Scheduling surgery after transarterial embolization: does timing make any difference to intraoperative blood loss for renal cell carcinoma bone metastases?

Abstract

Renal cell carcinomas (RCCs) are one of the leading causes of cancer-related death worldwide (1). About one-third of RCCs are metastatic at initial diagnosis, and skeletal metastases are the second most frequent type of RCC metastases following lung metastases (43%) (2, 3). Surgical intervention is an option for the treatment of skeletal metastases of RCCs. Although local ablative therapies like thermal ablation may be preferred for tumors <3 cm, systemic chemotherapy and radiotherapy are other options for suitable patients (4). However, RCCs are usually chemo/radio-resistant (50%), and these treatment options are usually favored for palliative intent (3-5).The 5-year overall survival of patients with RCC bone metastases increases when surgical metastasectomy is performed (4). However, since RCC metastases in the skeletal system are usually hypervascular, the operative blood loss could be as high as 18500 mL, which could threaten patients' lives (6). Transarterial embolization (TAE) of bone tumors was first described in 1975 (7). The operative blood loss can be reduced by adequate devascularization after TAE of the bone metastases (8-11), and a blood loss of less than 3000 mL was defined as clinical success for spinal tumor surgeries (12). Selective TAE of bone metastases can be performed pre-operatively in a single session. Successful embolization can clarify the tumor margins from the surrounding tissue planes, simplifying surgical manipulation of the tumors. Thus, recurrence rates may be lower in patients undergoing this treatment PURPOSE Our purpose is to clarify the optimal timing of surgery after transarterial embolization (TAE) for renal cell carcinoma (RCC) bone metastases. METHODSThis retrospective study included 41 patients with RCC bone metastases embolized between 2013 and 2019. Different-sized particulate and/or liquid embolic agents were used for TAE. Embolizations were categorized into groups 1-3 according to the interval between TAE and surgery (group 1: <1 day, group 2: 1-3 days, group 3: >3 days). Degree of embolization after TAE was graded visually based on angiographic images (<50%, 50%-75%, 75%-90%, >90%). The relationship between the TAE-surgery interval and intraoperative blood loss (IBL) and the correlation between IBL and embolization grade were examined. Lesion sizes and the relationships among lesion localizations and contrast media usage, intervention time, and IBL were also analyzed. RESULTSForty-six pre-operative TAEs (single lesion at each session) were performed in this study (26 in group 1, 13 in group 2, 7 in group 3). Lesion sizes and distributions were similar between groups (p = 0.897); >75% devascularization was achieved in 40 (TAEs 86.96%), but the IBL showed no correlation with the embolization rate (r=0.032, p = 0.831). The TAE-surgery interval was 1-7 days. The median IBL in group 1 (750 mL; range, 150-3000 mL) was significantly lower than those in the other groups (p = 0.002). Contrast media usage (p = 0.482) and intervention times (p = 0.261) were similar for metastases...

The effect of timing between preoperative embolization and surgery: A retrospective analysis of hypervascular bone metastases

“…10,[14][15][16][17][18] Our analysis sought to evaluate how the timing between embolization and surgery impacts peri-operative outcomes in Previous analyses have evaluated how different time intervals between embolization and surgery impacts blood loss and the risk of transfusion peri-operatively with mixed evidence reported in the literature. 4,[7][8][9]16 In their analysis of 66 patients with hypervascular spinal metastases, Kato et al found significantly higher blood loss days after embolization (2000 [600-2500]; p = 0.002). 4 Conversely, Sun et al found no differences in EBL between patients undergoing surgery within 24 h and those waiting greater than 36 h from embolization (575 vs. 402 mL; p > 0.05).…”

“…4,[7][8][9]16 In their analysis of 66 patients with hypervascular spinal metastases, Kato et al found significantly higher blood loss days after embolization (2000 [600-2500]; p = 0.002). 4 Conversely, Sun et al found no differences in EBL between patients undergoing surgery within 24 h and those waiting greater than 36 h from embolization (575 vs. 402 mL; p > 0.05). 10 This was further seen in the analysis by Tang et and transfusion requirement between patients undergoing surgery the same day as embolization compared with those undergoing surgery the following day.…”

“…Previous studies have shown that patient's undergoing embolization within 1-day of the procedure have significantly lower intraoperative blood loss and transfusion risk compared with those with delayed surgery following embolization. 4,8 Conversely, other analyses have shown no difference in outcomes between those with delayed or immediate surgery. 9,10 Furthermore, a large majority of currently available information regarding embolization timing is based on embolization of isolated spinal metastases which contrains generalizability to metastases in other anatomic locations.…”

“…widely implemented when treating this oncologic patient population. 4 The optimal timing between embolization and surgery has yet to be established. [5][6][7] However, most musculoskeletal oncologists aim embolize the metastatic lesion within 24 h of the procedure to help prevent the possibility of revascularization.…”

Minimally Invasive Interventional Procedures for Metastatic Bone Disease: A Comprehensive Review

“…Intraoperative blood loss was lower with complete vs partial embolization (mean ± standard deviation, 809 ± 835 vs. 1210 ± 904 mL, p = 0.03); among patients with complete embolization, intraoperative blood loss was lower if the surgery was performed on the same day of the embolization [ 35 ]. Another recent study that included 41 patients with spinal and extra-spinal renal cell carcinoma metastases suggested that preoperative embolization was more effective in reducing blood loss when surgery was scheduled on the same day of the embolization [ 36 ]. Clausen et al conducted a randomized controlled trial including 45 patients with metastases of the spine from variable primary cancers, 23 of whom received preoperative embolization and 22 surgery without preoperative embolization.…”