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.