Case 2
A 9-year-old patient with Wilms tumor was treated with vincristine, actinomycin, doxorubicin and then upstaged due to poor response to more aggressive chemotherapy, including carboplatin, etoposide, doxorubicin, cyclophosphamide, and whole abdominal radiation. He presented three years later with a paravertebral mass at L3 with no other sites of disease. His relapse was not responsive to salvage chemotherapy with vincristine and temozolomide and re-irradiation was not possible. He was pain free and multidisciplinary decision was to perform vertebroplasty for local tumor control. The procedure was uneventful and was able to stabilize tumor growth for five months, when he developed intermittent right leg pain due to tumor progression. This required a combination of oral acetaminophen with codeine, and gabapentin for management. Chemotherapy was stopped and new vertebroplasty was done at the L3 level. His pain resolved over the next three weeks and he stopped all oral pain medications. His disease remained stable for 14 months, when it again relapsed at the L3 level, causing intermittent right leg pain requiring gabapentin. Cryoablation of the tumor was performed. His pain progressed during the first 48-hours post-procedure, requiring increased doses of gabapentin and codeine. Three weeks after the thermal ablation, his pain had completely resolved, with all pain medications discontinued. His pain returned three months later and was severe, requiring palliative radiation that stabilized his disease for the next 18 months. At age 13, he had further recurrence at the L3 level, which was again associated with severe pain requiring high doses of oral morphine and gabapentin. A new vertebroplasty was done, with significant reduction in his pain medications over the next month. He passed five months after his last intervention.