Introduction

Knee osteoarthritis (OA) is a highly prevalent and frequently debilitating musculoskeletal disorder that imposes a substantial burden on the general population. In patients with cancer, OA complicates pain management, which is frequently multifaceted owing to the complex interplay between malignancy-related inflammatory changes and side effects from cancer therapies. Additionally, chemotherapy and radiation used to treat the malignancy can complicate musculoskeletal pain and contribute to bone density loss, worsening joint health and complicating pain management.¹ Consequently, addressing pain in this patient population requires an approach that accounts for the underlying malignancy while targeting the joint pathology.

Palliative care is often employed in patients with advanced cancer. However, the complex nature of treatment-resistant pain requires alternative management strategies.^{2, 3} Standard pharmacologic and surgical interventions are often limited by advanced disease, comorbidities, and active cancer treatment, requiring exploration of alternative management. Intra-articular steroid injections, while safe, are usually of limited durability in advanced OA.⁴ Additionally, patients may also have concomitant higher opioid tolerances secondary to other chronic pain treatment, thus further complicating effectiveness.

Geniculate artery embolization (GAE) is a promising, minimally invasive technique for managing refractory knee OA pain, particularly in patients who are ineligible for total knee arthroplasty (TKA). By selectively targeting the hypervascularized geniculate arteries, GAE modulates synovial hypervascularity and inflammatory processes, key contributors to nociceptive pain.⁵ The ability to precisely target the affected vascular structures minimizes systemic effects while providing durable, localized pain relief, which is especially advantageous in frail patients. In the context of palliative oncology, these improvements can contribute not only to the patient’s physical comfort but also to their psychological and emotional well-being.

In this study, we present a retrospective analysis of 12 patients with advanced cancer initially evaluated by orthopedic specialists, deemed unsuitable candidates for TKA due to oncologic diagnosis, and subsequently managed with conservative measures. Owing to their refractory symptoms, these patients were referred to interventional radiology for GAE.

Methods

Study Design and Patient Population

This study was conducted across 2 institutions from January 2023 to February 2025. The study cohort comprised 12 patients with an underlying malignancy, including 9 patients actively undergoing cancer treatment and 3 patients under imaging surveillance. Patient demographics, clinical characteristics, and treatment histories were extracted from electronic medical records. Those who were not surgical candidates for reasons other than treatment for active underlying malignancy or those who underwent GAE for other indications were excluded. Per the research protocol, institutional review board approval was not required.

Procedure

Unilateral GAE was performed successfully on all patients in an outpatient setting under intravenous sedation. Using a contralateral common femoral artery approach and standard angiographic techniques, the geniculate artery was catheterized, and embolization was performed with microspheres ranging from 100 to 300 µ in diameter. Postembolization angiography confirmed successful synovial hyperemia resolution and distal branch vessel pruning in all cases.

Data Collection and Analysis

Data collected included patient age, sex, cancer type and stage, procedural details, immediate outcomes, and 3- and 6-month clinical follow-up. Baseline, 3-month, and 6-month Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Kellgren-Lawrence (K/L) scores were also collected and analyzed. Descriptive statistics were used to summarize the data. Given the small sample size, statistical analyses were primarily descriptive, focusing on median values and ranges. Analysis of variance, paired t -tests, and Pearson R correlation were used to analyze variables from follow-up clinical data.

Results

Patient Characteristics

The mean age of the included cohort was 75.8 years (range: 65-90 years, SD 7.9, 75% male). 45% ( n = 5) had a diagnosis of primary lung malignancy. The mean preprocedure WOMAC and K/L scores were 64.8 (SD 6.8) and 3.3 (SD 0.5), respectively ( Table 1 ). 75% of patients ( n = 9) had stage 4 disease at presentation for GAE.

Table 1.

Patient Characteristics, Baseline WOMAC, and K/L Scores

BMI, body mass index; Dx, diagnosis; F, female; K/L, Kellgren-Lawrence; M, male; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

Procedural Outcomes

Technical success was achieved in all embolization procedures and was defined by post-embolization angiography demonstrating vascular pruning and resolution of prior hyperemia without immediate complications ( Figure 1 ). All procedures were completed on a same-day outpatient basis.

Figure 1.

Superselected negative digital subtraction angiography of the left superior lateral geniculate artery demonstrating synovial hyperemia in the patient’s reported area of concern.

Safety and Complications

No immediate postprocedural complications were observed, nor were any observed during the mean follow-up period of 6 months.

Follow-Up

At 3-month follow-up, the mean WOMAC score was 42.7 (SD 6.5, P < .001), with a mean difference of –22.1 from preprocedural baseline. At 6-month follow-up, the mean WOMAC score was 42.6 (SD 5.9, P < .001), with a mean difference of –22.2 from baseline ( Table 2 ).

Table 2.

Follow-Up WOMAC and K/L Scores at 3 and 9 Months Postprocedure

All K/L grades remained unchanged (3 or 4) across time points, indicating no radiographic progression or improvement at 3 or 6 months.

K/L, Kellgren-Lawrence; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

There was no change between pre- and postprocedural K/L score for any patients at 3- or 6-month follow-up. Additionally, no significant differences between WOMAC or K/L scores were observed when comparing 3- and 6-month follow-up data ( Tables 3, 4 ; Table 5 ). There was no correlation between preprocedure body mass index and 3- or 6-month follow-up WOMAC scores in our cohort ( Table 6 ).

Table 3.

Descriptive Statistics of Patient Age, WOMAC, and K/L Scores

Age ranges from 65 to 90 years (mean 75.8).

Pre-WOMAC (mean ~64.8) drops by ~22 points at both 3 and 6 months (means ~42.7 and~42.6).

K/L remains stable (3.3±0.47) across all time points.

K/L, Kellgren-Lawrence; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

Table 4.

Mean Differences and ANOVA for WOMAC and K/L Scores

WOMAC scores improve by ~22 points from pre to both 3 months and 6 months ( P < .001).

No further change between 3 and 6 months.

K/L scores do not show any change at follow-up.

ANOVA, analysis of variance; K/L, Kellgren-Lawrence; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

Table 5.

Comparison of Pre → 6-Month WOMAC Improvement by Baseline K/L Grade

Both K/L=3 and K/L=4 groups show a substantial negative Δ (ie, improvement of ~20+ points).

The K/L=3 group’s mean improvement is about –23.5 points, and the K/L=4 group’s is about –19.5 points.

Although the K/L=3 group’s average improvement is numerically a bit larger, the difference is not statistically significant ( P = .21), using Welch 2-tailed t -test, within this sample of 12 patients.

K/L, Kellgren-Lawrence; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

Table 6.

BMI and WOMAC Correlations

BMI does not appear to influence WOMAC scores at baseline or follow-up in this cohort (all P > .05).

BMI, body mass index; K/L, Kellgren-Lawrence; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

Discussion

Although TKA remains the therapy of choice for osteoarthritic knee pain, numerous prospective studies have established GAE as a safe, effective, and minimally invasive alternative.^{5 - 7} To our knowledge, however, GAE has not been studied in patients with OA knee pain and concurrent advanced malignancy who are not candidates for surgical management. Thus, this population represents a uniquely vulnerable cohort warranting special consideration beyond other nonoperative TKA candidates.

Unlike patients excluded from arthroplasty based solely on anesthetic risk, advanced age, or cardiopulmonary comorbidities, oncology patients face a distinctly complex pain syndrome, in which malignancy-related inflammation synergizes with degenerative joint disease, while chemotherapy and radiation undermine musculoskeletal integrity through accelerated bone demineralization and iatrogenic cartilage degradation.¹ A cycle then ensues in which cancer treatment exacerbates joint pathology while OA-related pain limits mobility and functional status. This has the potential to compromise oncologic outcomes during a critical treatment window.

Our findings support the incorporation of GAE into pain management algorithms for advanced OA in oncology patients, who face multiple challenges such as increased opioid tolerances, failure of steroid injections, and nonoperative status secondary to cancer treatment. For these patients, GAE offers a viable alternative intervention that directly addresses the vascular component without systemic toxicity, surgical morbidity, or interference with ongoing cancer therapy. These advantages are particularly meaningful when every treatment decision carries heightened stakes and functional preservation impacts quality of life.

Integrating GAE requires careful consideration of patient-specific goals and alignment with the overall palliative approach. Differences in patient priorities, for example,, achieving long-term survival versus maintaining quality of life, can impact treatment decisions that fulfill each goal.⁸ Discussing the potential outcomes of GAE with patients and their families is essential to shared decision-making and ensures that patient values are central to all therapeutic choices.⁹

Optimal patient outcomes require the collaboration of oncologists, interventional radiologists, pain specialists, orthopedic surgeons, and palliative care physicians. In so doing, GAE has the potential to relieve overwhelming OA-related pain, allowing patients to continue daily living activity with improved functionality.⁵

Our findings contribute to this growing body of evidence, demonstrating that GAE can be a safe and effective alternative for patients unable to undergo surgery due to malignancy-related comorbidities.

The limitations of our study include its small sample size and retrospective design. Further large-scale, randomized controlled trials are warranted to validate these findings and establish standardized protocols for patient selection and procedural techniques.

Conclusion

GAE represents a promising therapeutic option for knee OA pain in patients with active malignancy but who are not candidates for surgery. Its minimally invasive nature, coupled with a favorable safety profile and medium-term durability, positions GAE as a valuable addition to pain management strategies in this patient population.

Affiliations

1. 1 Hofstra University Zucker School of Medicine and Northwell Health, Hempstead, New York
2. 2 Emory University School of Medicine, Atlanta, Georgia
3. 3 University of South Florida Morsani College of Medicine and Moffitt Cancer Center, Tampa, Florida

References

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