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Abstract
The combination of percutaneous vertebroplasty with radiofrequency ablation (verteblation) has not shown to be an effective measure of pain management in patients with metastatic lesions of the spine. The use of this novel technique has not been previously described in metastatic disease from thyroid cancer. We would like to report our experience after treating a patient affected by a thyroid carcinoma and an osteolytic spine metastasis. The patient suffered from life-limiting pain and was successfully treated with a combination of vertebroplasty and radiofrequency ablation. This case shows that the indications of verteblation may be expanded in the palliative treatment of metastatic disease from thyroid carcinoma.
- Vertebroplasty
- radiofrequency ablation
- pain management
- thyroid carcinoma
- palliative treatment
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Introduction
Vertebroplasty has an established role in the management of patients with osteoporotic vertebral fractures.1 The combined use with radiofrequency ablation (verteblation) has shown positive results in the pain management of patients with metastatic lesions of the spine.2
Purpose of this case report is to reveal the role of this novel treatment for the pain management of a patient with metastasis of the spine from thyroid carcinoma.
Case report
A 64-year-old woman with a history of papillary thyroid carcinoma was referred to our hospital due to life-limiting, excruciating axial back pain in the lumbar region that lasted for several weeks and was refractory to symptomatic medical management. Attempts of pain control with non-steroidal anti-inflammatory drugs, steroids and opioids in combination with physiotherapy were performed but without success. In the past 6 months the visual analogue scale (VAS) trend was increased from 3 to 7. The patient had undergone thyroidectomy 3 years earlier with histological diagnosis of well-differentiated follicular type carcinoma with lymph node involvement. Postsurgery, the patient received treatment with radioiodine-131 (every 3–9 months during the first 2 years and then once a year) and thyroxin; the latter was administered at suppressive doses between radioiodine-131 treatment courses.
The case was discussed in the multidisciplinary team (MDT) meeting and MRI and positron-emission tomography (PET)-CT were suggested. Imaging revealed a lytic lesion in the left anterior portion of the L2 vertebral body that was partially eroding the cortex wall without causing epidural compression (figure 1). A CT-guided biopsy confirmed the metastatic nature of the lesion from papillary thyroid carcinoma. The MDT did not consider any surgical options due to the high morbidity and suggested the combination of radiofrequency ablation with vertebroplasty given the positive results that this treatment has offered for patients with multiple myeloma.
(A) CT scan confirmed the presence of a lutic lesion in the L2 vertebral body; (B) avid uptake of the PET-CT tracer from the lesion (arrow). PET, positron-emission tomography.
Written informed consent was obtained. The procedure was performed under local anaesthesia with 1% lidocaine combined with conscious sedation using midazolam (4 mg) and fentanyl (100 mg) in a day-case setting. Clindamycin (600 mg) and dexamethasone (6 mg) were administered intravenously preoperatively. The patient was in prone position with CT-fluoroscopic guidance using a right transpedicular route. A 10-gauge vertebroplasty needle was first advanced into the L2 body and then an 18-gauge Starburst Array radio frequency ablation (RFA; Angiodynamics, Cambridge, UK) needle was coaxially advanced (figure 2). The lesion was ablated using 150 W of energy for 5 min reaching a temperature of 98°C. Following the ablation, cement polymethylmethacrylate (CementoRe set; Optimed, Ettlingen, Germany) was delivered under close imaging guidance in the lesion. A CT scan was obtained immediately after the procedure, demonstrating appropriate homogeneous distribution of the cement in the lesion (figure 3A) excluding leakage in the epidural/paravertebral space and the surrounding veins. No signs of spinal cord damage (haematoma, compression) were detected.
Transpedicular approach to the lesion with a vertebroplasty needle and an RFA electrode. RFA, radio frequency ablation.
(A) Satisfactory result postablation and cement injection with no leakage in the spinal canal; (B) no uptake is noted in the PET-CT scan a month post-treatment. PET, positron-emission tomography.
Immediately after the procedure, the patient reported a considerable reduction of back pain (VAS dropped down to 2.5) without any neurological symptoms. The patient was discharged 6 hours after the procedure with a 7-day corticosteroid therapy scheme (methylprednisolone sodium succinate). A PET-CT was performed 1 month later and confirmed no tracer uptake (figure 3B). At 3 months follow-up, the patient continued to report excellent pain control (VAS 2); no pain control medication was required and she resumed her normal daily activities.
Discussion
Vertebroplasty is an established minimally invasive augmentation technique that consists in the introduction of cement in a fractured vertebral body via a needle that is placed under CT or fluoroscopic guidance.1 Vertebral reinforcement reduces micro movements and provides stability. Imaging guidance minimises the risk of unintended damage to adjacent structures and allows the immediate visualisation of possible cement extravasations.
In previous series the combination of vertebroplasty with RFA has shown promising results in metastatic disease.2 Radiofrequency ablation causes tissue necrosis when the temperature rises above 60°C. Furthermore, when performed prior to percutaneous vertebral augmentation, it reduces the risk of cement extravasation due to the perilesional oedema and the involvement of the peritumoural vessels.3
In the management of vertebral metastasis, surgery is seldom an option because spinal procedures are highly invasive and are generally not suitable because of high risk of complications.4 Although radiotherapy showed promising results, it needs time to obtain pain control and vertebral stabilisation.
Long-term follow-up studies are missing and there are no studies comparing vertebroplasty alone versus RFA followed by vertebroplasty in the treatment of spine metastasis. To the best of our knowledge, there is only one study comparing RFA alone with RFA followed by vertebroplasty in the treatment of spine metastasis involving <20 patients;5 this study reports no difference between the two approaches but studies on larger series should be performed.
We believe that vertebroplasty combined with RFA plays a central role in axial back pain management due to vertebral lytic metastases refractory to medical approach. Vertebral augmentation and RFA provide significant reduction in pain, with minimal procedure-related morbidity aiding mobility, response to physiotherapy and quality of life with minimal interference with adjuvant therapies reducing side effect of analgesics and increasing the quality of life of the oncological patient.
Footnotes
Contributors GO was involved in text editing and manuscript planning. MK was involved in text editing and submission. MR was involved in text editing and guarantor content. AR, MAT and LM were involved in literature research.
Competing interests None declared.
Patient consent Obtained.
Ethics approval Institutional Review Board.
Provenance and peer review Not commissioned; internally peer reviewed.