Cancer Treatment

Radiofrequency coagulation for osteoblastic osteoma.

Osteoid osteoma is a benign osteoblastic tumor. The literature suggests a history of resolving pain and healing of the lesions, but teh 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 consisting of aspirin or other NSAIDs.There is a variety of operative approaches.

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 currenlty 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%. Cure with a second ablation procedure is approximately 100%. and recurrence is very rare.

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.

Intra-arterial(IA) chemotherapy for peripheral osteosarcoma

Local control of osteosarcoma primarily is a surgical problem, but histologic response to neoadjuvant therapy is the single most important prognostic factor for long-term survival in nonmetastatic osteosarcoma of the extremity.IA therapy might be able to provide better guidance but this is not proven. Currently, doxorubicin, cisplatin, high-dose methotrexate with leucovorin rescue and ifosfamide are considered the most active agents against osteosarcoma.

IA cisplatin is not standard of care. It is not NCCN recommended. Instead, NCCN on Bone-C,1 recommends for fits-line: docetaxel/gemcitabine, cisplatin and doxorubicine, MAP, doxirubine/cisplatin/ifosfamide/high-dose methotrexate, ifosfamide/cisplatin/epirubicin.

 

PLDD, Percutaneous Laser Disc Decompression

The percutaneous laser discectomy is a procedure which consists of passing a side firing laser probe into specific regions of a lumbar or cervical disc under X-Ray visualization. The lasery is then directed at the "degenerate" tissues, with the purported effect to reduce inflammation in the disc and to reduce pressure upon nerves passing over the disc protrusion.

A recent review(Schenk et al) states that the success rates in the larger studies varied from 75% (95% confidence interval [CI], 69%–81%)17 to 87% (95% CI, 80%–94%). The definition of "successful outcome" varied strongly between the different studies, depending on the outcome measures used. The duration of follow-up ranged from 310 to 8412 months. Because of insufficient improvement of symptoms or recurrent herniation, 4.4%20 to 25% of patients received additional surgical treatment. In most cases, surgery revealed the presence of free fragments in the spinal canal.

I quote teh conclusion of this review: "No randomized, controlled trials were available. Almost all trials were case series, with a relatively low strength of evidence. Furthermore, the sample size in most trials was relatively small, resulting in broad 95% CIs that made interpretation of success rates difficult. Generalization of the results into general practice remains difficult, because of the different inclusion and exclusion criteria, laser types, and outcome measures used and the large variation in duration of follow-up. These individual differences impair the mutual comparability of the studies and, more important, limit the possibilities for a valid comparison to studies evaluating the outcome of conventional surgical treatment for lumbar disk herniation.

Despite the fact that PLDD has been around for almost 20 years, scientific proof of its efficacy still remains relatively poor, though the potential medical and economic benefits of PLDD are too high to justify discarding it as experimental or ineffective on the sole basis of insufficient scientific proof. Well-designed research of sufficient scientific strength, comparing PLDD to both conventional surgery and conservative management of lumbar disk herniation, is needed to determine whether PLDD deserves a prominent place in the treatment arsenal for lumbar disk herniation. "

The PLDD method has not been subjected to ar igorous designed trila and reported success rates are poorly defined. Pain control is a notoriously poor predictor of success in back conditions. There are no ongoing US trials but there is a comparative trail ongoing in England, Current Controlled Trials ISRCTN25884790.

B. Schenk et al, Percutaneous Laser Disk Decompression: A Review of the Literature American Journal of Neuroradiology 27:232-235, January 2006

Gibson JN, Grant IC, Waddell G. Surgery for lumbar disc prolapse (Cochrane review). Cochrane Database Syst Rev. 2000;(3):CD001350.

Patrick A Brouwer et al,  Effectiveness of percutaneous laser disc decompression versus conventional open discectomy in the treatment of lumbar disc herniation; design of a prospective randomized controlled trial BMC Musculoskeletal Disorders 2009, 10:49

 

Epidural Injections

ODG recommends epidural injections only in the acute phase of pain and specifically does NOT recommend a series of three. Epidural injections were subject of a TEC assessment, which concluded: ....The average magnitude of effect is small, and the generalizability of the observation is limited by the small number of studies, limited to highly selected patient populations, the few techniques and doses studied, and variable comparison treatments....Their routine use for these indications is not recommended (Level B, Class I–III evidence).
Data on use of epidural steroid injections to treat cervical radicular pain are inadequate to make any recommendation (Level U).

ODG, Back Pain

Armon C, Argoff CE, Samuels J, Backonja MM, Therapeutics and Technology Assessment Subcommittee of the American. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2007 Mar 6;68(10):723-9. [27 references]