Cancer Pain Case

Ankit M. Patel, MD

Disclosure• I have NO RELEVANT financial disclosures.

Objectives• Comprehensive evaluation of

pain in a patient with history of cancer

• Systematic & multidisciplinary treatment approach

• Interventional pain management options

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

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

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

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

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

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

Clinical Case

• MRI STIR sequence images reveal:• Edema in T12• Edema in L4

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

Clinical case: Treatment

• Bracing: TLSO

• Physical therapy

• Opioids

• Calcitonin

Interventions: the fourth step?

http://www.nationalpainfoundation.org/

Clinical Case: Intervention• T12 & L4 kyphoplasty

with bone biopsies

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

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

Which cancer type is associated with osteoblastic skeletal metastases?

• A) Multiple Myeloma

• B) Prostate cancer

• C) Thyroid cancer

• D) Lung cancer

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

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

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 ) 

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

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.

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)

Does vertebral augmentation increase the risk of an adjacent level fracture?

5/2004

9/2005

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

RCTs of vertebroplasty

Exclusion criteria were evidence or suspicion ofneoplasm in the target vertebral body

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

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