Microwave Ablation of Bone Tumors 9811674787, 9789811674785

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Qingyu Fan Editor

Microwave Ablation of Bone Tumors

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Microwave Ablation of Bone Tumors

Qingyu Fan Editor

Microwave Ablation of Bone Tumors

Editor Qingyu Fan Air Force Medical University Xi’an, China

ISBN 978-981-16-7478-5    ISBN 978-981-16-7479-2 (eBook) https://doi.org/10.1007/978-981-16-7479-2 Jointly published with Henan Science and Technology Press The print edition is not for sale in China (Mainland). Customers from China (Mainland) please order the print book from: Henan Science and Technology Press. © Henan Science and Technology Press 2022, corrected publication 2023 B&R Book Program This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publishers, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publishers nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publishers remain neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Foreword

The field of musculoskeletal oncology has seen dramatic advances over the course of our careers over the last half century. The 1970s ushered in standardized histologic definitions, systemic chemotherapy, and the development of axial imaging along with a greater understanding of the concepts of surgical margins and the natural history of primary bone tumors. These developments were coupled with the early but widespread adoption of limb salvage techniques to preserve both life and function for the benefit of patients. However, the early experience in limb salvage saw frequent failures from poor implant durability, fixation, and wear. Material scientists and physicians engaged in the care of patients with bone tumors came together in 1981 to form the International Society of Limb Salvage (ISOLS) to partner for the betterment of care of patients with bone tumors. This collaboration continues to this day as a vibrant society dedicated to improve the care of patients with bone tumors. In the ensuing four decades, the ISOLS society has continued to bring engineers and physicians together to advance the outcomes of patients. Much of this work has centered on the use of megaprostheses and related technologies (bulk allografts, allograft-prosthetic composites), which are familiar in contemporary practice. However, advances in these areas have become incremental, and outcomes appear to be plateauing as these technologies mature and their limitations in durability and function become apparent. In this context, the pioneering work of Professor Fan is a welcome addition and original approach to the care of bone tumor patients. Rather than relying on formal en bloc resection and reconstruction, Fan presents his series of a novel innovation in bone tumor care, namely in situ microwave ablation without resection. This series details his progressive development and improvement in the ability to provide curative treatment of patients’ completely irradiated tumor mass without en bloc removal. This technique minimizes or eliminates the need for reconstruction as the natural anatomic scaffold of the limb remains and provides the substrate for a durable biologic reconstruction. In this light, Professor Fan’s work embodies the driving spirit of the ISOLS group, namely the close collaboration of engineers and physicians to refine and improve the care of patients. The history of the development of this technique also embodies the goal of international collaboration inherent in the ISOLS group and other similar societies which is critical for the advancement of patient care worldwide. Specifically, after initial disappointing results with liquid nitrogen ablation in the early 1980s, Professor Fan traveled as an exchange scholar to the Hospital for Joint Diseases in New York in 1986 under the tutelage of Professor David Present. Returning to Xi’an in 1989, he began using microwave ablation for in situ tumor treatment. His early clinical work in this novel area was based on basic science and animal experiments to refine the concept prior to human use. In the following decades, Professor Fan and colleagues have continued to refine this technique and carefully catalog their case series and results. The technique involves the surgical isolation of critical structures away from the tumor followed by the insertion of microwave antennae to lethally ablate tumors in an en bloc manner without formal resection. While devitalized soft tissues are removed, the bony structure remains in place after treatment to maintain limb continuity and provide an anatomic scaffold for biological healing and limb reconstruction and preservation. v

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Early and promising clinical results were presented at the 1994 Chinese-Speaking Orthopedic Society (CSOS) meeting in Hong Kong. Our group at the Mayo Clinic and colleagues at Johns Hopkins University learned of his developments and invited him to the United States for further academic interchange. Professor Fan helped to organize and host the International Orthopedic Research Forum in Xi’an in 2000 where he reported further encouraging results and refinements in technique and instrumentation. Additional advances have been reported in ISOLS workshops in Orlando in 2015 and Kanazawa in 2017. The current state of this technology has now advanced to incorporate 3D printing, surgical navigation, and finite element analysis to provide maximum accuracy of microwave antenna array placement for accurate tumor volume treatment while sparing adjacent structures—the goal of all limb salvage procedures. Additional development of flexible antennae permits the intramedullary treatment of skip metastases, the use of confocal antenna, and the irreversible electroporation principle allows for safe and selective ablation of tumors adjacent to the spinal cord, and other critical structures. In this background, the monograph by Professor Fan presents carefully documented evolution and results of this technology when applied to bony neoplasms. It provides a proof of concept which defines this as a viable alternative to traditional en bloc surgical resection. The technique by design provides for limb salvage while minimizing many of the complications of traditional treatment techniques (implant failure, loosening, prosthetic wear, bone, and soft tissue non-union). It also offers a theoretical immune stimulation to guard against local or distant tumor recurrence. Moving forward, this work presents the salient features, development, and contemporary results of in situ curative microwave ablation of bony neoplasms in limb salvage procedures. It also embodies the innovation and success that can come from collaboration between surgeons and engineers to improve patient care. These results provide a baseline from which other centers may adapt and expand these techniques. Subsequent comparative clinical trials will allow the greater oncologic community to understand the proper indications and contraindications of microwave ablation compared to traditional resection, it’s role in the care of patients, and how it may influence their oncologic and functional outcomes. As the equipment and procedure can be refined, it can potentially be standardized to allow for more widespread adoption as directed by clinical evidence. The format of ISOLS or similar societies provides a natural mechanism for the exploration and comparative evaluation of Professor Fan’s innovative work. We congratulate Professor Fan for this presentation of his life’s work, nearly four decades of progressive refinement and adaptation of this novel method to treat bone tumor patients. His work embodies the spirit of collaboration between physicians and engineers to improve patient care. All individuals involved in the care of patients with bone tumors are encouraged to study this thesis and consider the application and implications to their own patients and to consider collaborative trials of this and other techniques.

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Franklin H. Sim, MD

Edmund Y. S Chao, PhD

Franklin H.  Sim was born in Halifax, Nova Scotia, Canada, and graduated from Dalhousie University Medical School in 1964. He completed his orthopedic residency training at Mayo Clinic, and received his Master of Orthopedic Surgery from the University of Minnesota. He joined the orthopedic staff of Mayo Clinic in 1970 and became a leading innovator and proponent of limb sparing surgery in patients with bone and soft tissue tumors. He was a founding member of the Musculoskeletal Tumor Society (MSTS) as well as the International Society of Limb Salvage (ISOLS) and has been active in the International Skeletal Society (ISS). He is a member of numerous medical societies, including the American Academy of Orthopedic Surgeons (AAOS), the American Orthopedic Association (AOA), and the Canadian Orthopedic Association (COA).  During Dr. Sim’s 48-year career on the Mayo Clinic faculty he has trained hundreds of residents and more than 60 orthopedic oncology fellows from the USA and overseas. His research and clinical interests have centered on the outcomes of complex limb and pelvic reconstruction for tumor resection and work in the areas of complex hip and knee replacement.  He has authored many of the seminal papers in the field of musculoskeletal oncology. His prolific publication record includes almost 500 published articles and 200 book chapters. Over the course of his career, Dr. Sim has received many prestigious awards, including the John Charnley Award of the Hip Society, the Canadian Orthopedic Association Outstanding Service Award, the Distinguished Mayo Clinician Award, the Dalhousie Alumnus of the Year Award, the AOA Distinguished Contributions to Orthopaedics Award, and the American Academy of Orthopedic Surgeons Diversity Award. Currently, he is Emeritus Professor of Orthopedic Surgery and emeritus chair of the Division of Orthopaedic Oncology at Mayo Clinic in Rochester, Minnesota. Edmund Y.  S. Chao received his BS degree in Agricultural Engineering from the National Taiwan University in 1960 and the MS degree in Agricultural Engineering with a minor in Mechanical Engineering from the Virginia Polytechnic Institute in 1964. After that, he worked as a senior engineer at the Research and Technical Center of Deere & Company in Moline, Illinois, from 1964 to 1968. He then entered the University of Iowa and pursued his PhD in Applied Mechanics from 1968 to 1971. He remained there as Assistant Professor in the Department of Mechanics and Hydraulics for one year and moved to the Mayo Clinic and created its first Biomechanics Laboratory while serving as Consultant in Orthopedics and Professor of Bioengineering from 1972 to 1993. Then, he joined the Johns Hopkins University as Professor of Orthopedic Surgery and started a new biomechanics research program and served as the Vice Chair of Research in the Department. He also held adjunct appointments in the Departments of Biomedical Engineering and Mechanical Engineering at Hopkins. His primary interest is to develop virtual human musculoskeletal simulation models for dynamic analysis to determine the skeletal forces, joint contact pressure, ligament tension, and the state of stress and strain during activities. He has also worked in the fields

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of bone fracture and/or defect repair augmentation, the reconstruction of segmental bone and joint defects after resection of bone tumor, or joint replacement revision surgery with massive bone defect, and pioneered the field of computer-aided preoperative planning and surgical navigation. He has received many honors including an honorary PhD degree from the University of Rennes in France for his contributions in limb salvage after bone tumor treatment, distinguished Alumni Awards from the Mayo Clinic and the University of Iowa, and Volvo Award for his work in low back pain, has been elected as the member of the National Academy of Engineering USA, and is Distinguished Visiting Professor at the Hong Kong University of Science and Technology and the National Chung-Kung University in Tainan, Taiwan. He is Emeritus Professor of the Mayo Clinic and the Johns Hopkins University. Currently, he still serves as Honorary Guest Professor at the Red Cross Hospital in Xi’an, and at the School of Medicine, in Yen-An, China. He has published over 400 refereed journal papers and 7 books and monographs. He has mentored countless physicians, scientists, and engineers to utilize the knowledge of biomechanics and biomaterials to enrich their teaching, medical practice, and research as well as industrial career. He was able to apply engineering principles and technologies to benefit several other medical and dental subspecialties in patient care. He wishes to serve as a role model for engineers who wish to pursue a rewarding career in a clinical environment and being accepted as a colleague by his medical peers. Franklin H. Sim Emeritus Professor, Mayo Clinic, Rochester, MN, USA Edmund Y. S. Chao Emeritus Professor, Mayo Clinic, Rochester, MN, USA Johns Hopkins University, Baltimore, MD, USA

Preface

Bone sarcoma is the most common primary bone tumor in children and adolescents with a manifestation peak occurring during the second and third decades of life. Epidemiology: According to the data of USA of 2006, the annual incidence in the United States, which remains relatively constant, was approximately 6000 to 7000 soft tissue sarcomas and 2750 bone sarcomas (China population: 1,319,000,000. American population: 301,950,000) If add metastatic bone cancer, it is hard to say this population is rare. Most common bone sarcomas are osteosarcoma, chondrosarcoma, and Ewing sarcoma. Approximately, 10% of newly diagnosed malignant tumors in children, adolescences, and adults are comprised of bone and soft tissue malignancies [1]. Bone and soft tissue tumors originated from the mesoderm, with a low incidence. The etiology of bone and soft tissue tumors is still unknown; only a few cases occur on the basis of rare congenital syndrome, such as Ollier’s disease (enchondromatosis), Maffucci syndrome, Familial retinoblastoma syndrome, Rothmund–Thomson syndrome…and so on. A comprehensive knowledge of bone and soft tissue tumors is readily available in the three authoritative books listed below or other related books: 1. Timothy AD, Orthopaedic surgery essentials oncology and basic science. Lippincott Williams & Wilkins; 2008 2. Alberto P (Ed.) Pediatric Bone and Soft Tissue Sarcomas. Springer-Verlag Berlin Heidelberg; 2006 3. Canale & Beaty: Campbell’s Operative Orthopaedics, 11th ed. Mosby, An Imprint of Elsevier; 2007. In this monograph, only related surgeries are going to focus on. For the great majority of solid malignant tumors, only using radiation therapy is not curative, and only chemotherapy is even less useful. Neoadjuvant chemotherapy combined with surgery is now the standard treatment paradigm. The agents such as adriamycin, cisplatin, ifosfamide, and cyclophosphamide were integrated into various regimens and administered in an effort to destroy silent pulmonary micrometastases which are considered to be present in at least 80% of patients at the time of diagnosis. The application of preoperative (neoadjuvant) chemotherapy is also helpful to achieve safe surgical resections. Unfortunately, there are nearly 30% of patients who are insensitive to chemotherapy. Biotherapy is also in the process of exploration, not much progress has been made in more than three decades (Figs. 1 and 2). Figures 1 and 2 show a neoplastic embolus in the subpatellar vessels of the distal femur osteosarcoma. It means that present of circulating tumor cells. So, adjuvant chemotherapy is necessary to destroy silent pulmonary micrometastases. In most cases, multidisciplinary treatment is essential. The surgery remains the mainstay for local control, and the local control of tumor is the precondition of systemic control. Amputation was the only option to achieve local control in malignant bone and soft tissue tumors of the extremity about forty years ago. Over the past nearly four decades, the therapy has shifted toward limb salvage. En bloc resection of isolated tumor mass has been the standard in ix

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Fig. 1  Osteosarcoma of distal femur. A tumor emboli in a descending genicular vessel was found

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Fig. 2  A tumor emboli in a deep large vein

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limb-sparing surgery. Prosthetic replacement has been the widely used method for limb salvage after en bloc resection. Artificial prostheses made of non-biological material, metal and plastic, have inherent defects: muscles, tendons, and ligaments can be hard to firmly attach to it; theoretically, there is a potential gap between the soft tissue and the prosthesis. This may be the cause of a late infection, especially with pelvic device. Despite the use of bone cement, it is difficult for the prosthesis and host bone to achieve a permanent strong bond, and loosening is only a matter of time. The overall event-free prosthesis survival was 63% at 5 years and 36% at 10 years [2], and the 15-year probability of implant revision-free survival was only 16% [3]. About 70% of patients at 10 years required further surgical procedures and reported a 25% risk of amputation [4]. The situation was worse for the treatment of pelvic sarcoma. Possibly, the young patients who are the susceptible population for osteosarcoma would face several times of revision surgeries during his/or her lifetime. So, an alternative technique for limb salvage has been a rather urgent work. A newly developed limb salvage method, that is microwave ablation, will be introduced in detail in this monograph. Temperature is one of the most important environmental factors for all of living cells. The upper temperature limit for plants and animals is