When Metastatic Cancer Weakens Bone, the AORIF Procedure Can Help

When cancer spreads, or metastasizes, to the bone, it can be painful and also affect mobility—some people can’t get out of bed or they may even lose the ability to walk. This form of cancer can make a bone brittle and weak and, in the worst cases, lead to disabling pathological fractures caused not by force or injury, but by the underlying disease.

Currently, most pathological fractures are treated with open surgical procedures, which require a hospital stay and a prolonged recovery process.

But there is a minimally invasive treatment providing hope for these patients; it can improve their quality of life and restore mobility so they can keep pursuing treatments, such as chemotherapy, radiation, and immunotherapy, that will address their primary cancer.

Igor Latich, MD, an interventional radiologist, and Francis Y. Lee, MD, PhD, MBA, an orthopaedic oncologist and surgeon, developed a minimally invasive interventional oncologic procedure at Yale called AORIF (Ablation Osteoplasty Reinforcement Internal Fixation). It’s a way to treat and strengthen damaged bone, and it can even be used to kill cancer cells in the area being treated.

This minimally invasive procedure uses tiny incisions and high-tech imaging to guide treatment directly to the area cancer has invaded. Major surgery is the traditional treatment used to stabilize bones that are damaged by cancer and susceptible to collapse, but recovery can take weeks or months—a critical stretch of time when patients might otherwise be undergoing potentially lifesaving or life-prolonging treatments.

What’s more, for patients receiving cancer treatment in clinical trials, undergoing major surgery can mean suspending their participation. “If a patient stops a cancer treatment associated with the trial for even a day or two, sometimes it may disqualify them from the trial,” Dr. Latich says. “And that means they may no longer have access to that cancer treatment.”

The AORIF procedure, however, allows patients to go home the same day and continue their other treatments with little—or no—interruption.

“This is a comprehensive procedure. We not only improve pain, but also try to kill the invading cancer cells locally and strengthen the affected bone to prevent its collapse,” says Dr. Lee. “That is much different than 10 years ago, when bone cancer surgery was considered ‘successful’ if it only relieved pain.”

Drs. Lee and Latich have been providing AORIF for several years and have published research articles on their approach. They have helped at least 200 patients who would have had difficulty preventing or treating pathological fractures related to bone metastases in any other way.

“The primary intent is not to cure cancer but to control its local spread and address any mechanical issues—weight-bearing fractures, for instance—as well as pain,” says Dr. Latich. “If a patient has only one small cancerous lesion in the area being treated, however, then, in theory, we could approach it with curative intent.”

Below, the two Yale experts answered questions about the AORIF procedure.

First, some background. Interventional radiology is a specialty that combines radiology and minimally invasive therapies to provide nonsurgical treatments for a variety of conditions, from opening blocked blood vessels to performing tissue biopsies. Specialists use advanced imaging, such as X-rays, ultrasounds, MRIs, and CT scans, to get a clear view inside the body while they work. They make tiny incisions through which they insert small instruments to treat abnormalities with a high level of precision.

There are different types of treatment approaches in interventional radiology that use heat or ice to destroy cancer cells. One is called radiofrequency ablation (RFA), which uses heat to burn away cancer cells.

In the AORIF procedure, a needle or probe that carries high-frequency electrical currents is passed through a small incision to deliver cancer-destroying heat to an area containing cancer cells. Then, an orthopaedic oncologist uses metal implants and bone cement to surgically stabilize the weakened bones affected by cancer.

Drs. Lee and Latich use this method to treat bones infiltrated by cancer cells that have broken away from a primary tumor in a location such as a breast, lung, kidney, thyroid, or prostate and traveled to the bone through the bloodstream or lymph nodes.

If left untreated, bone metastases can destroy the bone, leading to fractures and collapse, or they can continue to grow uncontrollably, invading and eroding adjacent structures. The procedure is especially valuable to patients who are too sick to undergo major surgery to treat the metastasized cancer.

Primary bone cancer originates in a bone and is uncommon, accounting for only about 1% of all cancers. Bone metastases is the term for when the cancer starts in one part of the body, such as the lung or breast, and spreads to the bone. “If you put cells that have metastasized to the bone under a microscope, they will look like cancer cells in the organ they came from,” explains Dr. Latich.

In a healthy body, old bone breaks down while new bone forms. Two types of bone cells drive this process: osteoblasts that form new bone and osteoclasts that break down old bone. Cancer cells from another location can cause these cells to function abnormally, and this disruption can lead to pain, fractures, compression of the spinal cord, and other problems.

There are a variety of therapies that focus on treating the cancer, including medications, internal and external radiotherapy (including external beam radiation therapy), chemotherapy, and targeted cancer drugs. Orthopaedic surgery may also be performed to stabilize bones at risk for collapse or fracture.

Still, in the vast majority of cases, bone metastases cannot be cured, and many do not respond to radiation and/or drug therapies.

AORIF has been especially powerful for cancers in the acetabulum, a weight-bearing area that is important to mobility, explains Dr. Latich. The hip is what’s known as a “ball-and-socket” joint. The “ball” is the head of the femur (thighbone), which has a rounded, ball-like shape. The “socket” is the acetabulum, a cup-shaped part of the pelvis. The rounded head of the femur (known as the femoral head) fits inside the cup-shaped acetabulum. When the hip flexes and moves, the femoral head rotates within the acetabulum.

Because the acetabulum is situated in a deep anatomic location, traditional open surgeries on a broken acetabulum require an extensive surgical dissection (a cut or separation) through healthy muscles, thereby increasing complications and recovery time. The doctors at Yale use X-ray and computed tomography (CT) guidance to insert guide wires through tiny incisions around the hip to see the diseased bone. “Once the wires are in an appropriate position, we place probes that use radiofrequency ablation to kill cancer cells,” Dr. Latich says.

Surgical cement and screws are then used to reinforce the damaged bone in the hip. Drugs that slow bone loss, called bisphosphonates (also used for osteoporosis), are mixed into the cement to further protect the bone from cancer-induced bone loss.

The two doctors have treated cancer cells in the acetabular portion of the ball-and-socket hip joint, which involves working through deep bone. “Being able to treat this area with radiofrequency ablation is a game-changer,” Dr. Lee says, explaining that major surgery would be extensive (more on that below).

The routine is the same for all weight-bearing joints, including the knees, Dr. Latich explains.

Yes. Tumors in the scapula (shoulder blade) and sacrum (a bone located at the bottom of the spine), for instance, can cause severe pain. “The process is still the same, but the goals are slightly different,” Dr. Latich says. “It’s not about preventing collapse; instead, it is used to stabilize the bone, minimize further erosion, and, most importantly, relieve pain for the patient.”

He says the instruments and some of the skillsets used to perform the operation are borrowed from vertebroplasty, another minimally invasive, X-ray-guided procedure that uses a mixture of bone cement and other tools to stabilize and heal damaged vertebrae.

While performing the AORIF procedure, the doctors also treat other conditions, including noncancerous problems, such as arthritis that causes back pain. Depending on the condition, examples of additional treatments include epidural injections, nerve ablations for benign nerve pain, or visceral blocks to control pain in the abdomen and pelvis.

“Procedures that previously would have required multiple visits on different days can now be done at the same time,” Dr. Latich says.

Dr. Latich also says he had a patient with a knee metastasis who had other medical issues that would have made open surgery difficult or impossible. “We were able to fix a hole in the knee percutaneously [through a minor incision] in a same-day procedure that allowed the patient to walk on that leg again,” he says.

Patients typically are referred to Yale by another specialist, such as an oncologist or orthopaedist. Once both Dr. Lee and Dr. Latich have seen a new patient, they try to schedule their procedure quickly. “We try to make it as comfortable and as low-key as possible because we know that most patients are fatigued from their cancer treatments,” says Dr. Latich. “Some patients have been living with cancer for years, if not decades.”

Patients are instructed to stop taking blood-thinner medications, if appropriate, and fast for six hours before the procedure. They arrive at the hospital an hour before the start of the procedure, which takes about two to three hours, followed by several hours in recovery before they go home—and the vast majority go home the same day. “The procedure is not painful and can provide rapid relief from the pain caused by the cancer,” says Dr. Lee.

Patients will need to follow up with their doctor about a week later for a recovery assessment and to discuss how the procedure has impacted or improved their day-to-day activities.

Multiple studies of noncancerous hip conditions show that preventing fractures and collapse at the hip joint has a positive impact on life expectancy, the doctors say. “Hip fractures are one of the more devastating injuries among older adults,” Dr. Latich says. “When a person is lying in bed for weeks or months while they recover, it’s more difficult to take deep breaths, and blood circulation becomes impaired, which can lead to blood clots in the lungs, infections, and pneumonia.”

What’s more, hip issues are difficult even if there is no fracture because they cause pain and interfere with structural soundness. “Not only do you have pain, but your hip feels unstable,” Dr. Latich says. “Your body knows that something doesn't feel right. You don't walk properly and bear most of the weight down on the other hip, which creates the additional problems mentioned above."

Drs. Lee and Latich have published multiple research articles showing that many of their patients have reported significant improvements in pain and function and have not had complications or needed secondary interventions.

Traditional surgery, by comparison, can remove destructive lesions and potentially repair fractures, says Dr. Lee. But, it can be extensive, involving muscle dissections, with risks not only of infection but also of dangerous bleeding and complications, such as loosening of any implants. Recovery is also painful and often lengthy.

In addition, some patients find that ablation is their only option, Dr. Lee adds. “Cancer destroys bone cells by creating inflammation in the bone, and many cancers are radiation- and chemotherapy-resistant. So, the cancer remains in a place like the pelvis, destroying bone despite the use of radiation and chemotherapy. If we only stabilize the bone without killing the cancer cells, then bone destruction will continue, and cancer cells will grow locally,” he says. “So, our goal with this procedure is to kill those treatment-resistant cancer cells.”

One finding reported by Drs. Lee and Latich is that all patients they have treated with AORIF have shown increases in healthy bone mass in damaged areas. “Bone comes back dramatically with this procedure,” Dr. Lee says.

Many people still don’t know about interventional radiology or oncologic orthopaedics—or their specialized uses for specific types of cancer treatment, say Drs. Lee and Latich. The doctors want to raise awareness, not only among patients but also among specialists who might tell their patients about this option. As treatment for advanced cancers improves, they say that more patients will be living longer with their disease and will be candidates for this type of treatment.

“You focus so much on fighting cancer, and it's important to try to rid your body of it,” says Dr. Latich. “But, if, in the process, you can't get out of a chair or even use a walker to get around, your quality of life is severely diminished. This can help.”