Case 1
A 14-year-old patient presented with widely metastatic alveolar
rhabdomyosarcoma and extensive disease throughout the pelvis, abdomen
and chest and multiple bony metastases in the long bones and vertebrae.
She was treated with 12 weeks of standard chemotherapy including
vincristine, actinomycin and cyclophosphamide, and a PET-CT scan showed
complete response. Given that the site of primary tumor was unclear at
diagnosis and that radiation to all sites of disease was not possible,
the patient received additional 12 weeks of chemotherapy, followed by
consolidation with high dose chemotherapy with autologous stem cell
rescue. There was disease progression at 9 months post treatment with
widespread metastases in the chest, abdomen and pelvis, as well as in
the T7 and T12 vertebral bodies, causing significant pain in the back
and lower extremities. The patient received salvage chemotherapy with
irinotecan and temozolomide, with good response. However, there was
ongoing severe back pain (7/10) which was refractory to oral morphine 10
mg six times a day, and deterioration of the performance status with a
Lansky score dropping from 100 to 70. Multidisciplinary decision was for
vertebroplasty of the two levels, which occurred uneventfully. The pain
reduced to 5/10 seven days after the procedure and the opioid intake
decreased to oral morphine 10 mg twice a day. Over the next three weeks,
the pain completely resolved (0/10) and the Lansky score improved to
100. The patient returned to playing competitive high-level basketball
and participated in other high impact activities including skydiving.
Palliative chemotherapy was continued, and the patient remained pain
free and off all pain medications for three months, at which time there
was tumor progression in the pelvis. Back pain returned seven months
after vertebroplasty, shortly before the patient passing from pulmonary
metastatic disease.