Exploring the Efficacy of Combining Radiofrequency Thermal Ablation or Microwave Ablation with Vertebroplasty for Pain Control and Disease Management in Metastatic Bone Disease—A Systematic Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

In my opinion, the manuscript by Faiella et Al. is clear and easily understood.  The selection criteria and literature review are described in detail. Results according to the techniques used are fully reported. Figures and tables are self-explanatory. Conclusions are supported by the text.

Author Response

Comments and Suggestions for Authors: In my opinion, the manuscript by Faiella et Al. is clear and easily understood.  The selection criteria and literature review are described in detail. Results according to the techniques used are fully reported. Figures and tables are self-explanatory. Conclusions are supported by the text.

Thank you for your positive feedback. We are glad the manuscript was clear, and we appreciate your encouraging comments.

Reviewer 2 Report

Comments and Suggestions for Authors

Introduction:
Pathological fractures in the spine can not only result in bone pain but also lead to neurologcal complications. Please add.

Materials and Methods:
Inclusion/exclusion criteria:  studies utilizing this combination in skeletal  segments other than the vertebrae oR treating benign lesions;

Question: why did you exclude laesions in the pelvis where cementoplasty is also feasable? 

Discussion:
4.1: RTA and VP: change in RFA and VP

Question: do the authors of the various articles specify how the procedure is performed? Using fluoroscopy or CT guidance? By orthopedic surgeon of radiologist? 

Comments on the Quality of English Language

some minor spelling errors

Author Response

Comments 1: “Pathological fractures in the spine can not only result in bone pain but also lead to neurologcal complications. Please add.”

Response 1: We appreciate your input. We have incorporated this information into the 'Introduction' chapter and highlighted the addition in yellow for your reference (lines 45-50).

Comment 2: “Inclusion/exclusion criteria:  studies utilizing this combination in skeletal  segments other than the vertebrae oR treating benign lesions”.

Response 2: Thank you for highlighting the error. We have promptly corrected it in the text.

Comments 3: “Question: why did you exclude laesions in the pelvis where cementoplasty is also feasable?”

Response 3: Thank you for your question. In this review, we chose to focus specifically on vertebral lesions to provide a detailed examination of their impact, including functional impairment. Although cementoplasty is also feasible for lesions in the pelvis, we decided to narrow our scope to vertebral lesions because the majority of scientific articles are focused on vertebral cases. This approach allowed us to ensure that the results are as comparable and homologous as possible, providing a more consistent analysis of the functional outcomes and treatment considerations specific to the spine.

Comments 4: “4.1: RTA and VP: change in RFA and VP”.

Response 4: Thank you for noting this. The change in RFA and VP has been made.

Comments 5: “Question: do the authors of the various articles specify how the procedure is performed? Using fluoroscopy or CT guidance? By orthopedic surgeon of radiologist?”.

Response 5: We appreciate your inquiry. Most of the procedures were performed using both fluoroscopic and CT guidance, with the majority conducted by interventional radiologists. This information has been added to the Results section (lines 127-128).

Comments 6: “Some minor spelling errors.”

Response 6: Thank you for your suggestion. We have made the necessary edits to improve the English language throughout the manuscript.

Reviewer 3 Report

Comments and Suggestions for Authors

In this manuscript, the authors explore the increasing importance of interventional radiology techniques, specifically radiofrequency ablation (RFA) and microwave ablation (MWA), combined with vertebroplasty (VP), in managing metastatic bone disease. The authors conducted a systematic review of studies up to April 2024, focusing on pain management and disease control in adults using these combined treatments. Among 42 studies that met the inclusion criteria, significant pain relief and effective local tumor control were observed. The authors concluded that combining RFA or MWA with VP is a valuable approach in the clinical management of vertebral metastases.

General Comments

The review is clearly and accurately written. However, it is unclear what type of review is being presented. It is classified as a systematic review before the title, and the authors state that they followed PRISMA guidelines. However, the title does not include the term "systematic review," which is required by PRISMA (as noted in the PRISMA checklist under the title heading). Additionally, the format of the review resembles more of a narrative review. Apart from two summary tables—which are more synthetic than analytical—the authors present the results of individual studies in the results and discussion sections, sometimes comparing them with each other.

While the heterogeneity of the studies may preclude a meta-analysis, it would be more informative for readers to have synthesized information, such as pooled rates or at least medians and ranges of the outcomes observed using the described methods. Moreover, the statement "The methodological quality of the included studies was assessed using the PRISMA guidelines" is unclear. PRISMA guidelines require the assessment of bias risk, which 1) was not conducted in this study (as is evident in the checklist), and 2) is typically done using other tools (such as ROBINS-I for assessing bias risk in non-randomized studies).

Finally, if the authors conclude that their analysis supports the efficacy of combining RFA or MWA with vertebroplasty, it would be beneficial for readers to have more detailed information on the preferable indications for these integrated treatments (e.g., specific locations of lesions, the number of metastases).

Specific Comments

• Line 236: The reference to source 53 does not appear to be consistent with the content of the sentence. Please verify.
• Line 285: Please check for accuracy.
• Reference 56: This citation does not seem correct, as the sentence refers to bone metastases, while the reference pertains to prostatic tumors. Please review.
• Reference 57: I could not find the citation for reference 57 in the text. Please ensure it is correctly cited.

Author Response

Comments 1: “The review is clearly and accurately written. However, it is unclear what type of review is being presented. It is classified as a systematic review before the title, and the authors state that they followed PRISMA guidelines. However, the title does not include the term "systematic review," which is required by PRISMA (as noted in the PRISMA checklist under the title heading). Additionally, the format of the review resembles more of a narrative review. Apart from two summary tables—which are more synthetic than analytical—the authors present the results of individual studies in the results and discussion sections, sometimes comparing them with each other. While the heterogeneity of the studies may preclude a meta-analysis, it would be more informative for readers to have synthesized information, such as pooled rates or at least medians and ranges of the outcomes observed using the described methods. Moreover, the statement "The methodological quality of the included studies was assessed using the PRISMA guidelines" is unclear. PRISMA guidelines require the assessment of bias risk, which 1) was not conducted in this study (as is evident in the checklist), and 2) is typically done using other tools (such as ROBINS-I for assessing bias risk in non-randomized studies). Finally, if the authors conclude that their analysis supports the efficacy of combining RFA or MWA with vertebroplasty, it would be beneficial for readers to have more detailed information on the preferable indications for these integrated treatments (e.g., specific locations of lesions, the number of metastases)”.

Response 1: Thank you for your valuable feedback. We have made substantial revisions to the results section (highlighted in yellow in the text, lines 134-191). Additionally, we have included a new paragraph in the discussion section that addresses the assessment of bias risk (paragraph 4.4, lines 315-333). If, despite these changes, you still believe that it is better not to define this as a systematic review, we will make further adjustments accordingly. 

Comments 2 “Line 236: The reference to source 53 does not appear to be consistent with the content of the sentence. Please verify”

Response 2: We have added two additional citations to the sentence to further support the statement, ensuring that it is now justified by multiple sources.

Comments 3: Line 285: Please check for accuracy.

Response 3: Thank you for pointing that out. We have corrected the error.

Comments 4:  Reference 56: This citation does not seem correct, as the sentence refers to bone metastases, while the reference pertains to prostatic tumors. Please review.

Response 4:  We included this citation because, although it primarily focuses on a different type of tumor, the article presents a thorough analysis of radiomics methods that could potentially be applied to facilitating early diagnosis and treatment planning of bone metastases in the future. If the reviewer believes that this connection is too tenuous or may be confusing, we are willing to remove the citation.

Comments 5: Reference 57: I could not find the citation for reference 57 in the text. Please ensure it is correctly cited.

Rensponse 5: We have added the citation to the text, thank you for bringing it to our attention.