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Adrenal
lular carcinoma after occlusion of tumor blood supply. Radiology 2000; 217:119-126.
9:00 a.m.
Q&A 9:20 a.m. Break 9:40 a.m. Kidney/ Adrenal Peter R. Mueller, MD Massacbusetts General Hospital Boston, MA
9:55 a.m. Bone William Charboneau, MD Mayo Clinic Rochester, Minnesota Approximately 40% of patients with cancer develop metastatic disease, and of these patients, 50% have poorly controlled pain. 0-3) Conventional therapeutic options for pain control include radiation therapy and/ or chemotherapy, surgery, and the use of opioid and other analgesics. Despite these measures, the quality of life for these patients is often poor because of intolerable pain. Reasons for failure of traditional thera pies to control pain include: radiation insensitivity of the neoplasm or limitations of radiation dose to normal structures, poor therapeutic response or toxicity to the chemotherapeutic agent, and intolerable analgesic-related side effects with increasing analgesic doses. Unfortunately, many patients faU to derive satisfactory pain relief with these therapies and relief, when achieved, may not occur until 4-12 weeks after the initiation of the treatment. Percutaneous image-guided therapy of metastatic neoplasms involving bone may offer an alternative to conventional therapies for pain control. Percutaneous radiofrequency (RF) ablation has been studied extensively for the treatment of primary and metastatic disease involving the liver. In preliminary reports, Dupuy (4) and Gevargez and their coworkers (5) found that RF ablation might provide a new method for palliation of painful metastases involVing bone. We recently reported our initial experience using RF to ablate painful metastases to bone. (6) The pain relief following RF was significant and sustained. In this study, 12 adult patients with painful osteolytic metastatic lesions, who had failed conventional radiation treatment and/ or chemotherapy with 2:4/ 10 worst pain over a 24 h period, were treated with percutaneous CT or US-guided radiofrequency (RF) ablation with a multi-tip needle (RITA Medical Systems) (Figure 1). As part of a subsequent multicenter trial involving
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Figure 1. Prone CT scan shows RF electrode deployed in an osteolytic renal cell metastasis involving the left acetabulum. This patient's maximum pain- decreased from 8/10 before RF to 0/10 after RF and he remained pain free until his death 7 months later.
forty-three patients, we again found patients with pain due to metastatic disease obtained relief following treatment with RF ablation (median follow-up 16 weeks). All patients experienced a decrease in worst pain ("Please rate your pain by circling the one number that best describes your worst pain over the past 24 hours") over the course of the follow-up period. The mean patient response for worst pain prior to RF treatment was 8/ 10. Four, twelve and twenty-four weeks following treatment, this mean response dropped to 4.5/10 (p < 0.0001), 3.0/10 (p < 0.0001), and 1.4/10 (p < 0.0005), respectively (Figure 2). Forty-one of 43 patients (95%) reported at least a two-point drop in worst pain over the past 24 h period at some point in the follow-up period. These patients derived sustained benefit for the sixmonth follow-up period. In addition, opioid usage significantly decreased at weeks 8 and 12.7 The mean percent score for how pain treatments or medications have proVided relief from pain is shown in Figure 3. ("In the past 24 hours, how much relief has pain treatments or medications provided?") The average relief from pain provided by treatments or medications prior to RF ablation treatment was 43%. Four, twelve, and twenty-four weeks following treatment this averaged response increased to 73% (p < 0.0001), 79% (p < 0.0001), and 84% (p < 0.003), respectively. The mechanism of action responsible for the decreased pain at the metastatic site following RF ablation is unclear. Several possible mechanisms responsible for decreased pain include: (1) physical destruction of adjacent sensory nerve fibers involving the periosteum and cortex of bone inhibiting pain transmission, (2) mechanical decompression of tumor volume decreasing stimulation of sensory nerve fibers, (3) destruction of tumor cells that produce nerve stimulating cytokines (tumor necrosis factor, interleukins, and others), which may sensitize nerve fibers and affect pain transmission, and (4) inhibition of osteoclast activity which may cause pain. (9-11) In summary, RF ablation provides an alternative
9:00 a.m.
Q&A 9:20 a.m. Break 9:40 a.m. Kidney/ Adrenal Peter R. Mueller, MD Massacbusetts General Hospital Boston, MA
9:55 a.m. Bone William Charboneau, MD Mayo Clinic Rochester, Minnesota Approximately 40% of patients with cancer develop metastatic disease, and of these patients, 50% have poorly controlled pain. 0-3) Conventional therapeutic options for pain control include radiation therapy and/ or chemotherapy, surgery, and the use of opioid and other analgesics. Despite these measures, the quality of life for these patients is often poor because of intolerable pain. Reasons for failure of traditional thera pies to control pain include: radiation insensitivity of the neoplasm or limitations of radiation dose to normal structures, poor therapeutic response or toxicity to the chemotherapeutic agent, and intolerable analgesic-related side effects with increasing analgesic doses. Unfortunately, many patients faU to derive satisfactory pain relief with these therapies and relief, when achieved, may not occur until 4-12 weeks after the initiation of the treatment. Percutaneous image-guided therapy of metastatic neoplasms involving bone may offer an alternative to conventional therapies for pain control. Percutaneous radiofrequency (RF) ablation has been studied extensively for the treatment of primary and metastatic disease involving the liver. In preliminary reports, Dupuy (4) and Gevargez and their coworkers (5) found that RF ablation might provide a new method for palliation of painful metastases involVing bone. We recently reported our initial experience using RF to ablate painful metastases to bone. (6) The pain relief following RF was significant and sustained. In this study, 12 adult patients with painful osteolytic metastatic lesions, who had failed conventional radiation treatment and/ or chemotherapy with 2:4/ 10 worst pain over a 24 h period, were treated with percutaneous CT or US-guided radiofrequency (RF) ablation with a multi-tip needle (RITA Medical Systems) (Figure 1). As part of a subsequent multicenter trial involving
P256
Figure 1. Prone CT scan shows RF electrode deployed in an osteolytic renal cell metastasis involving the left acetabulum. This patient's maximum pain- decreased from 8/10 before RF to 0/10 after RF and he remained pain free until his death 7 months later.
forty-three patients, we again found patients with pain due to metastatic disease obtained relief following treatment with RF ablation (median follow-up 16 weeks). All patients experienced a decrease in worst pain ("Please rate your pain by circling the one number that best describes your worst pain over the past 24 hours") over the course of the follow-up period. The mean patient response for worst pain prior to RF treatment was 8/ 10. Four, twelve and twenty-four weeks following treatment, this mean response dropped to 4.5/10 (p < 0.0001), 3.0/10 (p < 0.0001), and 1.4/10 (p < 0.0005), respectively (Figure 2). Forty-one of 43 patients (95%) reported at least a two-point drop in worst pain over the past 24 h period at some point in the follow-up period. These patients derived sustained benefit for the sixmonth follow-up period. In addition, opioid usage significantly decreased at weeks 8 and 12.7 The mean percent score for how pain treatments or medications have proVided relief from pain is shown in Figure 3. ("In the past 24 hours, how much relief has pain treatments or medications provided?") The average relief from pain provided by treatments or medications prior to RF ablation treatment was 43%. Four, twelve, and twenty-four weeks following treatment this averaged response increased to 73% (p < 0.0001), 79% (p < 0.0001), and 84% (p < 0.003), respectively. The mechanism of action responsible for the decreased pain at the metastatic site following RF ablation is unclear. Several possible mechanisms responsible for decreased pain include: (1) physical destruction of adjacent sensory nerve fibers involving the periosteum and cortex of bone inhibiting pain transmission, (2) mechanical decompression of tumor volume decreasing stimulation of sensory nerve fibers, (3) destruction of tumor cells that produce nerve stimulating cytokines (tumor necrosis factor, interleukins, and others), which may sensitize nerve fibers and affect pain transmission, and (4) inhibition of osteoclast activity which may cause pain. (9-11) In summary, RF ablation provides an alternative