Image-guided ablation of skeletal metastases
- Anil Nicholas Kurup, MD
Anil Nicholas Kurup, MD
- Assistant Professor of Radiology
- Mayo Clinic College of Medicine
- Matthew R Callstrom, MD, PhD
Matthew R Callstrom, MD, PhD
- Professor of Radiology
- Mayo Clinic
- Section Editors
- Reed E Drews, MD
Reed E Drews, MD
- Section Editor — Complications of Cancer
- Associate Professor of Medicine
- Harvard Medical School
- Janet Abrahm, MD
Janet Abrahm, MD
- Section Editor — Pain: Assessment and Management
- Professor of Medicine
- Harvard Medical School
Skeletal metastases are a common manifestation of distant relapse from many types of solid cancers, especially those arising in the lung, breast, and prostate. Bone involvement can also be extensive in patients with multiple myeloma, and bone may be a primary or secondary site of disease involvement in patients with lymphoma. For the purpose of this review, all of these will be considered under the term "skeletal metastases." (See "Clinical features, laboratory manifestations, and diagnosis of multiple myeloma" and "Primary lymphoma of bone".)
Among patients with advanced malignancy, skeletal metastases represent a prominent source of morbidity due to pain, dysfunction, pathologic fracture, and neurovascular compromise. Bone-related cancer pain is frequently undertreated with nearly 80 percent of patients experiencing severe pain before a sufficient palliative treatment plan is initiated . (See "Evaluation and management of complete and impending pathologic fractures in patients with metastatic bone disease, multiple myeloma, and lymphoma" and "Clinical features and diagnosis of neoplastic epidural spinal cord compression, including cauda equina syndrome" and "Overview of cancer pain syndromes", section on 'Multifocal bone pain' and "Cancer pain management: General principles and risk management for patients receiving opioids", section on 'The problem of undertreatment'.)
Treatment of skeletal metastases usually requires a multipronged approach:
●Analgesics, glucocorticoids, osteoclast inhibitors (bisphosphonates, denosumab), and bone-targeted radioisotopes can all provide pain relief, and osteoclast inhibitors are useful to decrease the frequency of skeletal-related events in patients with bone metastases. (See "Cancer pain management with opioids: Optimizing analgesia" and "Cancer pain management: Adjuvant analgesics (coanalgesics)", section on 'Adjuvant drugs used for bone pain' and "Osteoclast inhibitors for patients with bone metastases from breast, prostate, and other solid tumors" and "Bone metastases in advanced prostate cancer: Management", section on 'Bone-targeted radiopharmaceuticals'.)
●External beam radiation therapy (RT) with or without systemic therapy is the standard of care for alleviation of pain caused by skeletal metastases. Reduction in pain is achieved in 50 to 80 percent, and it is complete in up to one-third of patients . Newer radiation techniques, in particular stereotactic body radiotherapy, have been utilized in patients with limited metastatic disease to deliver higher radiation doses in a single or few sessions. (See "Radiation therapy for the management of painful bone metastases", section on 'External beam RT' and "Radiation therapy techniques in cancer treatment", section on 'Stereotactic RT techniques'.)
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- Patient selection
- PRE-PROCEDURAL IMAGING
- General aspects
- Radiofrequency ablation
- Focused ultrasound
- Other emerging percutaneous techniques
- - Bone pain
- - Local tumor control
- Choice of method
- SUMMARY AND RECOMMENDATIONS