left untreated, bone metastases can eventually cause the bone to fracture--seriously
affecting a patient's quality of life. This is particularly true for long bones of the extremities where a fracture
may render a limb nonfunctional. These patients may require surgical intervention to restore the function of their
limbs. More commonly, metastases involve the ribs, pelvis, and spine.

For the most part, the goal of treating bone tumors is not curative, but rather palliative by reducing pain,
preventing additional bone destruction, and improving function.

In treating cancer patients with painful bone metastases, interventional radiologists may use one of the two
different thermal ablation techniques--radiofrequency ablation and cryoablation. This form of therapy is aimed at
desensitizing the bone by killing the nerve endings in the vicinity of the metastasis. They can also treat painful
vertebral metastases or fractures with vertebroplasty.

Prevalence

Bone is the third most common site of metastatic cancer.

About 100,000 cases of bone metastasis are reported each year in the United States. Of those
reported, 75 percent are caused by tumors in the breast, prostate, lung and kidney.

Symptoms

Bone pain affects 70 percent of patients with bone metastases

Bone fracture
Spinal cord compression

Bone Cancer Diagnosis

There are a number of tests that can help in the diagnosis of cancer, including blood tests, physical examination
and a variety of imaging techniques including X-rays (e.g., chest X-rays and mammograms); computed
tomography (CT); magnetic resonance (MR) and ultrasound. Usually, however, the final diagnosis cannot be
made until a biopsy is performed. In a biopsy, a sample of tissue from the tumor or other abnormality is
obtained and examined by a pathologist. By examining the biopsy sample, pathologists and other experts also
can determine what kind of cancer is present and whether it is likely to be fast or slow growing. This
information is important in deciding the best type of treatment. Open surgery is sometimes performed to obtain
a tissue sample for biopsy. But in most cases, tissue samples can be obtained without open surgery with
interventional radiology techniques.

Needle biopsy

Needle biopsy, also called image-guided biopsy, is usually performed using a moving X-ray technique
(fluoroscopy) computed tomography (CT), ultrasound or magnetic resonance (MR) to guide the procedure. In
many cases, needle biopsies are performed with the aid of equipment that creates a computer-generated
image and allows radiologists to see an area inside the body from various angles. This "stereotactic" equipment
helps them pinpoint the exact location of the abnormal tissue.

Needle biopsy is typically an outpatient procedure with very infrequent complications; less than 1 percent of
patients develop bleeding or infection. In about 90 percent of patients, needle biopsy provides enough tissue for
the pathologist to determine the cause of the abnormality.

Advantages of needle biopsy include:

With image guidance, the abnormality can be biopsied while important nearby structures such as blood
vessels and vital organs can be seen and avoided.
The patient is spared the pain, scarring and complications associated with open surgery.
Recovery times are usually shorter and patients can more quickly resume normal activities.

1 trong 5 12/3/2010 12:56 AM

Nonsurgical Treatments for Metastatic Cancer in Bones - SIR http://www.sirweb.org/patients/bone-cancer/

An X-ray of a needle inserted into the lung to obtain a sample for biopsy.

Large core needle biopsy. In this technique, a special needle is used that enables the radiologist to obtain a
larger biopsy sample. This technique is often used to obtain tissue samples from lumps or other abnormalities
in the breast that are detected by physical examination or on mammograms or other imaging scans. Because
approximately 80 percent of all breast abnormalities turn out not to be cancer, this technique is often preferred
by women and their physicians because it:

is less painful and requires less recovery time than open surgical biopsy, and
avoids the scarring and disfigurement that may result from open surgery.

A similar technique called fine needle aspiration can be used to withdraw cells from a suspected cancer. It
also can diagnose fluids that have collected in the body. Sometimes, these fluid collections also may be drained
through a catheter, such as when pockets of infection are diagnosed.

Many interventional radiology procedures for the diagnosis and treatment of cancer can be performed on an
outpatient basis or during a short hospital stay. In many cases, the procedures:

offer new minimally invasive cancer treatment options

are less painful and debilitating for patients
result in quicker recoveries
have fewer side effects and complications.

Bone Cancer Treatments

As vascular experts, interventional radiologists are uniquely skilled in using the vascular system to deliver
targeted treatments via catheter throughout the body. In treating cancer patients, interventional radiologists can
attack the cancer tumor from inside the body without medicating or affecting other parts of the body.

Thermal Ablation Treatments

Radiofrequency Ablation

Radiofrequency ablation (RFA) offers a nonsurgical, localized treatment that kills the target tissue with heat,
while sparing the healthy tissue. Because of the localized nature of this treatment, RFA does not have any
systemic side effects. Radiofrequency ablation can be performed without affecting the patient's overall health
and most people can resume their usual activities in a few days.

In this procedure, the interventional radiologist uses imaging to guide a small needle through the skin into the
tumor. From the tip of the needle, radiofrequency energy is transmitted into the target tissue, where it produces
heat and kills the tumor. Although the dead tumor tissue shrinks, the bone that is already eaten away will not
grow back.

Click on images to enlarge

Efficacy

Preliminary studies have demonstrated that RFA significantly reduced bone pain from metastatic disease in
over 90 percent of patients who had failed or were not suitable candidates for conventional therapy. In these
studies, there were only few patients who suffered any side effects or complications. Therefore, RFA was
demonstrated to be safe and effective in selected patients. A multicenter clinical trial is underway to further
investigate the role of RFA in management of painful bone metastases. A direct comparison of RFA and
radiation therapy may be warranted in the future.

2 trong 5 12/3/2010 12:56 AM

Nonsurgical Treatments for Metastatic Cancer in Bones - SIR http://www.sirweb.org/patients/bone-cancer/

BEFORE AFTER

A LIVER TUMOR TREATED WITH RFA

Dead tissue appears larger and darker than the living tumor. Over time, the tumor shrinks as the
body absorbs and excretes dead cells

Benefits

May be performed under conscious sedation or general anesthesia

Is well tolerated. Most patients can resume their normal routines the next day and may feel tired only for
a few days.
Can be repeated if necessary
May be combined with other treatment options
Can relieve pain and suffering for many cancer patients

Interventional radiologists use special X-ray equipment to guide therapy directly to

the site of tumors

Cryoablation

Cryoablation is similar to RFA in that the energy is delivered directly into the tumor by a probe that is inserted
through the skin. But rather than killing the tumor with heat, cryoablation uses an extremely cold gas to freeze
it. This technique has been used for many years by surgeons in the operating room, but in the last few years,
the needles have become small enough to be used by interventional radiologists through a small nick in the skin,
without the need for an operation. The "ice ball" that is created around the needle grows in size and destroys
the frozen tumor cells.

Vertebroplasty

The spine is one of the most common sites of metastasis. Vertebral bodies involved by the tumor may become
painful and may eventually fracture. Surgical intervention with reconstruction of the spinal column is indicated
only if the tumor causes compression of the spinal cord or instability of the spine. Vertebroplasty is an
outpatient procedure performed using conscious sedation. An interventional radiologist inserts a needle through
a small incision in the back, directing it under fluoroscopy (continuous, moving X-ray imaging) into the fractured
vertebra. The physician then injects a medical-grade bone cement into the vertebra. The cement hardens within
about 15 minutes and stabilizes the fracture. This treatment reduces pain, prevents further collapse of the
vertebra, and restores mobility. Vertebroplasty dramatically improves back pain within hours of the procedure,
provides long-term pain relief and has a low complication rate, as demonstrated in multiple studies.

Bone cement is injected to stabilize collapsed bones in the spine and relieve pain.

3 trong 5 12/3/2010 12:56 AM

Nonsurgical Treatments for Metastatic Cancer in Bones - SIR http://www.sirweb.org/patients/bone-cancer/

New Cancer Treatments on the Horizon

Interventional radiology is playing a role in developing new techniques that may improve cancer treatment in the
future, including the use of magnetic particles to draw cancer-killing agents into tumors; and the delivery of
genetic material, called gene therapy, to fight or prevent cancers. These techniques are still investigational, but
they offer new hope in the war against cancer.

"Magnetic"Chemotherapy

Interventional radiologists are currently investigating a new technique in which magnets are used to pull
chemotherapy drugs into tumors. Microscopic magnetic particles are attached to the cancer-killing drugs and
infused through a catheter into the blood vessel that feeds the tumor. A rare earth magnet is positioned over
the patient’s body directly above the site of the tumor. The magnet pulls the drug-carrying particles out of the
blood vessel so that they lodge in the tumor. Although the technique is still experimental, early research is
promising. Physicians are hopeful that it will bolster the effects of chemotherapy while avoiding some of the
drugs’ side effects, such as hair loss and nausea.

Gene Therapy

In recent years, scientists have gained a new understanding about

genes—the basic biological units of heredity—and the role they play in
disease. This knowledge has set the stage for medical science to
alter patients’ genetic material to fight or prevent cancer. Although the
science of gene therapy is still in the early, experimental stages,
researchers are hoping that in the future the therapy can be used to: Researchers in gene therapy search for new ways
to treat cancer and other genetic diseases

alter the cells of a patient’s natural immune system with cancer-fighting genes and returning them to the
body, where they could more forcefully attack the cancer;

remove cancer cells from the body and alter them genetically so that the patient’s own immune system
will mount a strong defense against them. In this technique, the altered cancer cells would act as a
cancer vaccine;

replace a faulty gene responsible for the growth of cancer with a "good" gene;

inject a tumor with genes that will make it more susceptible to chemotherapy or other cancer-fighting
agents; and

make bone marrow and other organs resistant to chemotherapy, so that the drugs will destroy tumors
without damaging healthy tissue.

One of the challenges of gene therapy is finding safe and effective ways to deliver genes or genetically altered
cells to the site of the tumor. Interventional radiologists, with their special expertise in using X-rays and other
imaging techniques to guide catheters and other tools through the body are expected to play an important role
in this new technology.

Treatments for Cancer Complications

There are also a number of interventional radiology techniques that are used to treat the complications of
cancer, including pain, bleeding, obstruction of vital organs, blood clots and infection. Although these treatments
do not cure cancer, they can make patients more comfortable, extend life by treating serious complications and
improve the quality of life for cancer patients.

Treating Pain

Control of pain is one of the most important aspects of cancer care. Pain not only affects patients’ quality of life
and ability to function, it may also lower their tolerance for needed cancer treatments.

In many cancer patients, pain results from the spread of the tumor into surrounding nerves and other tissues.
For example, patients with cancer of the pancreas or stomach, sometimes experience pain from the spread of
the tumor into a network of nerves and blood vessels in the abdomen called the celiac plexus. To treat the pain,
interventional radiologists insert catheters or needles into the affected area and administer alcohol or other
agents that destroy the nerves causing the pain.

A particularly painful complication of cancer is when the disease spreads (metastasizes) to bones. In a
technique called transcatheter embolization, interventional radiologists inject tiny particles, the size of grains
of sand, through a catheter and into the artery that supplies blood to the tumor. The particles cause clotting that
decreases the tumor’s blood supply, reducing pain and decreasing the likelihood of bone fracture.

Controlling Bleeding

4 trong 5 12/3/2010 12:56 AM

Nonsurgical Treatments for Metastatic Cancer in Bones - SIR http://www.sirweb.org/patients/bone-cancer/

If a cancer spreads to the blood vessels it may cause hemorrhage or bleeding. An interventional radiology
technique called transcatheter embolization can be used to clot the affected blood vessels and stop the
bleeding.

Treating Organ Obstruction and Infection

Cancers can obstruct the normal flow of urine or bile, causing these fluids to
build up in the body. If left untreated, these conditions are not only painful but
may also result in organ failure or infection. Under X-ray guidance, catheters
can be inserted to drain the collection of fluids. Often, a small device called a
stent is inserted into the organ to bypass the obstruction and allow fluids to
drain internally.

Treating Blood Clots Small mesh cylinders called stents

are used to open obstructed organs
One common side effect of cancer or cancer treatments is the development of and allow fluids such as urine and
blood clots, or emboli, that can be life-threatening if they travel to the brain, bile to drain.
lungs or heart. There are two interventional radiology procedures that can
reduce the risks posed by blood clots:

Intra-arterial thrombolysis. In this technique, the interventional radiologist guides a catheter through the
blood vessels and to the site of a blood clot. Clot-busting drugs are infused through the catheter to
break up the clot.

Filter placement. This technique is most often used when a blood clot is detected in the blood vessels
of the leg (a condition called deep vein thrombosis). The interventional radiologist guides a small filter
into the blood vessel that receives blood from the lower body (the vena cava) and carries it to the heart.
If the blood clot dislodges from the vein in the leg, the filter will trap it before it can reach the heart.

Interventional Radiologists are Minimally Invasive Experts

Interventional radiologists work with other specialists on a multidisciplinary cancer team to determine the best
treatment for each individual patient. Interventional radiology is a recognized medical specialty by the American
Board of Medical Specialties. Interventional radiologists are board-certified physicians with extensive training in
disease diagnosis, management and treatment. Their board certification includes both Vascular and
Interventional Radiology and Diagnostic Radiology which are administered by the American Board of Radiology.
This training marries state-of-the-art imaging and diagnostic expertise, coupled with clinical experience across
all specialties and in-depth knowledge of the least invasive treatments. Interventional oncology is a growing
area within interventional radiology.

Copyright © 2010 Society of Interventional Radiology. All rights reserved.

3975 Fair Ridge Drive • Suite 400 North • Fairfax, Virginia 22033
800-488-7284 • 703-691-1805 • FAX 703-691-1855
Legal disclaimer/privacy policy

5 trong 5 12/3/2010 12:56 AM