Cancer Treatment Today » Procedures

Radiofrequency coagulation for osteoblastic osteoma

M Levin, MD — Thu, 20 Sep 2012 14:44:19 +0000

Osteoid osteoma is a benign osteoblastic (bone producing) tumor. The literature suggests that its natural history is a history of resolving pain and healing of the lesions, but the course can be variable. The course of this disease is unpredictable and protracted, with intervals of resolution of pain that sometimes last 6-15 years. Initial treatment of osteoid osteoma remains nonoperative, with medications such as aspirin on other non-steroidal pain and inflammation relievers.

Percutaneous radiofrequency coagulation or ablation of the nidus the osteoma is performed by using an electrode placed in the lesion, coupled with a radiofrequency generator that produces local tissue destruction by converting radiofrequency into heat. Complete or nearly complete relief of pain often occurs within 3 days. Patients are sent home on same day of surgery, and they have no limitations in weight bearing, though aggressive athletics are restricted for 2-3 months. Patients may then return to normal activities immediately or within 24-48 hours after surgery. For this reason, it is currently the favored procedure for osteoblastic osteoma. It works fast; Pain resolves quickly, and limping resolves within 24 hours. Furthermore, this procedure requires only a small osseous access to allow insertion of the electrode; therefore, no substantial structural weakening of the bone occurs. Primary cure rates are 83-94%. Cure with a second ablation procedure is approximately 100% and recurrence is very rare.

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Primary Sclerosing Cholangitis (PSC)

M Levin, MD — Tue, 17 Jul 2012 14:33:49 +0000

Primary sclerosing cholangitis (PSC) is a chronic, liver disease characterized by bile stasis within bile ducts and liver inflammation and fibrosis. It is thought to be an immune mediated, progressive disorder that eventually develops into liver cirrhosis, portal hypertension and hepatic decompensation, in the majority of patients. How does one follow the activity of this disease? Guidelines do not recommend routine MRCP or ERCP to screen for screening for cholangio or hepatocellular(liver) carcinoma. They do recommend these tests for patients with deterioration in their constitutional performance or worsening liver tests. These patients should have these tests to evaluate for a possible chalangiocarcinoma.

Routine MCP or ERCP Surveillance for Cholagniocarcinoma or Liver Cancer in Patients with Primary Biliary Cirrhosis.

M Levin, MD — Wed, 20 Jun 2012 22:09:44 +0000

Primary sclerosing cholangitis (PSC) is a chronic, cholestatic liver disease characterized by inflammation and fibrosis of both intrahepatic and extrahepatic bile ducts. It is thoughtto be an immune mediated, progressive disorder that eventually develops into cirrhosis, portal hypertension and hepatic decompensation, in the majority of patients. Guidelines do not recommend routine MRCP or ERCP to screen for chalngiocarcinoma or hepatocellular carcinoma. They do recommend that patients with deterioration in their constitutional performance status or liver biochemical-related parameters should undergo an evaluation for CCA.

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Neupogen for stem cell mobilization: Dose and Duration

M Levin, MD — Wed, 20 Jun 2012 17:47:02 +0000

Neupogen(filgrastim) is often used to drive progenitor cells into the peripheral blood so they can collected by the leukophereses for use in a stem cell transplant. It is FDA approved for this purpose.

Regarding dose, please look at the professional version. How long should Neupogen be used? It is recommended that NEUPOGEN® (filgrastim) be given for at least 4 days before the first leukapheresis procedure and continued until the last leukapheresis. The FDA says, “Although the optimal duration of NEUPOGEN® (filgrastim) administration and leukapheresis schedule have not been established‚ administration of NEUPOGEN® (filgrastim) for 6 to 7 days with leukaphereses on days 5‚ 6‚ and 7 was found to be safe and effective (see Clinical Experience for schedules used in clinical trials). Neutrophil counts should be monitored after 4 days of NEUPOGEN® (filgrastim) ‚ and NEUPOGEN® (filgrastim) dose modification should be considered for those patients who develop a WBC count > 100‚000/mm3.” In none of the studies listed in the Clinical Experience section, was Neupogen used for 14 days for stem cell mobilization.

Clinical studies have used longer administrations than the FDA recommends, for example, Ria et al, used a 12 day schedule. Nevertheless, the FDA approved dose and schedule are the most common and there is little evidence to prefer a longer schedule.

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TACE for Liver Metastases from Ovarian Cancer

M Levin, MD — Wed, 20 Jun 2012 17:40:13 +0000

Transcatheter arterial chemoembolization (TACE) of the liver is an alternative to conventional systemic or intra-arterial chemotherapy, and to various nonsurgical tumor-killing techniques. It is meant to treat resectable and non-resectable tumors. The rationale for TACE is that infusions of viscous material containing one or more chemo drugs may have synergy: chemotherapy killing cancer cells that are already weakened from a lack of oxygen in the area. Synergy can be further potentiated by attaching radioactive isotopes for localized radiotherapy. The liver is especially amenable to such an approach, given its unusual anatomy, the fact that it is fed by two main and independent blood sources, and the ability of healthy hepatic tissue to recover from chemotherapy and re-grow damaged cells and thus compensate for cells lost during chemoembolization, whereas the cancer cannot do so. Another rationale is that TACE delivers effective local doses, while minimizing systemic toxicities that can be caused by oral or intravenous chemotherapy.

Trans Arterial Chemoembolization is often used for hepatocellular carcinoma and neuroendocrine cancers of the liver. However for other types of cancer, less information is available. The safety and effectiveness of chemoembolization for breast cancer metastases is unknown as only case reports and series have so far been reported. The largest series reported in a 2008 abstract was of 217 patients but this was not a prospective study.

The Society of Interventional Radiology (SIR, 2009) stated that chemoembolization has shown promising early results with some types of metastatic tumors but that the evidence in the current medical literature is insufficient to demonstrate the efficacy of TACE for the treatment of liver metastases from other primary tumors, including but not limited to breast cancer, colorectal cancer, and other tumors of unknown primary sites, from ovarian cancer. Metastatic disease to the liver from tumors other than primary neuroendocrine tumors is generally treated with surgery, chemotherapy, or both.

Metastatic disease to the liver from ovarian cancer is somewhat less frequent than from breast cancer. A recent report from Vogl at al found that it is TACE is an effective palliative treatment in achieving local control in selected patients with liver metastases from ovarian cancer. It is the only study on this topic. This is similar to outcomes for the metastatic disease to the liver treated with TACE. Generally such results have not been thought to be adequate to recommend TACE of ovarian cancer because overall survival has not been increased.

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Combined Resection for Anal Cancer

M Levin, MD — Tue, 19 Jun 2012 19:51:27 +0000

The term ‘combined resection” refers to removing the primary cancer and one or a few metastatic area, in the hope that there are no metastases and that it will lead to a cure or prolonged period of being free of cancer. While a combined resection of rectal cancer and partial liver resection of metastases is well established, the same is not the case for anal cancer. Metastatic anal cancer is not well studied in regard to a combined resection. NCCN recommends only 5FU and cisplatin or cisplatin for metastatic anal cancer. A recent review states: ” Metastatic disease develops in 10%–17% of patients treated with chemoradiation therapy. The most common site of distant metastasis is the liver. There are limited published data on the use of chemotherapy, particularly newer agents, to treat metastatic anal carcinoma. Active agents include cisplatin plus 5-FU, carboplatin, doxorubicin, and semustine. Participation in a clinical trial should be discussed with all potentially eligible patients.”

Although there have been no randomized trials comparing surgery with radiation treatment or with combined chemoradiation, based on multiple studies and clinical experience for the last 20 years, there has been a substantial change in the management of epidermoid anal carcinomas, with more patients undergoing nonsurgical treatment.

I was not able to find credible literature supporting a combined resection approach for anal cancer. NCCN lists only 5 Fu and cisplatin for metastatic anal cancer therapy. The first report of this approach was a case report by Tokar in 2006 and no prospective trials have been reported.

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Sacroiliac Injection

M Levin, MD — Tue, 19 Jun 2012 19:48:52 +0000

Sacroiliac steroid injection can be used diagnostically or therapeutically. There are no prospective a controlled trials to support this procedure. Most support comes from case reports or case series. Case series are unreliable evidence due to the variable natural history of back pain, the presence of factors that can influence outcome and mislead the investigators, and the potential for a placebo effect. In general, the literature regarding injection therapy on joints in the back is of poor quality. The current evidence on sacroiliac joint arthrography and injections is insufficient to consider it medically appropriate.

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