Combination of Radiofrequency Ablation and Intramedullary Nailing for the Treatment of Femoral Metastases: Single-center, Retrospective Observational Study

Combination of Radiofrequency Ablation and Intramedullary Nailing for the Treatment of Femoral Metastases: Single-center, Retrospective Observational Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Combination of Radiofrequency Ablation and Intramedullary Nailing for the Treatment of Femoral Metastases: Single-center, Retrospective Observational Study Nokitaka Setsu, Suguru Fukushima, Nobuhiko Yokoyama, Kenji Shinozaki, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6829784/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Nov, 2025 Read the published version in World Journal of Surgical Oncology → Version 1 posted 11 You are reading this latest preprint version Abstract Background : Radiofrequency ablation (RFA) has gained attention as a palliative treatment for bone metastases, offering pain relief and local tumor control. While its use in trunk lesions is well documented, its application in long bones remains limited because ofconcerns about postablationfractures. These risks may be mitigated by combining RFA with prophylactic intramedullary nailing (IMN). Methods : Five consecutive patients with femoral metastases who underwent combined RFA and IMN, either as a single-stage procedure with intraoperative fluoroscopic guidance or in two stages using CT-guided RFA followed by IMN, were included. Pain relief, function, radiographic response, histology, and complications were retrospectively assessed. Results : All patients experienced early pain relief and regained mobility. The average amount of intraoperative blood loss was 48 ml, which was significantly lower than the historical control cases. At the final follow-up, one lesion had slightly progressed, three remained stable, and one decreased in size. The complicationsincluded one nonunion case requiring revision and one case of skin burn from electrode pad placement. While immediate pain relief was notable, the isolated midterm effect of RFA was difficult to evaluate because of concurrent IMN and frequent postoperative radiotherapy. No adverse interactions were observed with combined radiotherapy. Conclusion : RFA combined with IMN offers a minimally invasive, effective option for local control and functional recovery in patients with femoral metastases. Ideal candidates include those with impending fractures with preserved continuity of the femoral shaft, lesser trochanter avulsions, hypervascular tumors, or radiotherapy-resistant lesions. This approach may serve as an alternative to extensive resection in selected patients. Radiofrequency ablation Intramedullary nailing Bone metastases Impending fracture Femur Figures Figure 1 Figure 2 Background Pathological fractures or impending fractures caused by metastatic bone tumors in long bones, such as the femur and humerus, are commonly treated with intramedullary nailing (IMN), which is considered the standard approach. IMN is a minimally invasive procedure involving the insertion of an implant through several small incisions, stabilizing the fracture site, resulting in pain relief and enabling early weight-bearing. However, concerns remain regarding potential tumor seeding during nail insertion and implant failure in the case of tumor progression. To address local tumor control, palliative radiotherapy is often employed in conjunction, and for patients with a longer expected survival, more invasive treatments, such as tumor resection combined with tumor prosthesis replacement, may be selected [ 1 ]. Radiofrequency ablation (RFA) is a local ablative technique that delivers high-frequency electrical currents (~ 450 kHz) through needle-shaped electrodes, generating spherical thermal coagulation. Originally used for hepatocellular carcinoma, its application was expanded in Japan to include malignant bone tumors as of September 2022. The advantages of RFA in treating metastatic bone tumors include rapid pain relief [ 2 , 3 ], local tumor control [ 4 ], and intraoperative bleeding reduction when followed by surgery [ 5 , 6 ]. In comparison with radiotherapy, RFA offers several benefits: it can be completed within hours, is effective even for radioresistant tumors, and is not limited in the number of repeatable treatments. Furthermore, RFA and radiotherapy can be used in combination [ 7 , 8 ]. However, RFA also carries risks, including early complications such as thermal injury and transient pain exacerbation, as well as delayed complications such as pathological fractures due to postablation osteonecrosis [ 9 , 10 ]. This complication is particularly concerning in weight-bearing long bones such as the femur, which often necessitate surgical intervention. Only two previous reports have described the combined use of RFA and IMN for the treatment of metastatic lesions in long bones [ 5 , 6 ]. While its superiority remains unestablished, this combination is theoretically rational: IMN can compensate for RFA-induced structural weakening, whereas RFA can provide local control, which is a limitation of IMN alone. This approach may allow the application of minimally invasive procedures to patients with longer life expectancies by enabling early postoperative mobilization and pain control. In this study, we evaluated the safety and efficacy of combining RFA and IMN for the treatment of metastatic bone tumors in the femur. Methods Study Design We retrospectively evaluated the efficacy and safety of radiofrequency ablation (RFA) combined with intramedullary nailing (IMN) in patients with impending or pathological fractures of the femur due to metastatic bone tumors treated at our institution between July 2023 and July 2024. Historical control cases that underwent IMN alone were used to compare the amount of intraoperative blood loss and operative time. Statistical analysis was performed via a two-tailed t-test. Patient population Patients diagnosed with femoral metastatic bone tumors presenting with either impending or pathological fractures, who were considered appropriate candidates for intramedullary nailing (IMN) based on standard surgical indications, were included. Patients with the following conditions were not considered suitable candidates for this treatment: (1) lesions larger than 6 cm in diameter that were deemed unlikely to be sufficiently ablated by RFA; (2) lesions located in areas where RFA needle insertion was considered technically unfeasible; and (3) cases with severe osteosclerosis in which needle insertion was expected to be difficult. The introduction of RFA for the treatment of bone tumors was approved by the institutional clinical ethics committee. A multidisciplinary cancer board reviewed all the cases and determined treatment strategies before intervention. Informed consent was obtained from all patients before treatment. To select historical controls, we reviewed 22 consecutive cases of unilateral IMN performed between June 2021 and May 2023. Among these, 3 cases of fragility fractures, 2 atypical femoral fractures, 6 cases with bone metastases larger than 6 cm, and 3 cases with extensive sclerotic lesions were excluded because they were considered unsuitable for RFA based on the criteria described above. RFA procedure RFA was performed using the Cool-tip™ RFA System E Series (Covidien Japan), following the guidelines and protocols provided by the Japanese Society of Interventional Radiology. An electrode with a 3-cm exposed tip was used in all cases, and the number of ablation cycles was adjusted on the basis of the size and configuration of the lesion, assuming a spherical ablation zone approximately 3 cm in diameter. All procedures were performed in collaboration with interventional radiologists. Surgical Approach and Postoperative Management The choice between single-stage and two-stage treatment was based on the method of RFA guidance. When CT-guided RFA was preferred, the procedure was performed in an angiography suite, and IMN was subsequently carried out. When RFA was performed through the femoral medullary canal under fluoroscopic guidance, IMN was performed in the same session as a single-stage procedure. Postoperative care included routine pain control, early mobilization, and regular clinical and radiographic follow-up to monitor healing and identify any complications. Results Patient Overview Five patients underwent combined RFA and IMN treatment (Table 1 ). One patient (Case 1) experienced pain recurrence and tumor progression in the femur five months after palliative radiotherapy; the remaining four patients received postoperative radiation. Two patients underwent two-stage procedures: the IMN procedure was carried out 17 days after RFA in Case 1, and 6 days after RFA in Case 2. Table 1 Patient Profiles, Therapeutic Procedures, and Complications. Case Primary Age Sex Location Size (cm) Staged Procedure Ablation time Initial resistance Final Temp. Operative bleeding Complication RT history Post-op RT Other adjuvant 1 Lung 70 F Tr 3 Two 15' 78 Ω 60 ℃ 20 ml Skin burn + - - IFx* 7' 78 Ω 75 ℃ 2 Uterine 74 F Tr 4.5 Two NA 53 Ω > 60 ℃ 20 ml - - ་ Partial curettage IFx 7'40" 46 Ω > 60 ℃ 9'47" 52 Ω > 60 ℃ 3 Lung 80 M Tr 4 Single 5' 108 Ω 89 ℃ 50 ml - - ་ - IFx 2'05" 255 Ω 63 ℃ 4' 112 Ω 93 ℃ 4 Lung 70 F SubTr 6 Single 15' 117 Ω 81 ℃ 50 ml Nonunion - ་ - PFx 15' 112 Ω 75 ℃ 15' 120 Ω 100 ℃ 5 Kidney 71 F Tr~ 4 Single 3'13" 181 Ω 62 ℃ 100 ml - - ་ Partial curettage SubTr + 1.5 2'44" 119 Ω 64 ℃ Cementing + 1.5 8' 88 Ω 69 ℃ PFx 5' 282 Ω 87 ℃ Tr: trochanteric, IFx: Impending fracture, PFx: Pathological complete fracture, RT: radiotherapy *Impending fracture of the shaft accompanied by an avulsion fracture of the lesser trochanter. The eight historical control patients who underwent IMN alone included five with lung cancer, two with breast cancer, and one with hepatocellular carcinoma; all of these patients presented with impending fractures. Pain and functional outcomes The pain levels and functional outcomes during follow-up are summarized in Table 2 . In both two-stage cases, including a case with avulsion fracture of the lesser trochanter (Case 1), the NRS for movement-related pain improved to 0 within three days post-RFA, although the evaluation was performed under non-weight-bearing conditions. Following IMN, pain assessment may have been compromised by surgical site pain, but all patients were ambulatory with manageable pain by week 1. Pain evaluation was eventually compromised in Case 1 due to the progression of other bone metastases and in Case 4, who developed nonunion, as described later. Except for these patients, no treatment site-related complications or symptoms were observed during the follow-up period. Table 2 Movement-related Pain, Ambulatory Function, and Oncological Outcome. Case Pre-treatment 1 day post RFA 3 days post RFA 1 week post-op 4 weeks post-op 12 weeks post-op Progression of the ablated area Progression of other bone metastases Follow-up period Status 1 NRS 3 NRS 0 NRS 0 NRS 1 NRS 3 NRS 3 Minimal Enlargement 4M DOD NWB Cane Cane Walker progression Increase Lesser trochanter avulsion Sacral metastasis 2 NRS 2 NRS 5 NRS 0 NRS 0 NRS 0 NRS 0 Decreased NA 8M DOD NWB Cane Cane Independent (Solitary) 3 NRS 0 NA NA NRS 5 NRS 0 NRS 0 No change Increase 5M AWD NWB Walker Cane Cane 4 NA NA NA NRS 3 NRS 0 NRS 0 No change NA 10M NED Fractured Crutches Crutches Cane (Solitary) Non-weight bearing Non-weight bearing 5 NA NA NA NRS 5 NRS 3 NRS 0 No change Enlargement 6M DOD Fractured Walker Cane Cane RFA: Radiofrequency Ablation, NRS: Numerical Rating Scale, DOD: Died of Disease, AWD: Alive With Disease, NED: No Evidence of Disease, NWD: Non-Weight Bearing Imaging and Local Tumor Control In both two-stage cases, contrast-enhanced CT performed on the day after RFA revealed reduced enhancement at the RFA site (Fig. 1 ). At the final follow-up, one lesion had slightly progressed, three were stable, and one had decreased in size (Table 2 ). In all three patients with bone metastases at sites other than the treated lesion, disease progression was observed at those locations. No bone formation was observed at any RFA site. PET and bone scintigraphy findings and histological findings In Case 3, postoperative PET revealed no abnormal FDG uptake in the ablated lesion (Fig. 2 ), suggesting tumor inactivation by RFA. In contrast, bone scintigraphy at four months revealed preserved tracer uptake, suggesting the maintenance of osteogenic activity. Histopathological examination of intramedullary samples revealed degenerative changes, such as nuclear swelling, chromatin homogenization, and vacuolar degeneration, in all five cases. In cases where surgery was performed in a staged manner, inflammatory cell infiltration was also observed. In Case 1, where sampling was conducted 17 days after RFA, only minimal viable tumor cells were found. However, in the remaining cases, including Case 3 in which FDG uptake had disappeared, 20–50% of the tumor cells remained viable. Considering the overall clinical course, histopathological evaluation did not reliably reflect the therapeutic effects observed by imaging. Complications Nonunion One patient (Case 4) developed nonunion with IMN failure at 6 months and required revision surgery with proximal femoral resection and prosthesis replacement. Histological examination of the resected specimen revealed fibrous or necrotic tissue, approximately 60% preservation of osteocytes within the cortical bone, and no evident residual tumor cells, suggesting partial osteonecrosis due to excessive ablation temperature. Burn injury One patient developed a second-degree burn on the skin of the bilateral medial thighs, probably due to an electrical shortcut between the electrode pad on the contralateral thigh and the RFA needle. Modifying the electrode pad placement to the trunk prevented recurrence. Intraoperative and procedural tolerance Two patients reported discomfort during RFA under local anesthesia, which was managed with cooling, analgesics, and sedation. Blood loss during IMN procedures was minimal (mean 48 ml) and significantly lower than that in the control patients (Table 3 ). The mean operative time was longer in patients who underwent RFA, but the difference was not statistically significant. Table 3 Operative Blood Loss and Time: IMN with vs. without RFA. n Blood loss (ml), mean SD P-value Operative time (min), mean SD P-value RFA + IMN 5 48.0 32.7 0.011* 131.4 45.3 0.348 IMN control 8 156.9 88.9 105.6 46.2 RFA: Radiofrequency Ablation, IMN: Intramedullary Nailing, *Statistically significant (p < 0.05) Discussion When RFA is used for metastatic bone tumors, the primary goal is pain relief as part of palliative care. However, RFA also offers benefits in terms of local tumor control and intraoperative hemostasis during subsequent surgical procedures. Therefore, combining RFA with IMN fixation provides multiple advantages. In this study, the combination demonstrated short- to midterm safety and effectiveness, particularly for impending fractures. The RFA needle must be inserted carefully to avoid damaging major vessels and nerves, such as the femoral artery, vein, femoral nerve, and sciatic nerve. A vertical approach to the lesion might be preferable for cortical destruction or avulsion fractures at the lesser trochanter, making CT-guided RFA desirable. When intraoperative CT is available, a single-stage procedure may be feasible; otherwise, a two-stage approach—performing RFA under CT guidance, confirming the ablation area with contrast-enhanced CT imaging, and proceeding with IMN—is appropriate. In two-stage procedures, patients should be maintained in strict non-weight-bearing conditions between RFA and IMN to prevent fracture. Conversely, when the cortical bone remains intact and the lesion is confined within the medullary cavity, accessing the tumor longitudinally via the intramedullary canal under fluoroscopic guidance is more reasonable. In such cases, CT-guided RFA is technically challenging, and a single-stage procedure with simultaneous RFA and IMN is preferable. A single-stage procedure is also appropriate if direct intraoperative tumor ablation is needed. In this study, RFA achieved remarkable short-term pain relief in cases where immediate postablation assessment was possible. Notably, in one patient with an avulsion fracture of the lesser trochanter, marked relief of motion-induced pain was observed, suggesting the utility of RFA for lesser trochanter avulsions in which IMN cannot stabilize. Isolating the specific contribution of RFA to midterm pain relief remains challenging because IMN fixation alone affords substantial pain relief by stabilizing fractures. Previous retrospective studies have also suggested that RFA, when used adjunctively with IMN, tends to provide better pain control than radiotherapy with IMN [ 6 ]. However, in the present series, postoperative radiotherapy was performed in most patients, except for those with recurrence after prior radiation therapy. Therefore, it is difficult to evaluate the independent pain relief effect of RFA alone, similar to the challenges in assessing its tumor control effect. Notably, even when postoperative radiotherapy was combined with RFA, no increase in adverse effects was observed. Several reports have described the usefulness of combining RFA and radiotherapy for treating spinal metastases [ 7 , 8 ]; thus, similar synergistic effects may be expected in long bones such as the femur. At the very least, in cases where radiotherapy is contraindicated, unavailable, or less effective, RFA is a useful adjunctive therapy alongside IMN fixation. Tumor control via thermal ablation shares similarities with the pasteurization technique, a well-established method for autograft recycling that heats bone to 60°C to 65°C for 30 to 40 minutes to eradicate malignant cells while preserving the biomorphogenic properties of bone [ 11 ]. Nevertheless, similar to pasteurized bone, RFA-treated bone may show delayed union. Experimental studies have reported that although osteocyte remnants can be observed after RFA, partial bone necrosis occurs [ 12 ]. In one patient from this study where both PET and bone scintigraphy data were available post-RFA, FDG uptake disappeared, whereas bone scintigraphy activity remained, suggesting preserved bone metabolic activity despite tumor ablation. In contrast, in the case of nonunion, histological analysis revealed residual osteocytes without evidence of new bone formation, implying impaired osteoinductive potential, probably due to protein denaturation and necrotic tissue. Although some reports suggest that the pain-relieving effect of RFA is greater in patients with pathological fractures [ 13 , 14 ], applying RFA to fractured weight-bearing bones such as the femur carries a risk of delayed union and implant failure. Based on the above considerations, limiting indications to impending fractures with preserved cortical continuity with cement augmentation when specifically indicated is safer. To retain bone healing capacity in femoral lesions, we aimed to replicate conditions similar to pasteurization by not prioritizing roll-off protocols; instead, we interrupted ablation four minutes after initiation, confirmed temperatures, and aimed to maintain 60–70°C for approximately five minutes. Unlike the liver, bone ablation cannot be monitored by ultrasound. Furthermore, our cooling-electrode system did not allow real-time temperature monitoring during ablation; ablation must be paused for approximately 20 seconds to measure the temperature. Further investigation into the optimal timing for temperature checks is warranted. This study observed one case of each nonunion and thermal skin injury, but no other RFA-related complications occurred. IMN with RFA, which is consistent with previous reports [ 5 , 6 ], resulted in significantly less intraoperative blood loss than did control patients with IMN alone. This combined approach demonstrated a hemostatic advantage during IMN, suggesting its suitability for metastases originating from hypervascular tumors. Although the operative time was longer in the combined treatment group, the difference was not statistically significant. Notably, while all control cases involved impending fractures, two patients in the combined treatment group experienced complete fractures. This likely resulted in an upward bias in the operative time due to the additional steps required for the exposure and reduction of fractures, indicating that the observed prolongation may not be clinically meaningful. Overall, the combined RFA and IMN technique was generally safe and effective for impending fractures, offering pain relief, tumor control, and hemostasis benefits. However, in cases of complete pathological fractures, caution is warranted owing to the potential risk of impaired bone healing. Conclusion RFA combined with intramedullary nailing for long bone metastases appears to be a minimally invasive and effective strategy for achieving local tumor control while restoring function. Although wide resection and tumor prosthesis reconstruction are often preferred in patients with longer life expectancies, this combined technique may serve as a less invasive alternative. Currently, the most favorable indications for RFA combined with intramedullary nailing include impending fractures without complete cortical disruption, avulsion fractures of the lesser trochanter, hypervascular tumors anticipated to cause significant intraoperative bleeding, and cases that are resistant or less sensitive to radiotherapy. To ensure effectiveness and safety, we recommend checking the electrode tip temperature approximately four minutes after the start of ablation. Abbreviations Intramedullary nailing (IMN), radiofrequency ablation (RFA) Declarations Ethics approval and consent to participate The institutional review board of the NHO Kyushu Cancer Center approved this study (K2022037). Consent for publication Written informed consent was obtained from all patients via the institution’s standardized consent form. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was supported in part by the 44th General Research Grant from the Japanese Foundation for Multidisciplinary Treatment of Cancer. Portions of the abstract and figures from this manuscript have been included in the report of the above grant; however, no copyright transfer has occurred. Authors' contributions NS contributed to the conceptualization, analysis, and writing of the draft. SF, NY, TF, AN, and NF contributed to data acquisition. KS, MJ, and RS contributed to the data interpretation and revision. Acknowledgements Not applicable. Author contributions NS contributed to Conceptualization, Methodology, Investigation, Funding acquisition, and Writing – original draft. SF, NY, TF, AN, and NF contributed to Resources and Visualization. KS, MJ, and RS contributed to Data curation, Formal analysis, Supervision, and Writing – review and editing. References N. Araki, H. Chuman, T. Matsunobu, K. Tanaka, H. Katagiri, T. Kunisada, T. Hiruma, H. Hiraga, H. Morioka, H. Hatano, K. Asanuma, Y. Nishida, K. Hiraoka, T. Okamoto, S. Abe, M. Watanuki, T. Morii, H. Sugiura, Y. Yoshida, T. Ohno, H. Outani, K. Yokoyama, S. Shimose, H. Fukuda, Y. 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Cite Share Download PDF Status: Published Journal Publication published 10 Nov, 2025 Read the published version in World Journal of Surgical Oncology → Version 1 posted Editorial decision: Revision requested 06 Oct, 2025 Reviews received at journal 27 Sep, 2025 Reviewers agreed at journal 27 Sep, 2025 Reviewers agreed at journal 23 Sep, 2025 Reviewers agreed at journal 14 Sep, 2025 Reviews received at journal 24 Aug, 2025 Reviewers agreed at journal 20 Aug, 2025 Reviewers invited by journal 11 Jun, 2025 Editor assigned by journal 08 Jun, 2025 Submission checks completed at journal 06 Jun, 2025 First submitted to journal 05 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6829784","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":469763200,"identity":"66a4aea2-0b7b-46cc-a70e-0861487d5a34","order_by":0,"name":"Nokitaka Setsu","email":"data:image/png;base64,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","orcid":"","institution":"NHO Kyushu Cancer Center","correspondingAuthor":true,"prefix":"","firstName":"Nokitaka","middleName":"","lastName":"Setsu","suffix":""},{"id":469763201,"identity":"97891645-d498-4edd-a81a-96d585892589","order_by":1,"name":"Suguru Fukushima","email":"","orcid":"","institution":"NHO Kyushu Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Suguru","middleName":"","lastName":"Fukushima","suffix":""},{"id":469763202,"identity":"2e7fa9f8-0a99-462b-a2cd-7d38b6dccbab","order_by":2,"name":"Nobuhiko Yokoyama","email":"","orcid":"","institution":"NHO Kyushu Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Nobuhiko","middleName":"","lastName":"Yokoyama","suffix":""},{"id":469763203,"identity":"918f5892-492a-40a0-a1d4-0cbe1ecacc60","order_by":3,"name":"Kenji Shinozaki","email":"","orcid":"","institution":"NHO Kyushu Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Kenji","middleName":"","lastName":"Shinozaki","suffix":""},{"id":469763204,"identity":"9fbc51cd-9c64-452e-a2b2-a3ef027c5c01","order_by":4,"name":"Mikako Jinnouchi","email":"","orcid":"","institution":"NHO Kyushu Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Mikako","middleName":"","lastName":"Jinnouchi","suffix":""},{"id":469763205,"identity":"84a10a09-8120-4875-a6c3-5d37abed36b7","order_by":5,"name":"Takatoshi Fujishita","email":"","orcid":"","institution":"NHO Kyushu Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Takatoshi","middleName":"","lastName":"Fujishita","suffix":""},{"id":469763206,"identity":"53539901-6572-4ec4-bf96-2e12059f2211","order_by":6,"name":"Ai Nio","email":"","orcid":"","institution":"NHO Kyushu Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Ai","middleName":"","lastName":"Nio","suffix":""},{"id":469763207,"identity":"a4122988-4a0a-4c99-b481-c063badaf787","order_by":7,"name":"Nobuki Furubayashi","email":"","orcid":"","institution":"NHO Kyushu Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Nobuki","middleName":"","lastName":"Furubayashi","suffix":""},{"id":469763208,"identity":"23ca994f-472a-458a-ad07-99f6066f76c7","order_by":8,"name":"Rie Sugimoto","email":"","orcid":"","institution":"NHO Kyushu Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Rie","middleName":"","lastName":"Sugimoto","suffix":""}],"badges":[],"createdAt":"2025-06-05 13:53:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6829784/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6829784/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12957-025-04091-8","type":"published","date":"2025-11-10T15:58:24+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":84684998,"identity":"8a49e8e3-53b0-413e-b919-0e0761b37376","added_by":"auto","created_at":"2025-06-16 08:52:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":449164,"visible":true,"origin":"","legend":"\u003cp\u003eLocal control effect of RFA (Case 2).\u003c/p\u003e\n\u003cp\u003ePreablation CT image with contrast enhancement (arrow) (A). CT on the day after RFA showing reduced enhancement and central gas formation (B). Postoperative radiograph (C). Contrast-enhanced CT at 5 months postsurgery showing posterior extraosseous mass reduction without curettage in this area (arrow) (D).\u003c/p\u003e\n\u003cp\u003eRFA: Radiofrequency ablation.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6829784/v1/d4de80302f9b5b1ad6cffcb0.png"},{"id":84684999,"identity":"ea4d2874-e462-4226-8082-196d264b3351","added_by":"auto","created_at":"2025-06-16 08:52:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":468504,"visible":true,"origin":"","legend":"\u003cp\u003ePreservation of bone regenerative potential after RFA (Case 3).\u003c/p\u003e\n\u003cp\u003ePretreatment radiograph (A), pretreatment CT image (B), and fat-suppressed T2-weighted image (C) showing the metastatic lesion (arrow). Posttreatmentradiograph (D). PET-CT one month after treatment revealed uptake in multiple metastatic bone lesions (arrowheads) but no uptake at the RFA-ablated site (arrow) (E). Bone scintigraphy four months after treatment showing uptake comparable to that of the surrounding cortical bone (arrow) (F).\u003c/p\u003e\n\u003cp\u003eRFA: Radiofrequency ablation.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6829784/v1/2384d122f12641a99777dacc.png"},{"id":96105870,"identity":"efae6cc9-a48b-469a-b902-43646aeabebb","added_by":"auto","created_at":"2025-11-17 16:12:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1889669,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6829784/v1/65f32547-bb49-4f24-a6d9-6fb2418a5fd8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Combination of Radiofrequency Ablation and Intramedullary Nailing for the Treatment of Femoral Metastases: Single-center, Retrospective Observational Study","fulltext":[{"header":"Background","content":"\u003cp\u003ePathological fractures or impending fractures caused by metastatic bone tumors in long bones, such as the femur and humerus, are commonly treated with intramedullary nailing (IMN), which is considered the standard approach. IMN is a minimally invasive procedure involving the insertion of an implant through several small incisions, stabilizing the fracture site, resulting in pain relief and enabling early weight-bearing. However, concerns remain regarding potential tumor seeding during nail insertion and implant failure in the case of tumor progression. To address local tumor control, palliative radiotherapy is often employed in conjunction, and for patients with a longer expected survival, more invasive treatments, such as tumor resection combined with tumor prosthesis replacement, may be selected [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRadiofrequency ablation (RFA) is a local ablative technique that delivers high-frequency electrical currents (~\u0026thinsp;450 kHz) through needle-shaped electrodes, generating spherical thermal coagulation. Originally used for hepatocellular carcinoma, its application was expanded in Japan to include malignant bone tumors as of September 2022. The advantages of RFA in treating metastatic bone tumors include rapid pain relief [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], local tumor control [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and intraoperative bleeding reduction when followed by surgery [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In comparison with radiotherapy, RFA offers several benefits: it can be completed within hours, is effective even for radioresistant tumors, and is not limited in the number of repeatable treatments. Furthermore, RFA and radiotherapy can be used in combination [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, RFA also carries risks, including early complications such as thermal injury and transient pain exacerbation, as well as delayed complications such as pathological fractures due to postablation osteonecrosis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This complication is particularly concerning in weight-bearing long bones such as the femur, which often necessitate surgical intervention.\u003c/p\u003e \u003cp\u003eOnly two previous reports have described the combined use of RFA and IMN for the treatment of metastatic lesions in long bones [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. While its superiority remains unestablished, this combination is theoretically rational: IMN can compensate for RFA-induced structural weakening, whereas RFA can provide local control, which is a limitation of IMN alone. This approach may allow the application of minimally invasive procedures to patients with longer life expectancies by enabling early postoperative mobilization and pain control. In this study, we evaluated the safety and efficacy of combining RFA and IMN for the treatment of metastatic bone tumors in the femur.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eWe retrospectively evaluated the efficacy and safety of radiofrequency ablation (RFA) combined with intramedullary nailing (IMN) in patients with impending or pathological fractures of the femur due to metastatic bone tumors treated at our institution between July 2023 and July 2024. Historical control cases that underwent IMN alone were used to compare the amount of intraoperative blood loss and operative time. Statistical analysis was performed via a two-tailed t-test.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePatient population\u003c/h3\u003e\n\u003cp\u003ePatients diagnosed with femoral metastatic bone tumors presenting with either impending or pathological fractures, who were considered appropriate candidates for intramedullary nailing (IMN) based on standard surgical indications, were included. Patients with the following conditions were not considered suitable candidates for this treatment: (1) lesions larger than 6 cm in diameter that were deemed unlikely to be sufficiently ablated by RFA; (2) lesions located in areas where RFA needle insertion was considered technically unfeasible; and (3) cases with severe osteosclerosis in which needle insertion was expected to be difficult.\u003c/p\u003e \u003cp\u003eThe introduction of RFA for the treatment of bone tumors was approved by the institutional clinical ethics committee. A multidisciplinary cancer board reviewed all the cases and determined treatment strategies before intervention. Informed consent was obtained from all patients before treatment.\u003c/p\u003e \u003cp\u003eTo select historical controls, we reviewed 22 consecutive cases of unilateral IMN performed between June 2021 and May 2023. Among these, 3 cases of fragility fractures, 2 atypical femoral fractures, 6 cases with bone metastases larger than 6 cm, and 3 cases with extensive sclerotic lesions were excluded because they were considered unsuitable for RFA based on the criteria described above.\u003c/p\u003e\n\u003ch3\u003eRFA procedure\u003c/h3\u003e\n\u003cp\u003e RFA was performed using the Cool-tip\u0026trade; RFA System E Series (Covidien Japan), following the guidelines and protocols provided by the Japanese Society of Interventional Radiology. An electrode with a 3-cm exposed tip was used in all cases, and the number of ablation cycles was adjusted on the basis of the size and configuration of the lesion, assuming a spherical ablation zone approximately 3 cm in diameter. All procedures were performed in collaboration with interventional radiologists.\u003c/p\u003e\n\u003ch3\u003eSurgical Approach and Postoperative Management\u003c/h3\u003e\n\u003cp\u003eThe choice between single-stage and two-stage treatment was based on the method of RFA guidance. When CT-guided RFA was preferred, the procedure was performed in an angiography suite, and IMN was subsequently carried out. When RFA was performed through the femoral medullary canal under fluoroscopic guidance, IMN was performed in the same session as a single-stage procedure. Postoperative care included routine pain control, early mobilization, and regular clinical and radiographic follow-up to monitor healing and identify any complications.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient Overview\u003c/h2\u003e \u003cp\u003eFive patients underwent combined RFA and IMN treatment (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). One patient (Case 1) experienced pain recurrence and tumor progression in the femur five months after palliative radiotherapy; the remaining four patients received postoperative radiation. Two patients underwent two-stage procedures: the IMN procedure was carried out 17 days after RFA in Case 1, and 6 days after RFA in Case 2.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Profiles, Therapeutic Procedures, and Complications.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"15\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cthead\u003e 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\u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIFx*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7'\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e78 Ω\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e75 ℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUterine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTwo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e53 Ω\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60 ℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e20 ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e་\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003ePartial curettage\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIFx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7'40\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e46 Ω\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60 ℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9'47\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e52 Ω\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60 ℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLung\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5'\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e108 Ω\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e89 ℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e50 ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e་\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIFx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2'05\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e255 Ω\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e63 ℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4'\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e112 Ω\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e93 ℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLung\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSubTr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15'\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e117 Ω\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e81 ℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e50 ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNonunion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e་\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePFx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15'\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e112 Ω\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e75 ℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15'\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e120 Ω\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e100 ℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKidney\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTr~\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3'13\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e181 Ω\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e62 ℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e100 ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e་\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003ePartial curettage\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSubTr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2'44\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e119 Ω\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e64 ℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eCementing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8'\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e88 Ω\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e69 ℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePFx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5'\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e282 Ω\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e87 ℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTr: trochanteric, IFx: Impending fracture, PFx: Pathological complete fracture, RT: radiotherapy\u003c/p\u003e \u003cp\u003e*Impending fracture of the shaft accompanied by an avulsion fracture of the lesser trochanter.\u003c/p\u003e \u003cp\u003eThe eight historical control patients who underwent IMN alone included five with lung cancer, two with breast cancer, and one with hepatocellular carcinoma; all of these patients presented with impending fractures.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePain and functional outcomes\u003c/h3\u003e\n\u003cp\u003eThe pain levels and functional outcomes during follow-up are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. In both two-stage cases, including a case with avulsion fracture of the lesser trochanter (Case 1), the NRS for movement-related pain improved to 0 within three days post-RFA, although the evaluation was performed under non-weight-bearing conditions. Following IMN, pain assessment may have been compromised by surgical site pain, but all patients were ambulatory with manageable pain by week 1. Pain evaluation was eventually compromised in Case 1 due to the progression of other bone metastases and in Case 4, who developed nonunion, as described later. Except for these patients, no treatment site-related complications or symptoms were observed during the follow-up period.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMovement-related Pain, Ambulatory Function, and Oncological Outcome.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-treatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 day post RFA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 days post RFA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 week post-op\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 weeks post-op\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12 weeks\u003c/p\u003e \u003cp\u003epost-op\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eProgression of the ablated area\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eProgression of other bone metastases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eFollow-up period\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eStatus\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNRS 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNRS 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNRS 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNRS 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNRS 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNRS 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMinimal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEnlargement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e4M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eDOD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNWB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCane\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCane\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWalker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eprogression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIncrease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLesser trochanter avulsion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSacral metastasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNRS 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNRS 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNRS 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNRS 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNRS 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNRS 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDecreased\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eDOD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNWB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCane\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCane\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIndependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e(Solitary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNRS 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNRS 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNRS 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNRS 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIncrease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e5M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eAWD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNWB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWalker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCane\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCane\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNRS 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNRS 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNRS 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e10M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNED\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFractured\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCrutches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCrutches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCane\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e(Solitary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNon-weight bearing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNon-weight bearing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNRS 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNRS 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNRS 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEnlargement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eDOD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFractured\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWalker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCane\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCane\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRFA: Radiofrequency Ablation, NRS: Numerical Rating Scale, DOD: Died of Disease, AWD: Alive With Disease, NED: No Evidence of Disease, NWD: Non-Weight Bearing\u003c/p\u003e\n\u003ch3\u003eImaging and Local Tumor Control\u003c/h3\u003e\n\u003cp\u003eIn both two-stage cases, contrast-enhanced CT performed on the day after RFA revealed reduced enhancement at the RFA site (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). At the final follow-up, one lesion had slightly progressed, three were stable, and one had decreased in size (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In all three patients with bone metastases at sites other than the treated lesion, disease progression was observed at those locations. No bone formation was observed at any RFA site.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePET and bone scintigraphy findings and histological findings\u003c/h2\u003e \u003cp\u003eIn Case 3, postoperative PET revealed no abnormal FDG uptake in the ablated lesion (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), suggesting tumor inactivation by RFA. In contrast, bone scintigraphy at four months revealed preserved tracer uptake, suggesting the maintenance of osteogenic activity. Histopathological examination of intramedullary samples revealed degenerative changes, such as nuclear swelling, chromatin homogenization, and vacuolar degeneration, in all five cases. In cases where surgery was performed in a staged manner, inflammatory cell infiltration was also observed. In Case 1, where sampling was conducted 17 days after RFA, only minimal viable tumor cells were found. However, in the remaining cases, including Case 3 in which FDG uptake had disappeared, 20\u0026ndash;50% of the tumor cells remained viable. Considering the overall clinical course, histopathological evaluation did not reliably reflect the therapeutic effects observed by imaging.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eComplications\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eNonunion\u003c/strong\u003e \u003cp\u003eOne patient (Case 4) developed nonunion with IMN failure at 6 months and required revision surgery with proximal femoral resection and prosthesis replacement. Histological examination of the resected specimen revealed fibrous or necrotic tissue, approximately 60% preservation of osteocytes within the cortical bone, and no evident residual tumor cells, suggesting partial osteonecrosis due to excessive ablation temperature.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eBurn injury\u003c/strong\u003e \u003cp\u003eOne patient developed a second-degree burn on the skin of the bilateral medial thighs, probably due to an electrical shortcut between the electrode pad on the contralateral thigh and the RFA needle. Modifying the electrode pad placement to the trunk prevented recurrence.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eIntraoperative and procedural tolerance\u003c/strong\u003e \u003cp\u003eTwo patients reported discomfort during RFA under local anesthesia, which was managed with cooling, analgesics, and sedation. Blood loss during IMN procedures was minimal (mean 48 ml) and significantly lower than that in the control patients (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The mean operative time was longer in patients who underwent RFA, but the difference was not statistically significant.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOperative Blood Loss and Time: IMN with vs. without RFA.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBlood loss (ml), mean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOperative time (min), mean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRFA\u0026thinsp;+\u0026thinsp;IMN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.011*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e131.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e45.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.348\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIMN control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e156.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e88.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e105.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e46.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRFA: Radiofrequency Ablation, IMN: Intramedullary Nailing,\u003c/p\u003e \u003cp\u003e*Statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWhen RFA is used for metastatic bone tumors, the primary goal is pain relief as part of palliative care. However, RFA also offers benefits in terms of local tumor control and intraoperative hemostasis during subsequent surgical procedures. Therefore, combining RFA with IMN fixation provides multiple advantages. In this study, the combination demonstrated short- to midterm safety and effectiveness, particularly for impending fractures.\u003c/p\u003e \u003cp\u003eThe RFA needle must be inserted carefully to avoid damaging major vessels and nerves, such as the femoral artery, vein, femoral nerve, and sciatic nerve. A vertical approach to the lesion might be preferable for cortical destruction or avulsion fractures at the lesser trochanter, making CT-guided RFA desirable. When intraoperative CT is available, a single-stage procedure may be feasible; otherwise, a two-stage approach\u0026mdash;performing RFA under CT guidance, confirming the ablation area with contrast-enhanced CT imaging, and proceeding with IMN\u0026mdash;is appropriate. In two-stage procedures, patients should be maintained in strict non-weight-bearing conditions between RFA and IMN to prevent fracture. Conversely, when the cortical bone remains intact and the lesion is confined within the medullary cavity, accessing the tumor longitudinally via the intramedullary canal under fluoroscopic guidance is more reasonable. In such cases, CT-guided RFA is technically challenging, and a single-stage procedure with simultaneous RFA and IMN is preferable. A single-stage procedure is also appropriate if direct intraoperative tumor ablation is needed.\u003c/p\u003e \u003cp\u003eIn this study, RFA achieved remarkable short-term pain relief in cases where immediate postablation assessment was possible. Notably, in one patient with an avulsion fracture of the lesser trochanter, marked relief of motion-induced pain was observed, suggesting the utility of RFA for lesser trochanter avulsions in which IMN cannot stabilize. Isolating the specific contribution of RFA to midterm pain relief remains challenging because IMN fixation alone affords substantial pain relief by stabilizing fractures. Previous retrospective studies have also suggested that RFA, when used adjunctively with IMN, tends to provide better pain control than radiotherapy with IMN [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, in the present series, postoperative radiotherapy was performed in most patients, except for those with recurrence after prior radiation therapy. Therefore, it is difficult to evaluate the independent pain relief effect of RFA alone, similar to the challenges in assessing its tumor control effect. Notably, even when postoperative radiotherapy was combined with RFA, no increase in adverse effects was observed. Several reports have described the usefulness of combining RFA and radiotherapy for treating spinal metastases [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]; thus, similar synergistic effects may be expected in long bones such as the femur. At the very least, in cases where radiotherapy is contraindicated, unavailable, or less effective, RFA is a useful adjunctive therapy alongside IMN fixation.\u003c/p\u003e \u003cp\u003eTumor control via thermal ablation shares similarities with the pasteurization technique, a well-established method for autograft recycling that heats bone to 60\u0026deg;C to 65\u0026deg;C for 30 to 40 minutes to eradicate malignant cells while preserving the biomorphogenic properties of bone [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Nevertheless, similar to pasteurized bone, RFA-treated bone may show delayed union. Experimental studies have reported that although osteocyte remnants can be observed after RFA, partial bone necrosis occurs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In one patient from this study where both PET and bone scintigraphy data were available post-RFA, FDG uptake disappeared, whereas bone scintigraphy activity remained, suggesting preserved bone metabolic activity despite tumor ablation. In contrast, in the case of nonunion, histological analysis revealed residual osteocytes without evidence of new bone formation, implying impaired osteoinductive potential, probably due to protein denaturation and necrotic tissue. Although some reports suggest that the pain-relieving effect of RFA is greater in patients with pathological fractures [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], applying RFA to fractured weight-bearing bones such as the femur carries a risk of delayed union and implant failure. Based on the above considerations, limiting indications to impending fractures with preserved cortical continuity with cement augmentation when specifically indicated is safer. To retain bone healing capacity in femoral lesions, we aimed to replicate conditions similar to pasteurization by not prioritizing roll-off protocols; instead, we interrupted ablation four minutes after initiation, confirmed temperatures, and aimed to maintain 60\u0026ndash;70\u0026deg;C for approximately five minutes. Unlike the liver, bone ablation cannot be monitored by ultrasound. Furthermore, our cooling-electrode system did not allow real-time temperature monitoring during ablation; ablation must be paused for approximately 20 seconds to measure the temperature. Further investigation into the optimal timing for temperature checks is warranted.\u003c/p\u003e \u003cp\u003eThis study observed one case of each nonunion and thermal skin injury, but no other RFA-related complications occurred. IMN with RFA, which is consistent with previous reports [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], resulted in significantly less intraoperative blood loss than did control patients with IMN alone. This combined approach demonstrated a hemostatic advantage during IMN, suggesting its suitability for metastases originating from hypervascular tumors. Although the operative time was longer in the combined treatment group, the difference was not statistically significant. Notably, while all control cases involved impending fractures, two patients in the combined treatment group experienced complete fractures. This likely resulted in an upward bias in the operative time due to the additional steps required for the exposure and reduction of fractures, indicating that the observed prolongation may not be clinically meaningful.\u003c/p\u003e \u003cp\u003eOverall, the combined RFA and IMN technique was generally safe and effective for impending fractures, offering pain relief, tumor control, and hemostasis benefits. However, in cases of complete pathological fractures, caution is warranted owing to the potential risk of impaired bone healing.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRFA combined with intramedullary nailing for long bone metastases appears to be a minimally invasive and effective strategy for achieving local tumor control while restoring function. Although wide resection and tumor prosthesis reconstruction are often preferred in patients with longer life expectancies, this combined technique may serve as a less invasive alternative.\u003c/p\u003e \u003cp\u003eCurrently, the most favorable indications for RFA combined with intramedullary nailing include impending fractures without complete cortical disruption, avulsion fractures of the lesser trochanter, hypervascular tumors anticipated to cause significant intraoperative bleeding, and cases that are resistant or less sensitive to radiotherapy. To ensure effectiveness and safety, we recommend checking the electrode tip temperature approximately four minutes after the start of ablation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eIntramedullary nailing (IMN), radiofrequency ablation (RFA)\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe institutional review board of the NHO Kyushu Cancer Center approved this study (K2022037).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all patients via the institution\u0026rsquo;s standardized consent form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported in part by the 44th General Research Grant from the Japanese Foundation for Multidisciplinary Treatment of Cancer. Portions of the abstract and figures from this manuscript have been included in the report of the above grant; however, no copyright transfer has occurred.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNS contributed to the conceptualization, analysis, and writing of the draft. SF, NY, TF, AN, and NF contributed to data acquisition. KS, MJ, and RS contributed to the data interpretation and revision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNS contributed to Conceptualization, Methodology, Investigation, Funding acquisition, and Writing \u0026ndash; original draft. SF, NY, TF, AN, and NF contributed to Resources and Visualization. KS, MJ, and RS contributed to Data curation, Formal analysis, Supervision, and Writing \u0026ndash; review and editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eN. Araki, H. Chuman, T. Matsunobu, K. Tanaka, H. Katagiri, T. Kunisada, T. Hiruma, H. Hiraga, H. Morioka, H. Hatano, K. Asanuma, Y. Nishida, K. Hiraoka, T. Okamoto, S. Abe, M. Watanuki, T. Morii, H. Sugiura, Y. Yoshida, T. Ohno, H. Outani, K. Yokoyama, S. Shimose, H. Fukuda, Y. Iwamoto, Factors associated with the decision of operative procedure for proximal femoral bone metastasis: Questionnaire survey to institutions participating the Bone and Soft Tissue Tumor Study Group of the Japan Clinical Oncology Group, J Orthop Sci 22(5) (2017) 938-945.\u003cu\u003e \u003c/u\u003e\u003cu\u003ehttps://doi.org/10.1016/j.jos.2017.05.012\u003c/u\u003e .\u003c/li\u003e\n\u003cli\u003eM.P. Goetz, M.R. Callstrom, J.W. Charboneau, M.A. Farrell, T.P. Maus, T.J. Welch, G.Y. Wong, J.A. Sloan, P.J. Novotny, I.A. Petersen, R.A. Beres, D. Regge, R. Capanna, M.B. Saker, D.H. Gr\u0026ouml;nemeyer, A. Gevargez, K. Ahrar, M.A. Choti, T.J. de Baere, J. Rubin, Percutaneous image-guided radiofrequency ablation of painful metastases involving bone: a multicenter study, J Clin Oncol 22(2) (2004) 300-6.\u003cu\u003e \u003c/u\u003e\u003cu\u003ehttps://doi.org/10.1200/jco.2004.03.097\u003c/u\u003e.\u003c/li\u003e\n\u003cli\u003eN. Tanigawa, Y. Arai, K. Yamakado, T. Aramaki, Y. Inaba, S. Kanazawa, O. Matsui, M. Miyazaki, Y. Kodama, H. Anai, A. Hamanaka, Phase I/II Study of Radiofrequency Ablation for Painful Bone Metastases: Japan Interventional Radiology in Oncology Study Group 0208, Cardiovasc Intervent Radiol 41(7) (2018) 1043-1048.\u003cu\u003e \u003c/u\u003e\u003cu\u003ehttps://doi.org/10.1007/s00270-018-1944-x\u003c/u\u003e.\u003c/li\u003e\n\u003cli\u003eF. Deschamps, G. Farouil, N. Ternes, A. Gaudin, A. Hakime, L. Tselikas, C. Teriitehau, E. Baudin, A. Auperin, T. de Baere, Thermal ablation techniques: a curative treatment of bone metastases in selected patients?, Eur Radiol 24(8) (2014) 1971-80.\u003cu\u003e \u003c/u\u003e\u003cu\u003ehttps://doi.org/10.1007/s00330-014-3202-1\u003c/u\u003e.\u003c/li\u003e\n\u003cli\u003eK. Ogura, R. Miyake, S. Shiina, Y. Shinoda, T. Okuma, H. Kobayashi, T. Goto, K. Nakamura, H. Kawano, Bone radiofrequency ablation combined with prophylactic internal fixation for metastatic bone tumor of the femur from hepatocellular carcinoma, Int J Clin Oncol 17(4) (2012) 417-21.\u003cu\u003e \u003c/u\u003e\u003cu\u003ehttps://doi.org/10.1007/s10147-011-0319-y\u003c/u\u003e.\u003c/li\u003e\n\u003cli\u003eA. Di Francesco, S. Flamini, L. Zugaro, C. Zoccali, Preoperative radiofrequency ablation in painful osteolytic long bone metastases, Acta Orthop Belg 78(4) (2012) 523-30.\u003cu\u003e \u003c/u\u003e\u003c/li\u003e\n\u003cli\u003eM. Di Staso, L. Zugaro, G.L. Gravina, P. Bonfili, F. Marampon, L. Di Nicola, A. Conchiglia, L. Ventura, P. Franzese, M. Gallucci, C. Masciocchi, V. Tombolini, A feasibility study of percutaneous Radiofrequency Ablation followed by Radiotherapy in the management of painful osteolytic bone metastases, Eur Radiol 21(9) (2011) 2004-10.\u003cu\u003e \u003c/u\u003e\u003cu\u003ehttps://doi.org/10.1007/s00330-011-2133-3\u003c/u\u003e.\u003c/li\u003e\n\u003cli\u003eK.M. Prezzano, D. Prasad, G.M. Hermann, A.N. Belal, R.A. Alberico, Radiofrequency Ablation and Radiation Therapy Improve Local Control in Spinal Metastases Compared to Radiofrequency Ablation Alone, Am J Hosp Palliat Care 36(5) (2019) 417-422.\u003cu\u003e \u003c/u\u003e\u003cu\u003ehttps://doi.org/10.1177/1049909118819460\u003c/u\u003e.\u003c/li\u003e\n\u003cli\u003eR.L. Cazzato, J. Palussi\u0026egrave;re, P. Auloge, C. Rousseau, G. Koch, D. Dalili, X. Buy, J. Garnon, P. De Marini, A. Gangi, Complications Following Percutaneous Image-guided Radiofrequency Ablation of Bone Tumors: A 10-year Dual-Center Experience, Radiology 296(1) (2020) 227-235.\u003cu\u003e \u003c/u\u003e\u003cu\u003ehttps://doi.org/10.1148/radiol.2020191905\u003c/u\u003e.\u003c/li\u003e\n\u003cli\u003eE.F. Dierselhuis, P.C. Jutte, P.J. van der Eerden, A.J. Suurmeijer, S.K. Bulstra, Hip fracture after radiofrequency ablation therapy for bone tumors: two case reports, Skeletal Radiol 39(11) (2010) 1139-43.\u003cu\u003e \u003c/u\u003e\u003cu\u003ehttps://doi.org/10.1007/s00256-010-1013-2\u003c/u\u003e.\u003c/li\u003e\n\u003cli\u003eJ. Manabe, A.R. Ahmed, N. Kawaguchi, S. Matsumoto, H. Kuroda, Pasteurized autologous bone graft in surgery for bone and soft tissue sarcoma, Clin Orthop Relat Res (419) (2004) 258-66.\u003cu\u003e \u003c/u\u003e\u003cu\u003ehttps://doi.org/10.1097/00003086-200402000-00042\u003c/u\u003e.\u003c/li\u003e\n\u003cli\u003eS. Ghomashchi, C.M. Whyne, T. Chinnery, F. Habach, M.K. Akens, Impact of radiofrequency ablation (RFA) on bone quality in a murine model of bone metastases, PLoS One 16(9) (2021) e0256076.\u003cu\u003e \u003c/u\u003e\u003cu\u003ehttps://doi.org/10.1371/journal.pone.0256076\u003c/u\u003e.\u003c/li\u003e\n\u003cli\u003eJ. Levy, T. Hopkins, J. Morris, N.D. Tran, E. David, F. Massari, H. Farid, A. Vogel, W.G. O\u0026apos;Connell, P. Sunenshine, R. Dixon, A. Gangi, N. von der H\u0026ouml;h, S. Bagla, Radiofrequency Ablation for the Palliative Treatment of Bone Metastases: Outcomes from the Multicenter OsteoCool Tumor Ablation Post-Market Study (OPuS One Study) in 100 Patients, J Vasc Interv Radiol 31(11) (2020) 1745-1752.\u003cu\u003e \u003c/u\u003e\u003cu\u003ehttps://doi.org/10.1016/j.jvir.2020.07.014\u003c/u\u003e.\u003c/li\u003e\n\u003cli\u003eJ.P. Guenette, M.J. Lopez, E. Kim, D.E. Dupuy, Solitary painful osseous metastases: correlation of imaging features with pain palliation after radiofrequency ablation--a multicenter american college of radiology imaging network study, Radiology 268(3) (2013) 907-15.\u003cu\u003e \u003c/u\u003e\u003cu\u003ehttps://doi.org/10.1148/radiol.13122398\u003c/u\u003e. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Radiofrequency ablation, Intramedullary nailing, Bone metastases, Impending fracture, Femur","lastPublishedDoi":"10.21203/rs.3.rs-6829784/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6829784/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eBackground\u003c/em\u003e: Radiofrequency ablation (RFA) has gained attention as a palliative treatment for bone metastases, offering pain relief and local tumor control. While its use in trunk lesions is well documented, its application in long bones remains limited because ofconcerns about postablationfractures. These risks may be mitigated by combining RFA with prophylactic intramedullary nailing (IMN).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMethods\u003c/em\u003e: Five consecutive patients with femoral metastases who underwent combined RFA and IMN, either as a single-stage procedure with intraoperative fluoroscopic guidance or in two stages using CT-guided RFA followed by IMN, were included. Pain relief, function, radiographic response, histology, and complications were retrospectively assessed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResults\u003c/em\u003e: All patients experienced early pain relief and regained mobility. The average amount of intraoperative blood loss was 48 ml, which was significantly lower than the historical control cases. At the final follow-up, one lesion had slightly progressed, three remained stable, and one decreased in size. The complicationsincluded one nonunion case requiring revision and one case of skin burn from electrode pad placement.\u003c/p\u003e\n\u003cp\u003eWhile immediate pain relief was notable, the isolated midterm effect of RFA was difficult to evaluate because of concurrent IMN and frequent postoperative radiotherapy. No adverse interactions were observed with combined radiotherapy.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusion\u003c/em\u003e: RFA combined with IMN offers a minimally invasive, effective option for local control and functional recovery in patients with femoral metastases. Ideal candidates include those with impending fractures with preserved continuity of the femoral shaft, lesser trochanter avulsions, hypervascular tumors, or radiotherapy-resistant lesions. This approach may serve as an alternative to extensive resection in selected patients.\u003c/p\u003e","manuscriptTitle":"Combination of Radiofrequency Ablation and Intramedullary Nailing for the Treatment of Femoral Metastases: Single-center, Retrospective Observational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-16 08:52:17","doi":"10.21203/rs.3.rs-6829784/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-06T05:48:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-28T02:05:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227997244021065066162299360574482970554","date":"2025-09-27T21:05:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186441026309251580924136110021613768125","date":"2025-09-23T15:48:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329427167865618429707850853829804718329","date":"2025-09-14T20:57:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-24T10:19:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"121469848340278705262998471308769989216","date":"2025-08-20T22:39:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-11T06:14:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-08T14:28:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-06T07:25:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Surgical Oncology","date":"2025-06-05T13:39:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d01a04b3-cec8-4586-8c81-82fb5fbcc3af","owner":[],"postedDate":"June 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:10:24+00:00","versionOfRecord":{"articleIdentity":"rs-6829784","link":"https://doi.org/10.1186/s12957-025-04091-8","journal":{"identity":"world-journal-of-surgical-oncology","isVorOnly":false,"title":"World Journal of Surgical Oncology"},"publishedOn":"2025-11-10 15:58:24","publishedOnDateReadable":"November 10th, 2025"},"versionCreatedAt":"2025-06-16 08:52:17","video":"","vorDoi":"10.1186/s12957-025-04091-8","vorDoiUrl":"https://doi.org/10.1186/s12957-025-04091-8","workflowStages":[]},"version":"v1","identity":"rs-6829784","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6829784","identity":"rs-6829784","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}