Computed tomography-guided paravertebral doxorubicin injection for refractory pain in patients with spinal metastases: Two case reports.
计算机断层扫描引导下椎旁注射多柔比星治疗脊柱转移瘤患者顽固性疼痛: 2 例病例报告。
- 作者列表："Lu F","Zhong Q","Tian J","Zhang K
RATIONALE:Diagnosing and treating refractory cancer pain have become standardized and effective procedures with guidance from the Expert Consensus on Refractory Cancer Pain released in 2017 by the Committee of Rehabilitation and Palliative Care of China. Doxorubicin has been used for perineural injection in the treatment of chronic non-cancer pain owing to its retrograde sensory ganglion resection effect. Our study reports a new fourth-ladder treatment for cancer pain: CT-guided paravertebral doxorubicin injection for patients with refractory cancer pain caused by paraspinal metastasis. PATIENT CONCERNS:A 48-year-old female and a 47-year-old male patients suffered from refractory cancer pain over the past months. They had both undergone surgical tumor resection, chemotherapy, and precision radiotherapy but result in limited analgesic effect. The daily oral morphine dosage was around 60 to 100 mg and rescue analgesic methods had been used at the time. DIAGNOSES:Refractory cancer pain in 2 patients with renal cancer and hepatobiliary adenocarcinoma. INTERVENTIONS:The patients both received computed tomography (CT)-guided 1 mL of 0.5% doxorubicin paravertebral injection at each affected nerve root segments. OUTCOMES:The Visual Analog Scale and Douleur Neuropathique four Questions were used for 6-month follow-up, and the analgesic requirement was also recorded. The patients enjoyed satisfactory analgesia for up to 6 months without adverse reaction. In addition, the oral opioid analgesic doses were significantly reduced after the neurolytic block. LESSONS:The CT-guided paravertebral doxorubicin injection was an effective fourth-step analgesic interventional technology that allowed our 2 patients with refractory cancer pain to maintain satisfactory analgesia. This analgesia method taken at an appropriate stage, according to the latest analgesic concept, results in good analgesia and opioid use reduction. Also, with the imaging guidance, only a small amount of neurolytic agent is needed to achieve analgesia in a precise and safe way.
理由: 在中国康复与姑息治疗委员会 2017 年发布的难治性癌痛专家共识的指导下，诊断和治疗难治性癌痛已经成为规范和有效的程序。多柔比星由于其逆行感觉神经节切除的作用，已被用于神经周围注射治疗慢性非癌症疼痛。我们的研究报告了一种新的癌症疼痛的第四阶梯治疗: CT引导下椎旁注射多柔比星治疗椎旁转移引起的顽固性癌症疼痛患者。 患者顾虑: 一名 48 岁的女性和一名 47 岁的男性患者，在过去的几个月里患有顽固性癌痛。他们都接受了手术肿瘤切除、化疗和精确放疗，但镇痛效果有限。吗啡每日口服剂量约为 60 ~ 100 mg，当时已采用补救镇痛方法。 诊断: 2 例肾癌和肝胆腺癌患者顽固性癌痛。 干预措施: 患者均接受计算机断层扫描 (CT) 引导下 0.5% 多柔比星椎旁注射各受累root段 1 ml。 结果: 采用视觉模拟量表和Douleur神经病四题进行 6 个月随访，并记录镇痛需求。术后 6 个月镇痛效果满意，无不良反应。此外，神经松解阻滞后口服阿片类镇痛药的剂量显著减少。 教训: CT引导下椎旁注射多柔比星是一种有效的第四步镇痛介入技术，使我们的 2 例顽固性癌痛患者保持满意的镇痛。这种在适当阶段采取的镇痛方法，根据最新的镇痛概念，产生良好的镇痛和减少阿片类药物的使用。此外，在影像学指导下，仅需要少量的神经松解剂就可以以精确和安全的方式实现镇痛。
METHODS:OBJECTIVE:Large inoperable sacral chordomas show unsatisfactory local control rates even when treated with high dose proton therapy (PT). The aim of this study is assessing feasibility and reporting early results of patients treated with PT and concomitant hyperthermia (HT). METHODS: :Patients had histologically proven unresectable sacral chordomas and received 70 Gy (relative biological effectiveness) in 2.5 Gy fractions with concomitant weekly HT. Toxicity was assessed according to CTCAE_v4. A volumetric tumor response analysis was performed. RESULTS: :Five patients were treated with the combined approach. Median baseline tumor volume was 735 cc (range, 369-1142). All patients completed PT and received a median of 5 HT sessions (range, 2-6). Median follow-up was 18 months (range, 9-26). The volumetric analysis showed an objective response of all tumors (median shrinkage 46%; range, 9-72). All patients experienced acute Grade 2-3 local pain. One patient presented with a late Grade 3 iliac fracture. CONCLUSION:Combining PT and HT in large inoperable sacral chordomas is feasible and causes acceptable toxicity. Volumetric analysis shows promising early results, warranting confirmation in the framework of a prospective trial. ADVANCES IN KNOWLEDGE: :This is an encouraging first report of the feasibility and early results of concomitant HT and PT in treating inoperable sacral chordoma.
METHODS:BACKGROUND:National guidelines recommend screening and treatment for cancer-related bone disease and continued monitoring of bone-modifying agents. It is unclear whether a standardized screening tool is utilized to identify eligible patients and ensure appropriate supportive care is implemented. The purpose of this study was to evaluate current prescribing practices and optimize management of bone-modifying agents. METHODS:A retrospective chart review was performed to identify patients who received hormone deprivation therapy or had bone metastases through Hematology/Oncology or Urology clinics from 1 November 2016 to 31 October 2017. The primary endpoints of this study were the incidence of completed baseline dual-energy X-ray absorptiometry (DEXA) scan for patients on hormone deprivation therapy and percent of patients started on a bone-modifying agent for the prevention of skeletal-related events secondary to bone metastasis. Secondary endpoints included percent of patients with dental examinations prior to initiation, adequate calcium and vitamin D supplementation, incidence of osteonecrosis of the jaw or flu-like symptoms and education, and percent of bisphosphonate doses appropriately adjusted based on renal function. RESULTS:A total of 375 patients were assessed for baseline DEXA scans and bone-modifying therapy. Of the 226 patients on hormone deprivation therapy, 111 (49%) patients were appropriately screened with a DEXA scan prior to initiation of hormone deprivation therapy. Among the 149 patients with bone metastases, only 94 (63.1%) patients were started on a bone-modifying agent. CONCLUSIONS:Opportunities have been identified to optimize management of patients with cancer-related bone disease. Implementation of standardized tools may increase the rate of appropriate screening and initiation of bone-modifying therapy when warranted.
METHODS:PURPOSE:Low skeletal muscle mass has been associated with poor prognosis in patients with advanced lung cancer. However, little is known about the relationship between skeletal muscle mass and overall survival in patients with bone metastases from lung cancer. The objective of the present study was to evaluate the prognostic value of low trunk muscle mass in predicting overall survival in these patients. METHODS:The data from 198 patients who were diagnosed with bone metastases from lung cancer from April 2009 to May 2017 were retrospectively reviewed. The areas of the psoas and paravertebral muscles were measured at the level of the third lumbar vertebra on computed tomography scans taken at the time nearest to the diagnosis of bone metastasis. Muscle area was evaluated for male and female cohorts separately using different cutoff points. Cox proportional hazards analysis was performed to evaluate the factors independently associated with overall survival. RESULTS:The overall survival of patients in the lowest quartile for psoas muscle area or paravertebral muscle area was significantly shorter than that of patients above the 25th percentile for muscle area (p < 0.001). Multivariate analyses showed that paravertebral muscle mass (hazard ratio, 1.73; 95% confidence interval, 1.17-2.56; p = 0.006), epidermal growth factor receptor-targeted therapy, and performance status were independent prognostic factors. CONCLUSIONS:Low paravertebral muscle mass was associated with shorter survival, independently of known prognostic factors.