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Crossed-Probes Cryoablation for the Treatment of a Sclerotic Vertebral Metastasis Abutting the Spinal Canal

Ricardo Miguel Costa de Freitas, MD, PHD, José Guilherme Mendes Pereira Caldas, MD, PHD, Silvia Mazzali Verst, MD, PHD, Ana Oliveira Hoff, MD, PhD, João Evangelista Bezerra Neto, MD, PhD, and Maria Candida Barisson Villares Fragoso, MD, PhD

A 44-year-old woman presented with lumbar pain (visual analog scale [VAS] = 9) secondary to adrenocortical carcinoma sclerotic L4-vertebral metastasis. The positron emission tomography-computed tomography

hypermetabolic lesion (Fig 1a,d) was unresponsive to radiotherapy or chemotherapy. She refused surgery. Following general anesthesia and aseptic preparation, 2 power drill-mounted (Aesculap, Center Valley,

Figure 1. Positron emission tomography-computed tomography of the fourth lumbar vertebra in axial and sagittal planes, respectively, (a,d) before treatment, (b,e) after the first cryoablation session, and (c,f) after the second cryoablation session. (a,d) Hypermetabolic activity in the vertebral body (yellow arrows). (b,d) The first cryoablation session resulted in almost 90% of resolution of hypermetabolic activity, with residual FDG avidity in the right side of the vertebral body and close to the periosteal reaction of the posterior wall (b, empty yellow arrows; e, white arrow). (c,f) The second cryoablation session resulted in a complete resolution of FDG avidity in the periosteal reaction of the posterior wall. Only a small portion of hypermetabolism persisted in the anteroinferior vertebral body (empty white arrow) following subsequent examinations, predictable as residual metastatic disease. FDG = fluorodeoxyglucose.

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From the Department of Radiology (R.M.C.d.F., J.G.M.P.C.), Instituto de Radiologia, and Department of Endocrinology (M.C.B.V.F.), Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil; Endocrinology Unit (A.O.H.), Department of Oncology (J.E.B.N.), and Instituto do Câncer do Estado de São Paulo (R.M.C.d.F.), Av. Dr. Enéas de Carvalho Aguiar, s/n° - Rua 1 - Cerqueira César, 05403-900, São Paulo, SP, Brazil; and Interventional Radiology Unit (R.M.C.d.F.) and Neurophysiology Unit (S.M.V.), Rede de Hospitais São Camilo de São Paulo, São Paulo, SP, Brazil. Received September 13, 2019; final revision received November 4, 2019; accepted November 5,

2019. Address correspondence to R.M.C.d.F .; E-mail: ricardo.freitas@hc.fm. usp.br

None of the authors have identified a conflict of interest.

@ SIR, 2019

J Vasc Interv Radiol 2020; 31:284-285

https://doi.org/10.1016/j.jvir.2019.11.006

Figure 2. Computed tomography reformatted scans of the fourth lumbar vertebra in the (a) sagittal, (b) coronal, and (c) axial planes, respectively, during the first cryoablation session. (a,b) Cryoprobes positioned during first cryoablation session (white arrows). (d) T1-weighted axial plane magnetic resonance imaging of the vertebra after the first cryoablation session with crossed cryoprobes, showing the cryoprobe paths (*) and the posterior edges of the resultant frozen margins (small white arrows). (e) Motor- and somatosensory-evoked potentials surveillance showing standard signaling during the second cryoablation session. (f) Computed tomography scan in the axial plane during the second cryoablation session showing the angulation of the crossing- probes toward to the right (empty white arrow) aimed to reach the right-sided fluorodeoxyglucose-avid remnant areas observed in (b,e). (c) Compare with the different position of the cryoprobes in the first cryoablation session.

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Pennsylvania) k-wires were inserted in each vertebral pedicle with lat- eromedial opposite directions, resulting in crossed wires. Two 2.4- cryoprobes (Endocare, Austin, Texas) inserted via 2 8G-needles (T-lok, Argon Medical Devices, Frisco, Texas) (Fig 2a-c) delivered a 2-minute freezing/1-minute thawing double protocol. About 90% of the fluo- rodeoxyglucose (FDG)-avid lesion was treated (Fig 1b,e and Fig 2d). No neurological deficits developed. The pain score dropped (VAS = 2), but increased after 6 weeks (VAS = 7). A second cryoablation followed under motor-evoked potential (MEP) and somatosensory-evoked poten- tial (Fig 2e). The crossing-probes angulation toward to the right aimed the right-sided FDG-avid remnant areas (Fig 2f). There was 60% drop of the right L4-MEP amplitude, and 100-V stimulus intensity increase during a 3-minute freezing/1-minute thawing double protocol. Warm saline irrigation reversed transient P40 (somatosensory-evoked potential) drop. Final L4-MEP showed 30% amplitude drop. The lumbar pain

relieved (VAS = 0). Immediate right L4-paresis developed. Progressive and complete neurological recovery occurred in 6 months after daily active/passive physiotherapy. The periosteal reaction abutting the spinal canal was no longer FDG-avid (Fig 1c,f). A remnant anterior inferior vertebral body hypermetabolism was detected. Cryoablation was acknowledged as the main therapy, given the cryoablation magnitude, drug or radiotherapy inefficacy, the incipient adrenocortical carcinoma systemic immunotherapy or target-therapy. She underwent a third cry- oablation aiming at local disease control, with the same first protocol.

ACKNOWLEDGMENTS

The authors thank the support of endocrinologists Antonio Marcondes Lerario, Madson Queiroz Almeida, and Berenice Bilharinho Mendonça.