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Cancer Pain Case
Ankit M. Patel, MD
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Disclosure• I have NO RELEVANT financial disclosures.
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Objectives• Comprehensive evaluation of
pain in a patient with history of cancer
• Systematic & multidisciplinary treatment approach
• Interventional pain management options
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Clinical Case: Mr. HF
• 82 y.o. male, history of prostate cancer, on androgen deprivation therapy, left kidney tumor s/p resection
• C/o diffuse mid-back and low back pain, which began 4 weeks ago after working in his garden
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Evaluation of patients with cancer pain• Thorough H&P!
• Global assessment: impact of pain on function, mood & quality of life
• Always consider recurrence or progression of cancer
• Etiology of pain: - Primary tumor- Metastatic disease- Cancer treatment- Non-malignant
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Clinical Case
• Axial symptoms only, moderate to severe daily pain• Worse with standing, walking, sitting, bending, and twisting• Better with lying down• No fever, weight loss, or nocturnal pain
• Symptoms refractory to relative rest, acetaminophen, NSAIDs, tramadol, and elastic back brace
• Adverse impact of function, mood, and QOL• Difficulty getting out of bed and transferring in/out of a car• Spouse reported dysphoria and poor appetite
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Clinical Case
• Physical exam findings:• Loss of lumbar lordosis
• Pain with percussion along the thoracolumbar junction and lumbosacral junction
• No neurologic deficits, neural tension signs, or myelopathy
Imaging:Thoracic and Lumbar spine x-rays demonstrate vertebral compression fractures at T12, L3, and L4
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Which of the following studies is least likely to help with differentiating acute versus chronic compression fractures:
• A) MRI
• B) CT Scan
• C) Bone scan
• D) All of the above can help
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Clinical Case
• MRI T/L spine: • wedge fracture at T12
vertebral body
• superior endplate deformity at L3 and L4 bodies
• heterogeneous marrow signal concerning for metastatic disease
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Clinical Case
• MRI STIR sequence images reveal:• Edema in T12• Edema in L4
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Cancer Pain Management Pearls
• Communication with patient, family, and oncologist regarding goals of pain management
• Integration of plan with other cancer treatments i.e. chemotherapy, radiation, surgery
• Incorporation of patient’s prognosis & life expectancy
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Clinical case: Treatment
• Bracing: TLSO
• Physical therapy
• Opioids
• Calcitonin
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Interventions: the fourth step?
http://www.nationalpainfoundation.org/
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Clinical Case: Intervention• T12 & L4 kyphoplasty
with bone biopsies
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Clinical case: Intervention outcome
• 90% reduction in pain within the first 24hrs & at 2 week
• Improved ability to sit, stand, & ambulate with less pain
• Able to get in/out of a vehicle with less pain
• Decreased pain medication requirement
• Biopsies negative for cancer
• Evaluation with bone mineral & metabolism service for workup of osteoporosis
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Cancer-Induced VCFs
• An estimated 75K-100K cancer-induced VCF occur annually• Stage IV Breast and Lung
• Multiple Myeloma
• Stage III and IV of Prostate • Including secondary osteoporotic fractures due to
ADT treatment
• Metastatic thyroid and renal carcinoma
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Which cancer type is associated with osteoblastic skeletal metastases?
• A) Multiple Myeloma
• B) Prostate cancer
• C) Thyroid cancer
• D) Lung cancer
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Minimally invasive procedures
• Vertebroplasty & Kyphoplasty
• minimally invasive procedures to stabilize fracture and reduce pain
• V: PMMA is injected into a compressed vertebral body
• K: Tamp inflation/deflation followed by PMMA injection
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Vertebroplasty vs. Kyphoplasty
Vertebroplasty:>Less expensive>Faster for the operator and patient
Kyphoplasty:>More anatomic correction of spinal deformity than vertebroplasty>Greater height restoration in recent fractures, less than 3
months old***Taylor RS, Fritzell P, Taylor RJ. Balloon kyphoplasty in the
management of vertebral compression fractures: an updated systematic review and meta-analysis. Eur Spine J. 2007 Aug. 16(8):1085-100.
>Less PMMA extravasation, with better “controlled’ spread
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CAFE Study
• 134 pts, randomized to kyphoplasty vs. non-surgical management; multicenter trial
• Primary endpoint: back-specific functional status measured by the Roland-Morris disability questionnaire (RDQ) score at 1 month
Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomized controlled trial
Dr James Berenson MD, Robert Pflugmacher MD, et al. The Lancet Oncology - 1 March 2011 ( Vol. 12, Issue 3, Pages 225-
235 )
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CAFE Study Results
• At 1 month, the mean RDQ score reduction of 8.3 points in the kyphoplasty group; p<0·0001 (compared to 0.1 point reduction in control group)
• Common adverse events:• Symptomatic new vertebral fracture
• two in the kyphoplasty group vs. three in the control group
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Complications of vertebral augmentation
• 1–3% complication rate for benign disease and up to 10% with metastatic disease1-3
• Cement leakage: up to 41% of the cases, mostly asymptomatic4
• Foraminal/epidural cement leakage4
• Venous uptake of cement…. Pulmonary embolism5
• Leakage into the disc space6
• Others: rib fractures, TP fracture, pneumothorax, hematoma, infection, foreign body reactions to the cement
1. Cotten A, Dewatre F, Cortet B, et al. Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filling and the leakageof methyl methacrylate at clinical follow-up. Radiology 1996;200:525–30.2. Mathis JM, Ortix O, Zoarski GH. Vertebroplasty versus kyphoplasty: a comparison and contrast. AJNR Am J Neuroradiol 2004;25:840–45.3. Weill A, Chiras J, Simon JM, et al. Spinal metastases: indications for and results of percutaneous injection of acrylic surgical cement. Radiology 1996;199:241–7.4. Phillips FM, Wetzel FT, Lieberman T, Campbell-Mupp M. An in vivo comparison of the potential for extra vertebral cement leak after vertebroplasty and kyphoplasty. Spine 2002;19:2173-85. Jang J, Lee S, et al. Pulmonary Embolism of Polymethylmethacrylate After Percutaneous Vertebroplasty: A Report of Three Cases. Spine. October 2002 , Vol 27 (19), E416-86. Mirovsky Y, Anekstein Y, Shalmon E, et al. Intradiscal cement leak following percutaneous vertebroplasty. Spine 2006;31:1120–4.
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Lindsay – Osteoporos Int 2005
Prior VCF Increases Future VCF Risk
Lindsay 2001
• Lindsay 2001 analyzed VCF risk within one year in patients with 0, 1 or 2 or more prior VCFs. (JAMA 2001)
• Lindsay 2005 used the same patient cohort to analyze VCF risk within one year in patients with 0, 1, 2, 3, 4, 5, 6, 7, or 8 prior VCFs. (Osteoporos Int 2005)
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Does vertebral augmentation increase the risk of an adjacent level fracture?
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5/2004
9/2005
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Adjacent level fractures after vertebral augmentation (data from VERTOS II)
Klazen C, Venmans A, et al. Percutaneous Vertebroplasty Is Not a Risk Factor for New Osteoporotic Compression Fractures: Results from VERTOS II. American Journal of Neuroradiology, Sept 2010 (31), pp 1447-1450
• Mean follow up 11.4 months• Incidence of new VCFs not significantly different
between groups• Risk factor: number of VCFs at baseline
202 pts
Vertebroplasty
18 new fx’s in 15pts
Conservative tx
30 new fx’s in 21pts
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RCTs of vertebroplasty
Exclusion criteria were evidence or suspicion ofneoplasm in the target vertebral body
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Discussion
• VCFs are increasingly prevalent, with significant biopsychosocial impact
• Importance of multidisciplinary pain management, optimization of patient function, and prevention of new fractures
• Vertebral augmentation is commonly performed for painful compression fractures in cancer patients, with fairly good safety track
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Discussion
• Recent RCT’s challenge the role of vertebral augmentation for pain & raise more ?’s
• Limited data on outcomes from vertebral height restoration & anatomic correction of VCFs
• Role of posterior element in pain from VCFs?
• Individualized treatment with informed consent