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The MOTION Study: Evaluating Cryoablation for Painful Bone Metastases

Author Sara Stewart covers The MOTION Study: Evaluating Cryoablation for Painful Bone Metastases on BackTable MSK

Sara Stewart • Updated May 23, 2024 • 46 hits

Cryoablation is a promising treatment for oncologic patients with painful bone metastases. The MOTION Study, an international, prospective single-arm trial evaluating the effectiveness of cryoablation in reducing pain for patients with bone metastases, aimed to prove its benefit and encourage more widespread use of cryoablation by interventional radiologists and oncologists. This article highlights cryoablation’s indications, benefits, and challenges while providing an analysis of the MOTION Study from its lead investigator Dr. Jack Jennings.

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

• Cryoablation, a procedure using extreme cold to freeze and kill cancerous cells and lesions, is indicated for various bone metastasis sites, such as the ribs, ilium, and pelvis.

• According to Dr. Jennings, cryoablation offers benefits like easier navigation, treatment sculpting due to the visible ice ball, and less pain compared to heat-based ablations.

• The MOTION Study aimed to evaluate the effectiveness of cryoablation for patients with painful bone metastases, focusing on pain reduction and assessing changes in opioid use and quality of life over six months.

• The study demonstrated significant and durable pain relief six months after cryoablation, achieving the primary endpoint of more than a two-point reduction in pain scores from pre-treatment levels.

• Secondary endpoints showed a marked decrease in opioid use and significant improvement in quality of life over the six-month period, highlighting the comprehensive benefits of cryoablation.

The MOTION Study: Evaluating Cryoablation for Painful Bone Metastases

Table of Contents

(1) Evaluating the Effectiveness of Cryoablation in Painful Bone Metastases

(2) Cryoablation Indications, Benefits & Limitations

(3) Key Takeaways from the MOTION Study

Evaluating the Effectiveness of Cryoablation in Painful Bone Metastases

Patients diagnosed with cancer are living progressively longer, which increases the likelihood of disease progression and bone metastases. The MOTION Study aimed to evaluate the effectiveness of cryoablation for patients with painful bone metastases. This international, prospective single-arm trial focused on achieving a reduction in pain scores by more than two points from pre-treatment to post-treatment. Secondary endpoints included assessing changes in opioid use and quality of life over a six-month period. The study also sought to promote broader adoption of cryoablation for pain palliation and influence National Comprehensive Cancer Network (NCCN) Guidelines to support this treatment modality.

[Dr. Jack Jennings]
I'll start with the overview. Matt Kohlstrom, Damien Dupuis, and a few of my other great colleagues did a prospective trial similar to this in 2013, maybe, was published in Cancer. Now you take it another eight years from there. Our goal was multifold. People are living longer. It's about 1.9 million people have cancer, diagnosed with cancer every year. People are living longer, and thus, they're getting bone metastasis.

One of our main goals was to increase broader adoption and knowledge of this and for pain palliation. It was really a simple prospective single-arm trial. It was international. I think we had four European sites, many out of France, looking at people with painful single bone metastasis and treating with cryoablation. We enrolled very similar to the mass trials in the '60s, like '66 or something like that. We took it out for six months. The primary objective was greater than two-point reduction of the pain score.

Then we looked at opioid use, quality of life, and like I said, carried it out for six months. The big impetus was also to just reinvigorate this more global, broader adoption of it because it's a need. You and I have talked about this multiple times. We just need to get more and more people doing this. Equally, to get the NCCN Guidelines and guidelines to promote this. As you've seen, we talked about this last time. We made a lot of leaps and jumps with it, come to NCCN Guidelines and ablation for pain palliation.

Listen to the Full Podcast

The MOTION Study: Cryoablation for Painful Bone Metastases with Dr. Jack Jennings on the BackTable MSK Podcast)
Ep 38 The MOTION Study: Cryoablation for Painful Bone Metastases with Dr. Jack Jennings
00:00 / 01:04

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Cryoablation Indications, Benefits & Limitations

Cryoablation may offer significant advantages for patients with bone metastases, including easier navigation and treatment sculpting due to the visible ice ball, as well as less pain compared to heat-based ablations. This modality can be effective for various metastasis sites, such as the ribs, ilium, and pelvis. Although the spine is the most common site of bone metastases, cryoablation is not frequently used in this area because of the challenge of avoiding spinal nerves and the high risk of nerve damage.

[Dr. Jack Jennings]
Why cryo? We do a lot of it in bone for many reasons. One, you can see the ice ball. Now, when I say that, when it's dense bone, you don't see within the bone, but you can see it extending beyond the bone. Two, it's a modality that we can sculpt. We can make geometries that you can't make necessarily with some of the heat-based thermal ablations. Typically, it's less painful.

Matt's group published that trial, RF versus cryo as far as pain from the procedure. Finally, where we are, I think we're going to talk about this, when we are close to nerves and other structures, they are much more forgiving with ice than they are with some of our heat-based modalities. That's a 30,000 foot overview of why cryo in bone.

[Dr. Jacob Fleming]
Absolutely. Thank you for that explanation. The MOTION Study really is very impressive. As you said, there's really the all-star cast. I was looking and thinking this is the Avengers of musculoskeletal interventional oncology. It's just a really impressive cast of clinicians who participated in this from all around the world. One of the things that really struck me was just how many different bone metastasis sites there were. There obviously were some recurrent ones, but this is quite different from some of the other studies that have focused more so on spine ablation.

In this study, the most common index tumor location was actually in the rib in about 24% of patients and a smattering of all over. One thing I wanted to touch on is bone mets, of course, can show up anywhere. There are places where they are more common, and some of these have their own consternation associated with them. For example, ribs can really be difficult in some ways. One thing I was curious about, not necessarily limited just to the trial, but your experience ablating a lot of these lesions, tell us about some of these recurrent sites such as rib or ilium and maybe some of the particular challenges that come up with those.

[Dr. Jack Jennings]
Yes. One caveat, one thing I will tell you. Spine is the number one site of metastatic disease, which I think you were alluding to. Cryo is done less in the spine for many reasons. A, you've got the spinal cord and nerves, and I call it the silent killer, meaning even under conscious sedation, you can take out a nerve in the spinal cord versus heat, much more thermotoxic and patients under conscious sedation will not allow you. If you look at all these spine metastatic trials, treating those with thermal ablation, radiofrequency ablation is number one hands down. In fact, that's the first modality that got us even ablating anything with osteoid osteomas.

This trial, very few spine, and there's a reason for that because it's not a great trial. Those are very complicated, and that goes to answering your question about how complicated. Now, so, pelvis is the number two site of metastasis. Not surprising that if you take sacrum, pelvis, ischium, all those in there, that would, I don't remember all the numbers, but they for sure add up to be number one. Ribs are very common. These chest wall, pleural base, lung, whether it's primary lung or metastatic lung, those are very common metastases and ones that we ablate.

We're also taking out the intercostal nerve. I believe you've had Prologo on here, given there's nerve spiel, for sure, my good friend up on the pulpit. You're really doing a double good thing. You're treating the met as you're taking out that intercostal nerve, which helps with that chest wall pain. If I were to give the most challenging, it's anywhere near a nerve. I do use cryo pretty consistently in the posterior elements of the spine, or when there's paraspinal soft tissue.

With those, I use evoke potentials, and I think we talked about that, your passive and active thermoprotective techniques, and then posterior acetabulum, the sciatics right there. That's another cautionary place. Really, those are the ones that I find the most challenging. Anybody can put a needle in any of these places, it's staying out of trouble, and that's what I find the most challenging.

Yes, I'm not surprised. We endorsed doing real-world stuff, and this is real-world stuff. One point I would make, and you can correct me on this because I don't have it in front of me, but it was a huge number of, it was close to 60% were greater than four centimeters. Big lesions. I think it was greater than four centimeters or more. It was two-thirds of them. That's real life. That's less than ideal because we would love to catch these before, but this is all part of getting this message out to our oncology colleagues and whatever.

These were real lesions. These weren't like chip shot, one, two-centimeter ditzels. These were big boys. If you've got it in front of you, I think greater than four centimeters is close to 60-some percent, right?

[Dr. Jacob Fleming]
Yes. The mean size is actually 5.7. Pretty impressive and with a large standard deviation, they have about 60% or more than four centimeters. These are serious metastatic lesions. I think the fact that it was skewed so far in that direction, and the patients really did quite well with this. Could you just briefly summarize for us again the results of this and how patients did, how this helped out?

Key Takeaways from the MOTION Study

The MOTION Study demonstrated that patients experienced significant and durable pain relief six months after cryoablation for painful bone metastases, meeting the primary endpoint. Secondary endpoints showed a marked decrease in opioid use and significant improvement in quality of life over the same period. The study highlights the effectiveness of cryoablation for metastatic bone lesions and underscores its potential as a viable option for interventional radiologists and oncologists in managing painful bone metastases.

[Dr. Jack Jennings]
We used BPI, short-form worst pain, as the primary endpoint, and we showed durability because out to six months, patients had significant pain relief. Now with a 95% confidence interval, we picked eight weeks because we've done eight weeks for multiple other trials. You notice we just missed it by 0.2, whatever. I don't think that's the key. The key thing is, so we had a significant greater than two-point reduction all the way throughout, but if you take the 95th confidence interval, we were like minus 1.78, so just missed it at the eight weeks, but then everything after that was within the 95% confidence interval, which is what you want: durable, significant pain relief.

The graph goes like this and then all the way down and stays significant out to the six weeks. Then as we're looking at the morphine equivalent, there's very similar, the graphs. If you take pain and quality of life, they're both doing the same thing: significant decrease throughout the six-month interval, and that's the thing why I brought up the size. These were real lesions. With our trials, you want to be smart because you're trying to do the best.

You're not trying to, how do I say that, manipulate the trial, but there's people that are good study candidates and those who are not. You see here, these were big lesions, and I find with the bigger lesions. Now, we did do a univariate and multivariate analysis. The size did not impact whether those people were still at eight weeks or not. That being said, from my experience, the bigger lesions, it takes people some time to start feeling better. Anyway, so yes, if you look at all those three, the primary and secondary endpoints, they were significant throughout the six months.

[Dr. Jacob Fleming]
Absolutely. I think it's very impressive. As we know with these patients with bone metastatic lesions, they can really fall down the wrong path very quickly. It's always heartbreaking to me to see how a patient comes in who has been dealing with something for months and months and something that we really could have helped out sooner, but now they're on increasing doses of opioids, just trying to get it through the day and they're in a really tough spot. It always seems to me that the earlier we can get to handling these problems, the better. As you said, this is the real world. It's not always going to be on a silver platter at the tumor board, one centimeter solitary bone met. I think that's probably a much more rare situation than probably what was described in the study here.

[Dr. Jack Jennings]
I do think the good news is it's changing. We now are getting asked earlier on, and that is a testament, I believe, to what you guys are doing, what everybody's doing, Society of Interventional Oncology, SIR, everybody, name them all, CIRSE, just getting the message out, these podcasts, as I said, I think more and more people are doing it in these OBLs and not just at the "ivory towers". That's to me why I love what actually you all are doing and what everybody getting the message out. We are seeing much smaller lesions. I think we're making ground for sure.

[Dr. Jacob Fleming]
For sure. I've been really excited to hear about more and more people in the community setting who are starting to build up cryo programs and doing away with the notion, like you said, that this is just sort of an ivory tower practice. These patients are everywhere, and there have been a lot of people who have been successful setting up and taking care of these patients in their community, whether that's in an academic setting or somewhere more like a private practice setting. That's been really nice.

Podcast Contributors

Dr. Jack Jennings discusses The MOTION Study: Cryoablation for Painful Bone Metastases on the BackTable 38 Podcast

Dr. Jack Jennings

Dr. Jack Jennings is an inteventional radiologist with Washington University Physicians in St. Louis, Missouri.

Dr. Jacob Fleming discusses The MOTION Study: Cryoablation for Painful Bone Metastases on the BackTable 38 Podcast

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). (2024, January 5). Ep. 38 – The MOTION Study: Cryoablation for Painful Bone Metastases [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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