Cancer Treatment Today » Procedures

Radiofrequency coagulation for osteoblastic osteoma – pro

admin — Sun, 02 Sep 2012 14:57:50 +0000

Osteoid osteoma is a benign osteoblastic tumor. The literature suggests 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 non-operative, with medications consisting of aspirin or other NSAIDs. There is a variety of operative approaches. Surgical intervention is generally indicated for patients whose pain is unresponsive to medical therapy, patients who cannot tolerate prolonged use of NSAIDs, and those who are not amenable to activity restrictions.

Percutaneous radiofrequency coagulation or ablation of the nidus 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 osteoblstic osteoma. Pain resolves immediately, 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%.

The main disadvantages of this procedure are recurrence or persistence of the osteoid osteoma and the lack of histologic verification. Recurrent lesions can be managed with repeat percutaneous radiofrequency ablation, but lesions should be confirmed histologically by means of needle biopsy before ablation. Cure with a second ablation procedure is approximately 100% and recurrence is very rare. Lesions that are resistant to percutaneous radiofrequency ablation can easily be treated with open surgery. Another complication is local skin burns.

I had not been able to find guidelines that recommend RFA or comparative studies of surgery versus RFA. However, the literature appears to support RFA as the lass invasive and somewhat preferable option. For example a recent article (Montanez-Heredia et al) says: “CT-guided radiofrequency ablation of osteoid osteoma is neither invasive nor damaging. It has achieved a high rate of pain relief with a small morbidity rate in this series. It can be carried out on a one-day clinic basis. In cases in the lower extremity, immediate full-weight bearing is allowed following the procedure. Open surgery should be used only for cases in which the diagnosis is uncertain, or when the lesion is located near an important neurovascular structure and cannot be removed completely

Motamedi D, Learch TJ, Ishimitsu DN, Motamedi K, Katz MD, Brien EW, et al. Thermal ablation of osteoid osteoma: overview and step-by-step guide. Radiographics. Nov 2009;29(7):2127-41. [Medline].

Akhlaghpoor S, Aziz Ahari A, Ahmadi SA, Arjmand Shabestari A, Gohari Moghaddam K, Alinaghizadeh MR. Histological evaluation of drill fragments obtained during osteoid osteoma radiofrequency ablation. Skeletal Radiol. May 2010;39(5):451-5.

Volkmer D, Sichlau M, Rapp TB. The use of radiofrequency ablation in the treatment of musculoskeletal tumors. J Am Acad Orthop Surg. Dec 2009;17(12):737-43.

Rehnitz C, Sprengel SD, Lehner B, Ludwig K, Omlor G, Merle C, et al. CT-guided radiofrequency ablation of osteoid osteoma: correlation of clinical outcome and imaging features. Diagn Interv Radiol. Mar 8 2013

Elvira MONTAÑEZ-HEREDIA, José SERRANO-MONTILLA, María Luisa MERINO-RUIZ,

Francisco AMORES-RAMÍREZ, José VILLALOBOS-MARTÍN Osteoid osteoma : CT-guided radiofrequency ablation Acta Orthop. Belg., 2009, 75, 75-80

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Neupogen for Stem Cell Mobilization: Dose and Duration – pro

M Levin, MD — Sat, 04 Aug 2012 19:12:17 +0000

Neupogen is often used to mobilize hematopoietic progenitor cells into the peripheral blood for collection by leukophereses for members who are undergoing peripheral blood progenitor cell”. It is FDA approved: “NEUPOGEN® (filgrastim) is indicated for the mobilization of hematopoietic progenitor cells into the peripheral blood for collection by leukapheresis. Mobilization allows for the collection of increased numbers of progenitor cells capable of engraftment compared with collection by leukapheresis without mobilization or bone marrow harvest. After myeloablative chemotherapy‚ the transplantation of an increased number of progenitor cells can lead to more rapid engraftment‚ which may result in a decreased need for supportive care”.

The recommended dose of NEUPOGEN® (filgrastim) for the mobilization of PBPC is 10 mcg/kg/day SC‚ either as a bolus or a continuous infusion. It is recommended that NEUPOGEN® (filgrastim) be given for at least 4 days before the first leukapheresis procedure and continued until the last leukapheresis. This 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, for example, Ria et al, used a 12 day schedule. Nevertheless, the FDA approved dose and schdule are the most common and and there seems to be little reason to prefer a longer schdule.

Bassi Simona et a, A single dose of Pegfilgrastim versus daily Filgrastim to evaluate the mobilization and the engraftment of autologous peripheral hematopoietic progenitors in malignant lymphoma patients candidate for high-dose chemotherapy. Transfusion and Apheresis Science Volume 43, Issue 3 , Pages 321-326, December 2010

Tricot G, Barlogie B, Zangari M, van Rhee F, Hoering A, Szymonifka J, et al. Mobilization of peripheral blood stem cells in myeloma with either pegfilgrastim or filgrastim following chemotherapy. Haematological. 2008;93:1739–1742

R Ria et al, Comparison between filgrastim and lenograstim plus chemotherapy for mobilization of PBPCsBone Marrow Transplantation (2010) 45, 277–281

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TACE for Liver Metastases from Ovarian Cancer – pro

M Levin, MD — Sat, 04 Aug 2012 18:53:44 +0000

Transcatheter arterial chemoembolization (TACE) of the liver is a proposed alternative to conventional systemic or intra-arterial chemotherapy, and to various nonsurgical ablative techniques, to treat resectable and nonresectable tumors. The rationale for TACE is that infusions of viscous material containing one or more antineoplastic agents may exert synergistic effects: cytotoxicity from the chemotherapy, potentiated by anoxia in the infarcted region. The beneficial effect of chemoembolization may be further potentiated by labeling the infusate with radioactive isotopes for localized radiotherapy. The liver is especially amenable to such an approach, given its distinct lobular anatomy, the existence of two (2) independent blood supplies, and the ability of healthy hepatic tissue to grow and thus compensate for tissue mass lost during chemoembolization. Another rationale is that TACE delivers effective local doses, while possibly minimizing systemic toxicities associated with oral or intravenous chemotherapy.

Trans Arterial Chemoembolization is often used for hepatocellular carcinoma and neuroendocrine cancers of the liver. 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) states 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 or TAE 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, or, 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 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 ofr ovarian cancer because overall survival has not been increased.

Thomas J. Vogl et al, l Initial experience with repetitive transarterial chemoembolization (TACE) as a third line treatment of ovariancancer metastasis to the liver: Indications, outcomes and role in patient’s managementGynecologic Oncology Volume 124, Issue 2, February 2012, Pages 225–229

M . Giroux , R . Baum , M . Soulen. Chemoembolization of Liver Metastasis from Breast Carcinoma . Journal of Vascular and Interventional Radiology , Volume 15 , Issue 3 , Pages 289 – 291, 2004

Brown DB, Geschwind JF, Soulen M, et al. Society of Interventional Radiology (SIR) position statement on chemoembolization of hepatic malignancies. Society of Interventional Radiology. J Vasc Interv Radiol. 2006; 17(2):217-223.

Alexander T. Ruutiainen et al, Chemoembolization and Bland Embolization of Neuroendocrine Tumor Metastases to the Liver Journal of Vascular and Interventional Radiology Volume 18, Issue 7, July 2007, Pages 847-855

Society of Interventional Radiology (SIR). Interventional radiology treatments for liver cancer. 2009. Available at: http://www.sirweb.org/patients/liver-cancer/

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Combined Resection for Anal Cancer – pro

M Levin, MD — Fri, 03 Aug 2012 13:19:18 +0000

While a combined resection of rectal cancer and partial hepatectomy are well established, the same is not the case for anal cancer. Metastatic anal cancer is not well studied in regard to 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 by Tokar in 2006.

Principles and Practice of Gastrointestinal Oncology (Hardcover) by David P Kelsen (Editor), John M Daly (Editor), Scott E Kern (Editor), Bernard Levin Editor), Joel E Tepper (Editor) Publisher: Lippincott Williams & Wilkins; Second Edition edition (October 1, 2007), p.648 ISBN-13: 978-0781776172

NCCN.ORG, Anal Cancer 2012

Uronis, Hope E. , Bendell, Johanna C. Anal Cancer: An Overview Oncologist 2007 12: 524-534

Tokar M, Bobilev D, Zalmanov S, Geffen DB, Walfisch S. Combined multimodal approach to the treatment of metastatic anal carcinoma: report of a case and review of the literature. Onkologie. 2006 Feb;29(1-2):30-2.

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Sacroiliac Injection – pro

M Levin, MD — Fri, 03 Aug 2012 02:43:41 +0000

Sacroiliac 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 confounders of outcome, 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.

Manchikanti L, Datta S, Derby R, et al. A critical review of the American Pain Society clinical
practice guidelines for interventional techniques: part 1. Diagnostic interventions. Pain Physician.
2010 May-Jun;13(3):E141-74.

Rupert MP, Lee M, Manchikanti L et al. Evaluation of sacroiliac joint interventions: a systematic
appraisal of the literature. Pain Physician 2009; 12(2):399-418.

Manchikanti L, Datta S, Gupta S et al. A critical review of the American Pain Society Clinical
practice guidelines for interventional techniques: part 2. Therapeutic interventions. Pain Physician.
2010; 13(4):E215-64.

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Routine MCP or ERCP surveillance for Cholagniocarcinoma or Liver Cancer in Patients with Primary Biliary Cirrhosis – pro

M Levin, MD — Mon, 02 Jul 2012 16:41:31 +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.

Chapman R, Fevery J, Kalloo A, Nagorney DM, Boberg KM, Shneider B, Gores GJ, American Association for the Study of Liver Diseases. Diagnosis and management of primary sclerosing cholangitis. Hepatology 2010 Feb;51(2):660-78. http://www.aasld.org/practiceguidelines/Documents/Practice%20Guidelines/PSC_2-2010.pdf

Ali Shorbagi, Yusuf Bayraktar Primary sclerosing cholangitis – What is the difference between east and west? World J Gastroenterol 2008 July 7; 14(25): 3974-3981

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