In this episode, host Dr. Jacob Fleming interviews Dr. Jack Jennings about cryoablation, multidisciplinary care, and practice building for the treatment of desmoid tumors.

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SHOW NOTES

First, Dr. Jennings describes the typical presentation of desmoid tumors, also known as “aggressive fibromatosis.” These are neoplasms of fibrous connective tissue, but unlike sarcomas, they do not metastasize to other parts of the body. We quickly review characteristic imaging findings such as hypointense T1 and T2 signals. In the last decade, sorafenib (tyrosine kinase inhibitor) was established as a therapy for desmoid tumors. However, since sorafenib has failed to show significant efficacy, there has been exploration into other treatments such as surgical resection and cryoablation.

Dr. Jennings encourages IRs to attend sarcoma tumor boards to learn about desmoid cases and opportunities to perform cryoablations when desmoids cannot be surgically resected. In extra-abdominal desmoids, cryoablation is ideal, since the interventionist can see the low attenuation ice ball forming and sculpt ablation zones to match irregular desmoid shapes. Dr. Jennings recommends forming a 10mm ablation margin around the tumor. Additionally, he discusses both active and passive thermal protection techniques for surrounding tissues. He utilizes carbon dioxide, hydropneumodissection, and motor/somatosensory evoked potentials to keep non-target tissues out of the ablation zone. The bowel and nerves (especially in the extremities) are critically important to avoid.

For post-procedural care, Dr. Jennings emphasizes that pain is very common, due to large inflammatory responses. He usually admits patients overnight to monitor pain levels and give IV Decadron. Patients are then sent home with Medrol Dosepak. We also talk about the importance of informed consent about pain and potential nerve injuries.

Finally, we discuss how IRs can be advocates for patients with desmoids. Dr. Jennings believes that preemptive measures can go a long way when talking to third party payers. He will usually include current National Comprehensive Cancer Network (NCCN) guidelines and current cryoablation papers in his clinic notes to support his recommendations. He also encourages IRs to collaborate with oncologists, surgeons, and radiation oncologists to craft the best treatment plan for their patients.

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RESOURCES

Washington University MSK Interventions:
https://www.mir.wustl.edu/education/subspecialty-programs/musculoskeletal-imaging-and-interventions/

Neuroanatomic Considerations in Percutaneous Tumor Ablation:
https://pubs.rsna.org/doi/10.1148/rg.334125141

Anatomically Based Guidelines for Core Needle Biopsy of Bone Tumors: Implications for Limb-sparing Surgery:
https://pubs.rsna.org/doi/10.1148/rg.271065092

National Comprehensive Cancer Network (NCCN) Guidelines for Soft Tissue Sarcomas (including Desmoid Tumors):
https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1464

Society for Interventional Oncology (SIO):
http://www.sio-central.org/

Cryoablation for Palliation of Painful Bone Metastases: The MOTION Multicenter Study:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011449/