Evolution of Metastases | Bone Ablation for Local Tumor Control
Evolution of Metastases | Bone Ablation for Local Tumor Control
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- [Nick] Good morning everyone. My name's Nick Kurup, I'm from Mayo Clinic. And I'd just like to thank Kristin and the leadership for inviting me to speak. I'm gonna be talking about bone ablation for local tumor control, and these are my disclosures, research stuff,

and writing about this subject. So I'm mostly gonna focus on the why. Why do we do bone ablation for local tumor control and I'll talk about a rationale for focal therapy in these patients, a little bit about technique,

and then some evidence supporting ablation for these patients. So there's been an evolution in our understanding of patients with metastatic disease. Starting in the late 1800s with Dr Halsted, he described the orderly and contiguous understanding

of metastatic spread in the case of breast cancer. So the primary tumor moving through the lymphatics to the lymph nodes before spreading systemically. And he used this as justification for patients undergoing mastectomy or radiation therapy to the breast.

Another understanding of metastatic disease is that it's always widely disseminated. So if we have a patient like this that has a melanoma metastasis to the liver, if we only had more sensitive imaging techniques could really see what's going on,

we would see that there's not only the single metastasis, but really a host of other metastases, and these patients all have micrometastasis, cats out of the bag, there's nothing to do focally for these patients.

is enhanced recovery after procedure. And is short term for ERAP for microwave ablations and our TACE procedures. So what we do there is we give, in the pre procedure area we give medications. Analgesics, Tylenol, Celebrex.

We do paravertebral blocks, or certain blocks for the patients who are in the procedure. And after the procedure we actually do, we use adjuncts to decrease the opioid consumption, increase patient satisfaction. And we've heard it before,

the previous speakers talking about how peripheral nerve blocks help. They do help. So they do enhance, patient's love it. And this is what we're doin' and it's actually very unique.

I think we're one of the first to do this, roll this out, is enhanced recovery. And this is what's been taken, we've been doin' in the operating room. So we went to the operating room. And I said okay why don't,

if we're already doing enhanced recovery after surgery, why don't we do it after a procedure. They're the same patients. They bleed, they have blood, they still have pain. And it's been getting a lot of traction. And this is just us doing a peripheral nerve block

in the IR suite, and you can see actually the IR tech and the nurses are in the background actually helping me do the nerve block. We have a little regional nerve, anesthesia regional nerve block that we've put downstairs, our offsite block.

Which is pretty neat.

The stellate ganglion is one of the higher blocks and it's actually probably one of the more difficult blocks. Many of the pain specialists will do these blind which I think is kind of amazing,

considering you have the vertebral artery, you have the carotid artery, you have the esophagus in the vicinity, and so this is a block that I think should definitely be done under image guidance. There have been papers showing that when done under CT guidance, that there's a much greater accuracy

and success with this block. The stellate ganglion block is used to treat complex regional pain syndromes in the upper extremities, like reflex sympathetic dystrophy, hyperhidrosis. So if you have patients who have heavy sweating in the hands, you can use this block to address that.

It's also been used for refractory angina, which I thought was interesting. Phantom limb pain in patients that have had amputations of their upper extremity. Herpes zoster, as well as pain in the head and neck. This block also is used in Raynaud's syndrome

in a scleroderma, it's used in vasospasm syndromes, in patients that are post traumatic or have experienced frost bite, or have embolic syndromes in the upper extremity. And again, intractable angina is one that I actually learned when I was reading about this talk.

One of the indications that is not well known is the use of the stellate ganglion block for hot flashes in the setting of breast cancer. Many of these patients are on tamoxifen and other types of agents that can cause intense hot flashes and a stellate ganglion block can actually

improve those symptoms.

Yes. - [Audience member] So we do lymph nodes integrity

inductions in the breast. They're extremely painful and patients come not prepared for a discussion about what's gonna happen to them. How would you give informed consent to let them know what's gonna happen

without giving them negative stimulus? - [Elvira] Well typically in those settings when you do your informed consent, whether it's something painful or where you potentially might kill somebody you still obviously have to describe what might happen

but what you're gonna do about it. Say, okay you know, and you explain what's happening, so say we'll be numbing up the skin and then we'll be injecting the material and you might feel that. Some people experience it as warm, some as hot,

some as a sense of tingling yeah, but the key thing is we want you to be comfortable and it's very, very important that you always tell me what is happening. If something, let's say your risk of killing somebody during your procedure, you say, and I've done

a fair amount of high risk cases. If, for example, while we're going through your heart and do that your heart stops we are going to resuscitate you and while we can never guarantee any outcomes I can promise you we will be doing everything known to mankind

to make this go well. I mean that is all I can promise so one can go somewhere deeper into that but I am open and some people in embolization say well, is it gonna hurt? I say well you know, different patients

experience it very different. The key thing is you are gonna let me know anytime how you feel like. I do not want you to be a hero, even if you say I do not want you to be a hero, still the hero is still in there,

I really want you to work with me and I'm gonna do whatever I can to make this a good experience for you. Which is, I mean it's honest, it's what you really want.

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