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The Emerging Role of Interventional Radiology in Cancer Pain Management
Thomas O'Rourke • Feb 12, 2024 • 40 hits
As the field of interventional radiology continues to expand, patients continue to receive improved non-opioid-based pain management. In cancer patients particularly, there is a lot of potential to reduce tumor-related pain with procedures provided by interventional radiologists. Dr. Dunleavy discusses the field of interventional radiology as it finds a growing niche in cancer care. Advancements in spinal tumor ablation and vertebral augmentation offer promising results for reduced pain and improved patient outcomes.
This article features excerpts from the BackTable MSK Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable MSK Brief
• Working as a team to do what is best for the patient often allows for the optimal outcome. Dr. Dunleavy emphasizes the importance of tumor boards to ask about obscure imaging or recommended treatments.
• It is important that budding interventional radiologists do not become overly reliant on new technology such as Cone Beam CT. While it improves accuracy and efficiency in procedures such as bone biopsies and tumor ablation, there is merit in strong tactile skills.
• Strong tactile skills are especially important in cancer cases where normal anatomical landmarks may be absent or misshapen.
• Improved targeted approaches using cone beam CT and devices such as the SpineJack have the potential to significantly reduce the need for opioid use in these patients.
Table of Contents
(1) Recent Advancements in Spinal Tumor Ablation
(2) Balancing New Imaging Technology & Tactile Skills
(3) Interventional Radiology’s Expanding Role in Cancer Pain Management
Recent Advancements in Spinal Tumor Ablation
Dr. Dunleavy discusses the simplicity, safety, and efficacy of radiofrequency ablation for bone metastases, underscoring the importance of understanding various modalities and the role of interventional radiologists in managing spine-related issues. He highlights some of the significant new advancements in tumor ablation, citing a study by Dr. Jack Jennings. This study compares the safety and effectiveness of cryoablation, microwave ablation, and radiofrequency ablation, emphasizing the need for comprehensive knowledge of various technologies and devices for optimal patient outcomes. Unfortunately, such studies tend to have smaller sample sizes, making it difficult to compete with radiation oncologists.
[Dr. Jacob Fleming]
Tell us a little bit about your practice. How does the bone tumor ablation fit into that as well as vertebral augmentation? What's been your opinion of what's been unfolding in the last couple of years?
[Dr. Dana Dunleavy]
Sure. Again, with different mentors, including Sean Tutton, who I had the opportunity to work with a couple of days ago, really had tremendous amount of opportunity to learn from these guys who are really pioneers. I feel like now you and I are benefiting a lot from that and really taking the opportunity to improve quality and access to care across the country. I think that there are still tremendous opportunities we have to share with our colleagues, how simple, safe, efficacious, radiofrequency ablation is of bone metastases and knowing all the different modalities.
I think that we come out of training, for instance, really understanding what do you do with liver disease. Then you come out and you say, "Well, how do I grow my practice in interventional oncology focused on the spine?" There seems to be this big gap. The number one most helpful thing is being a helpful part of the team and by doing that, providing great quality biopsies. If we are capable of being present at tumor board, again, that's not just academic centers, it's private groups, that's office space settings. I mentioned a lot that COVID, one positive was that almost every tumor board is available remotely now.
Even a small-town office space guy like me participates in several tumor boards from multiple networks every week and always, people are bringing up, "Hey, there's this T5 little thing that lights up on PET. Patient had breast cancer five years ago. I wish there was some way we could figure out what this is." It's always short. That's really simple, really easy. If we can be a helpful part of the team, make the diagnosis, we also have that same ability to treat it. I think then the question is, can you do it safely?
To your point about all of the increasing data, I thought one of the interesting studies that a lot of our colleagues haven't read is one of the publications by Jack Jennings, where he showed cryoablation, microwave ablation, and radiofrequency ablation and intentionally, in this model made ablation zones that were far too large. The nice thing about that was to showed that even using those inappropriate temperatures and times still maintained a safe ablation within the spine because of that impedance in the cortex, but resulted in neuropathy and paralysis using cryoablation and microwave ablation.
It's just helpful for us to really understand how this can vary safely and quickly be performed if you understand each of the technologies. To your point again, about some of the developments in technology, I think it's good for us to have access and hands-on to all the devices. There's no reason that anyone should be locked into a single device. For instance, if we just go through radiofrequency ablation, Merits had a wonderful device, Medtronics had a wonderful device, Strykers had a wonderful device. All of them are really great in the right hands and the right experience and each of them have their different advantages.
It's interesting, right, that you go to different regions and people think that there is only one device and they've never heard of the others. I just think it's very important that we share with each other all of the different techniques you have. To just go back to what you're asking, I think the data continues to grow.
Unfortunately, many of our trials are very small and I think still when I present with radiation oncology, they will always win if we fall back on who has better data, who has more data. If we look at their trials with 20,000 patients in our trials with 200, it's a little challenging. It's the same challenge we have with PAE. We say TURP versus PAE, I think we have wonderful data, but it's still not as in-depth that TURP is. Do you want to move on to some of the mechanical augmentation too?
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Balancing New Imaging Technology & Tactile Skills
Dr. Dunleavy also highlighted some of the recent advancements in imaging and how they have impacted procedure performance. He discusses the benefits of combining fluoroscopic guidance with Cone Beam CT for precise targeting and confirmation in spinal procedures, especially in complex cases. Cone Beam CT has been shown to improve procedural outcomes, but it is important that physicians do not form too much of a reliance on such technology. This is especially true in the early stages of training. He also emphasizes the importance of adapting to distorted anatomy in oncological cases, where standard landmarks may be unreliable, requiring a balance of image guidance and tactile surgical skills.
[Dr. Jacob Fleming]
That's one of our challenges as image-guided surgeons, so to speak, is that we're so facile with the image guidance that a lot of times just doing things as simple as possible and knowing that you don't in certain instances need to be having your eyes glued to the fluoro monitor. That gets tricky too when we're talking about ONC cases, and sorry to beat the drum on this, but where the anatomy is just really distorted and there's often not a lot of good landmarks to go by.
Would you speak quickly about your thoughts about using advanced systems such as Cone-beam CT with needle guidance navigation? Your experience using that, how you think it fits in, and is it something that we should all be doing? Sorry to make this a multi-part question, but the danger of becoming reliant on these advanced techniques, your thoughts?
[Dr. Dana Dunleavy]
I can see you're speaking from multiple mentors at the same time. I love that because that is helpful for us to address why this is a emotional question. My feeling is that there is a benefit to having that technology. Now, I was just talking with some neurosurgeons yesterday, and within this big group they have guys that use navigation every day and guys that never do. The older guys that grew up without navigation existing say this is a handicap of the young guys that they're reliant on it just as you said.
However, I think it's really helpful to utilize it and then understand that anatomy and be able to pick and choose when you think it's appropriate or not. Certainly, it doesn't add something in every case. As an example, I think that as we have discussions about things like sacroiliac joint dysfunction and pain and we read some of the literature that says that 40% of implants for sacroiliac joint fusion are in the wrong place, we say, wow maybe there is a benefit to having CT guidance or Cone Beam CT or trajectory planning or navigation because that's just not right.
Right now we do know that some people with C-Arms don't ever have a complication. It certainly is not necessary in all cases, but as an example, most of us are all trained to do most biopsies, especially bone biopsies and CT. I'll tell you that my belief is the hybrid is the best. That doing bone biopsies with a C-Arm alone is quite challenging to know that you truly targeted it and promise to your medical oncologist or radiation oncologist that what you get, a benign biopsy, that it's not a false negative.
My technique is to do the access under fluoroscopy and that a Cone Beam CT, which proves my device is going right through the lesion. I find that's good for me, good for the patient, good for the nurses. It makes all of these procedures really easy. The hardest part for the patient right, is lying in these uncomfortable positions. I think that that's a wonderful hybrid. The same is true for all of my bone tumor ablation cases. That I will access with the knowledge of what the anatomy is and where the lesion is under fluoroscopic guidance. Then I'll use Cone Beam as confirmation.
Now, some people take the next step, and patient walks into the room, gets on the table, they do Cone Beam CT and then they use guidance software that has a different name for each device, each system that we have. For mine, it's called trajectory planning. It means that for anyone that's never used it, you can scroll through your axial images as an example, pick your target, pick your access, you can have multiple different planes that you're using, so you don't have to access at the same craniocaudal plane.
To me, there's a big advantage of using trajectory planning over CT fluoroscopic guidance where having a very coddle angulation through a T-5 pedicle, much easier to do in an angio room or a fluoroscopy room than it is in CT. I've seen some of my friends under a CT fluoroscopic guidance where they're accessing from the wrong side of the CT scanner because of that angulation, you just can't reach through the entire scanner. Remember that most of our high thoracics, the cannula handle is almost in the patient's hair. That's the right way to do it. If you're not doing it that way, you'll probably have some post-procedure paraesthesia because you're too close to the neural foramen.
That's what I think is the ideal is having a combination for the difficult lesions. To some degree, I use that information for education and teaching so that people can take that combination of fluoroscopic Cone Beam CT trajectory planning views and utilize it on a C-Arm because they can put that all in their mind but that's the balance I think.
Now, I'll tell you this morning as an example, I was doing an ablation of the ileum and it was a really tall patient, the room we're in, it's challenging to do Cone Beam CT when his arms and his head are all the way up as far as it goes. We're still trying to do a Cone Beam and trajectory planning down essentially in his proximal thighs.
It did combine all of the things you're mentioning, that we had to say trajectory planning doesn't really work here. Sometimes the angles that we choose, the machine will just tell you, not achievable, can't do it. You still couldn't access, which we did under fluoroscopic guidance and you still could visualize it with Cone Beam CT, but we did have to utilize those things we talked about before where we said we're almost in the right place, but I just have to use tactile feel to move myself 5 millimeters more coddle and more medial and then we were perfect.
Nobody wants to hear that you were okay, not terrible. We were really happy to be perfect after using that combination of knowledge and tactile feel. The short again, I think, is there's a combination and in my practice, I find that using that combination keeps me out of CT. I continue to live in CT for lung, but everything bone I think is better under fluoroscopy with the ability to do Cone Beam.
[Dr. Jacob Fleming]
Agreed. I think there's a lot to the hybrid approach. Sometimes for some of these very complex cases, I could see the benefit of having a true CT angio system, but in most cases that's probably like using a rocket launcher to hunt geese. I agree that what can be done in a standard angio suite, or even nowadays certain C-Arms have Cone Beam CT capability. That starts to extend into even the OBL setting.
[Dr. Dana Dunleavy]
It does. The one thing I would just say to that is depends what type of anesthesia you're doing. I think that those CRMs with Cone Beam are getting better. In general, they take a little bit longer, and a little bit longer means if the patient moves it all it's no longer useful. For those people working in ASCs, as an example, where patients under MAC, I think that works great for many of our patients. I find again, in my practice, you're oftentimes getting patients that neurosurgery and ortho, and PM&R are sending to you because they have severe COPD and cardiomyopathy and various other issues that don't allow you to sedate or do anesthesia. If the patient's moving, it can be challenging to do one of these really slow-speed Cone Beams.
Interventional Radiology’s Expanding Role in Cancer Pain Management
Techniques rooted in interventional radiology can significantly improve quality of life in cancer patients. Many of these techniques are done through targeted radiofrequency ablation and mechanical augmentation, significantly alleviating pain and improving patient mobility. Dr. Dunleavy discusses the potential for interventional radiologists to further address oncologic pain through techniques like dorsal column stimulation, nerve blocks, and rhizotomy, emphasizing the importance of targeted treatments in pain management and patient survival. Emerging areas of interest include neuromodulation for neuropathy and cancer pain, sacroiliac joint dysfunction, and the development of techniques to reduce adjacent-level fractures.
[Dr. Jacob Fleming]
Yes, that's really good information to consider, or something that we are used to as interventional radiologists, whether the patient passes the sniff test in terms of you look at him, and you say, "Can we do this under moderate?" Can we do that or MAC? Sometimes you just know it's going to be a general case. It's very helpful to have that. It's another reason why there's never going to be a point where all of these cases can be done in the OBL. There's always going to be a need for those higher levels of care and being able to do it either in the hospital or ASC setting. That is all I had, Dana. This has been an excellent conversation. I want to know any final thoughts. I do want to hear more general thoughts, but any final thoughts on the topic of bone tumor ablation and mechanical augmentation?
[Dr. Dana Dunleavy]
Overall, I just hope that people can see the passion that many of us across the country have because these patients come back, not only the patient, but their families, and really tell you this is the greatest thing you could ever do for a cancer patient. I neglected to mention that when I was in high school, my close friend's sister was diagnosed with leukemia. At the time I didn't know why, I guess I must have at least have shared with her my passion for healthcare to some degree, and that she told me she was counting on me to prevent this from happening to other children, and that I would have a role in oncology.
I didn't really see how until I ended up in this land. With doing bone tumor ablation, again, you have patients that come in, in a wheelchair, and they walk out, and they live a good life. I think this part won't be in video, but you can see here we're talking about New York matters. I think that this is one of many organizations. Obviously, I'm in New York, one of many organizations that's really focusing on preventing opioid overdoses and complications and hospitalizations related to narcotic use.
We have an amazing ability to help people that way. I think that the best way we can do it to avoid systemic therapy and complications is to be targeted. One of the terms people use for bone tumor ablation is targeted radiofrequency ablation or t-RFA. I think that the whole life that you're living right now is targeting things towards people's pain. We didn't have enough time to talk about NCCN guidelines, but remember that every year there's something new in NCCN focused on pain, and that pain actually, not only is important for people's quality of life, but actually has survival implications.
There's more and more emphasis not only on bone tumor ablation, or not only on vertebral augmentation but all the things that you and others are doing, including dorsal column stimulation, nerve blocks, rhizotomy, pumps. There's just an enormous amount of opportunity for us to help and I think that we call ourselves interventional oncologists. I think that there's a big opportunity for us to include treating people's pain within that category of interventional oncology.
I guess the last piece of that would be some of the adjunctive things that I think that you've already included in these MSK discussions, but talking about sacroiliac dysfunction, talking about painful diabetic neuropathy, again, I think that's a huge one that we'll probably come back to because many of our colleagues do a lot of arterial work, or maybe they do a lot of venous work. They're seeing patients with leg pain. One of the common things that I hear from the vascular surgeons is, it's really frustrating to revascularize someone's leg and you're really proud of your work, and the patients really disappointed because they still have leg pain.
Again if people haven't heard it, doing neuromodulation for painful diabetic neuropathy actually even has better outcomes than treating non-surgical pain, back pain, or failed spine surgery back pain. We're talking about really great outcomes. Some of it that's really fascinating. This is data that's been presented at the ADA and other types of societies unrelated to us, but is that you have improved innervation in the legs and the feet. People that had paresthesias or numbness in their feet because of diabetic neuropathy improve their sensation within their feet, and they improve their A1C.
I guess you can tell that I enjoy the world of changing people's lives through improved quality of life and improved functional abilities. It all fits in this world that I think that we enjoy. It's very minimally invasive. It's image-guided and includes all the anatomy we enjoy. It's still what we may say is an extension of orthopedics and neurosurgery. A lot of opportunity, and I think we're really learning now the next frontier or steps that we're taking is how do we also help people with neuromodulation within the oncology world. There's a lot of effort going into that.
[Dr. Jacob Fleming]
Absolutely. I'm really glad you brought that up. That's something that I wanted to throw out there to our listeners, definitely, as you and I were talking about earlier, a discussion unto itself. A lot of exciting stuff happening there, I think a lot of potential for involvement, especially for interventional radiologists who are providing these ablative diagnostic capabilities to extend that into neuromodulation, and targeted drug delivery. That's something that we really want to discuss in the future.
Also just bring a general awareness of the capabilities of those techniques, like you were saying, and painful diabetic neuropathy, definitely something we'll get back on very soon because this falls into the realm that interests people like you and I so much of situations that otherwise don't really have a very good solution. I think we've really gotten to talk about that today. It's been a fantastic conversation. I want to thank you for your time and humoring my many tangents. I've thoroughly enjoyed talking to you, Dana.
I want to, again, show my appreciation for you taking your time to talk to us about this. As always, I like to end by asking my guests about what on the horizon are you most excited about right now. We talked about a lot of things that are here and that are coming. What is something that you're really looking forward to being perhaps the next step for us, whether with oncology patients or something else?
[Dr. Dana Dunleavy]
I'm excited about too many things. To try to nail it quickly, I think right now we're working on three columns support for reducing adjacent level fractures, trying to really identify what the best techniques are to reduce additional fractures. I'm excited about those two areas we touched on at the very end neuromodulation for neuropathy, and for cancer pain, I would say that that is the one that's really clinching it for me right now because those are really growing problems.
The final would be-- there's several clinical trials being involved now including us as interventional radiologists for sacroiliac joint dysfunction. As Wayne alluded to, when you start asking and examining for it be amazed how common it is. I've been honored that the neurosurgery colleagues have supported me in that because it is one of those crossover areas that can be considered surgery or can be considered minimally invasive. I think it really is incredible to help people again, in a way where they said for 10 years, "I've had this pain but has limited me from doing things I want to do." We now have the ability to make this better and less invasive than ever.
That takes me to the last, last point that you said that we can't do all these things in the OBL. I think that the OEIS has also demonstrated that as well, and that all of us that do work not only at hospitals, but either at OBL or ASC, and many of us have done most of it at the OBL, must start thinking that if we want to be comprehensive, it probably won't all be in an OBL and start thinking for the next three to five years, how we want to develop that.
[Dr. Jacob Fleming]
Excellent. Just a lot of great topics to think about and have you back on the show in the near future. Dr. Dunleavy, thank you again so much for your time. Any closing thoughts?
[Dr. Dana Dunleavy]
No, I really appreciate it, Jacob, you're amazing that you put so much time into this as a fellow, it's really incredible. Thank you for having me.
[Dr. Jacob Fleming]
Well, thank you. Honestly, these conversations give me so much energy and really keep me going. I want to thank you for coming on my show tonight and like I said, won't be long before we have you back on.
[Dr. Dana Dunleavy]
Thank you.
Podcast Contributors
Dr. Dana Dunleavy
Dr. Dana Dunleavy is a musculoskeletal and vascular IR in Buffalo, New York.
Dr. Jacob Fleming
Dr. Jacob Fleming is a diagnostic radiology resident and future MSK interventional radiologist in Dallas, Texas.
Cite This Podcast
BackTable, LLC (Producer). (2023, October 18). Ep. 33 – New Frontiers in Spinal Tumor Ablation & Augmentation [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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