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.