Cryosurgical Ablation of Bone Tumors General Guidelines Cryosurgical ablation of bone tumors is applicable as an adjuvant to curettage in selected periarticular tumor types. The classic indications for the use of cryoablation are benignaggressive or metastatic tumors adjacent to a weight-bearing joint. By extending the margins of resection that had been achieved by curettage, cryoablation enables intralesional tumor 1-3 removal and sparing of the adjacent joint (Figure 1). The most common benign tumors that have been found suitable for treatment by cryoablation are giant cell tumor, aneurysmal bone cyst, and enchondromata. Cryosurgical ablation in the management of these tumors was shown to achieve high rates of local tumor 4-6 control and good function in the majority of patients. The technique has also been effectively used in the management of sacral tumors; the possibility of performing an intralesional tumor resection in lieu of wide resection at that site obviates the considerable 7 neurological deficit and loss of function associated with the latter. Contraindications for the use of cryoablation include high-grade sarcomas of bone or lesions in which the circumferential rim of cortex, remaining after tumor removal, is insufficient for ensuring a mechanically stable reconstruction. The consecutive stages of cryosurgical ablation of bone tumors are: Tumor curettage (Figure 2) High-speed burr drilling (Figure 3) Cryoablation (Figure 4). Direct pour of liquid nitrogen has been the traditional technique of cryoablation. Computer-controlled, closed cryoablation systems, entailing perfusion of argon gas through metal probes have recently become available, providing better control of the temperature and of the overall freezing time (Figure 5) Mechanical reconstruction of the tumor cavity (Figure 6) Correspondences to: Jacob Bickels, MD Attending Surgeon The National Unit of Orthopedic Oncology Tel-Aviv Soursaky Medical Center 6 Weizman Street Tel-Aviv, 64239 Israel E-mail address: email@example.com Martin M. Malawer, MD Director, Department of Orthopedic Oncology Washington Cancer Institute Washington Hospital Center Washington, DC USA E-mail address: firstname.lastname@example.org References 1. 2. Bickels J, Meller I, Shmookler BM, Malawer MM. The role and biology of cryosurgery in the treatment of bone tumors. A review. Acta Orthop Scand 1999;70:308-15. Gage AA, Greene GW, Neiders ME, Emmings FG. Freezing bone without excision. An experimental study of bone cell destruction and manner of regrowth in dogs. JAMA 1966;196:770-4. 3. 4. 5. 6. 7. Marcove RC, Weis LD, Vaghaiwalla MR, Pearson R, Huvos AG. Cryosurgery in the treatment of giant cell tumor of bone. A report of 52 consecutive cases. Cancer 1978;41:95769. Malawer MM, Bickels J, Meller I, Buch R, Kollender Y. Cryosurgery in the treatment of giant cell tumor. A long term follow-up study. Clin Orthp 1999;359:176-88. Schreuder HW, Pruszczynski M, Veth RP, Lemmens JA. Treatment of benign and low-grade malignant intramedullary chondroid tumours with curettage and cryosurgery. Eur J Surg Oncol 1998;24:120-6. Schreuder HW, Veth RP, Pruszczynski M, Lemmens JAM, Koops HS, Molenaar WM. Aneurysmal bone cysts treated by curettage, cryotherapy and bone grafting. J Bone Joint Surg 1997;79(Br):20-5. Kollender Y, Meller I, Bickels J, Flusser G, Isaakov J, Merimsky O, Marouani N, Nirkin A, Weinbroum AA. Role of adjuvant cryosurgery in intralesional treatment of sacral tumors. Results of a 3-11 year follow-up. Cancer 2003;97:2830-8. Legends for Figures 1. Plain radiograph showing a giant cell tumor of the proximal tibia. This is a benign-aggressive tumor, which usually occurs around a joint. Tumor curettage alone is associated with high rates of local tumor recurrence, while wide resection will result in a considerable loss of function due to the sacrifice of the adjacent side of the joint. Cryosurgical ablation extends the margins of resection achieved with curettage and burr-drilling, thus allowing intralesional tumor resection and joint preservation. 2. (A,B) Tumor curettage. 3. (A,B) High-speed burr-drilling 4. (A,B) Cryosurgical ablation using direct pour of liquid nitrogen 5. (A,B) Cryosurgical ablation using computer-controlled perfusion of argon gas through metal probes. 6. Mechanical reconstruction of the tumor cavity.