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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 35  |  Issue : 2  |  Page : 162-165

Humeroplasty for pain control in multiple myeloma


1 National Institute of Cancer, Mexico
2 MD Anderson Cancer Center, Houston, Texas, USA
3 Advanced Spine on Park Avenue, New York
4 Department of Pain Clinic, National Cancer Institute, Mexico

Date of Submission21-Jan-2021
Date of Decision08-Mar-2021
Date of Acceptance09-Mar-2021
Date of Web Publication31-Aug-2021

Correspondence Address:
Dr. B Carolina Hernández-Porras
San Fernando 22 Sección XVI, Tlalpan, Mexico City
Mexico
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_10_21

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  Abstract 


Pathological fractures in patients with primary skeletal cancer or metastases are associated with significant morbidity and poor prognosis. We present three cases of patients with osseous pain despite having received radiotherapy and multimodal analgesic management. Humeroplasty was offered to treat pain and decrease the risk of fracture. We report three patients with osseous pain secondary to osteolytic tumoral activity in the humerus and a Mirels score >7. Humeroplasty was performed under sedation and under fluoroscopy guidance. The three patients reported a decrease in pain most significantly with incidental pain and improved mobility. There were no fractures noted and no other complications. Percutaneous humeroplasty could be an option in multiple myeloma patients with impending humeral fractures, especially when the osteolytic lesion is localized in the humeral head. The procedure provided good pain relief to the patient. However, more studies should be conducted to asses efficacy and complications.

Keywords: Cancer pain, pain management, upper extremity


How to cite this article:
Plancarte R, Koyyalagunta D, Diwan S, Mota K, Hernández-Porras B C. Humeroplasty for pain control in multiple myeloma. Indian J Pain 2021;35:162-5

How to cite this URL:
Plancarte R, Koyyalagunta D, Diwan S, Mota K, Hernández-Porras B C. Humeroplasty for pain control in multiple myeloma. Indian J Pain [serial online] 2021 [cited 2021 Nov 30];35:162-5. Available from: https://www.indianjpain.org/text.asp?2021/35/2/162/325196




  Introduction Top


Cancer patients suffer significant morbidity due to skeletal metastasis, such as pain, and fractures. Some of the most common tumors (breast, prostate, thyroid, kidney, and lung) have a strong predilection to simultaneously metastasize to multiple bones.[1] Bone metastases in patients with cancer most commonly develop in the spine, ribs, pelvis, and long bones, and the majority of patients who develop bone metastases at first relapse will experience skeletal skeletal-related events (SREs).[2] SREs result in severe pain, hypercalcemia, anemia, increased susceptibility to infection, skeletal fractures, compression of the spinal cord, spinal instability, and decreased mobility, all of which compromise the patient's functional status, quality of life, and survival.[3],[4],[5]

External beam radiotherapy, endocrine treatments, chemotherapy, targeted therapies, and radioisotopes are the most important treatments for palliating bone metastatic pain. Bone cement augmentations and orthopedic interventions may be necessary to prevent impending fractures, for structural complications if bone destruction or nerve compression occurs, and to palliate pain refractory to radiotherapy and multimodal analgesics.[6]

Mirels proposed a scoring system for destructive processes affecting bones that predispose bone to an impending fracture. This screening tool for metastatic lesions in the long bone is based on four characteristics: pain, site, nature, and size of lesion. Prophylactic fixation is highly indicated for a lesion with an overall score of 9 or greater. A lesion with an overall score of 7 or less can be managed using radiotherapy, bone-strengthening drugs, and or analgesics. An overall score of 8 presents a clinical dilemma with a 15% probability of fracture and clinical judgment is recommended.[7]

Femoral bone augmentation has been presented as an option for patients with femoral metastases of the proximal third of the femur without fracture but in risk of fracture.[8],[9] Two reports have associated long bone augmentation with complications as fractures within the first 3 months after femoral cementoplasties.[10],[11] However, the majority of the patients presented a previous fracture or solution of continuity.[12] Humeroplasty has been described for acute Hill-Sach's injury,[13] as well as in the oncologic setting.[14],[15] A systematic review of long bone percutaneous osteoplasties has shown good pain relief, improved limb function, and secondary fractures were uncommon.[15]

However, to the best of our knowledge, there are no reported cases in the literature describing humeroplasty in multiple myeloma patients with refractory bone pain and impending fracture.

We describe the technique as well as the outcomes of the first three cases in patients with bone pain secondary to multiple myeloma and percutaneous cement injection in the humerus.


  Case Reports Top



  Case report 1 Top


History

A 65-year-old male, with multiple myeloma presented to the pain clinic in 2016 February with significant pain in the right arm, of moderate-intensity 6/10 on the visual analog scale (VAS) that increased with movement. Incidental movement-related pain was severe and made it difficult to him to perform basic physical activities. His current oncologic treatment included dexamethasone, zoledronic acid, and cyclophosphamide. He presented in the pain clinic, the orthopedist did not consider him candidate for surgical treatment. Patient was on opioids with a morphine equivalent daily dose of 15 mg, acetaminophen 1500 mg per day, and gabapentin 300 mg per day. In addition, he received palliative radiation therapy in both humerus doses of 20 Gy in 5 fractions and in the thoracic spine T3-T5 with doses of 30 Gy in 10 fractions, respectively.

In spite of pharmacological treatment, and radiotherapy, the patient continued with severe incidental pain in the right shoulder and associated nausea.

Assessement

Control chest computed tomography (CT) scan [Figure 1], reported an expansive lesion of osteolytic aspect in the right humerus. The risk of fracture was evaluated using a MIRELS scale, which resulted in 9 points (35% fracture risk). Percutaneous humeroplasty treatment was proposed for pain management and to diminish the risk of fracture. The patient rejected surgery, so humeroplasty was offered. Patient and family were informed about risks and complications, and we obtained informed consent. Humeroplasty was carried out after preoperative protocol.
Figure 1: Humeral metaphysis with a lytic lesion. In a lateral fluoroscopic projection, the needle was advanced through the humerus to achieve the lesion at the metaphysis

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Case report 2

History

A 73-year-old male with oncologic diagnosis of squamous cell carcinoma of the esophagus Stage IV (metastasis to bone and soft tissues) referred to axial thoracic pain and in the right shoulder. The intensity was severe 7/10 VAS, with oppressive character, that exacerbated to movements. He received tramadol 200 mg daily, acetaminophen 1500 mg per day, gabapentin 300 mg twice a day after palliative radiotherapy to a dorsal column at T9 to T12 and in the right shoulder, at doses of 20 Gy in 5 fractions in both regions

Assessment

In his imaging studies, positron emission tomography-CT reported lytic bone lesions in the axial skeleton and humerus. Mirels score was 8 points, so we offered the patient two possibilities, one conservative and the second bone augmentation in the right humerus. Patient and family chose percutaneous humeroplasty. Informed written and verbal consent was obtained for the procedure.

Case report 3

A 67-year-old woman with metastatic nonsmall-cell lung cancer in the bones and suprarenal gland, on treatment with osimertinib. Patient was unable to tolerate oral opioids due to side effects and had inadequate pain control with nonsteroidal anti-inflammatory drugs. He presents with severe pain in the left shoulder and leg, secondary to metastases. Mirels score was 9 points, and orthopedist did not considered surgery because of surgical risk and patient physical status, so the patient accepted humeroplasty for pain control and stability.

Humeroplasty technique

Patients were positioned supine with a pillow placed under the thoracic back, to rotate the shoulder 30°, to expose the humeral head, and separate the humerus from the acromion and glenoid cavity, keeping the elbow in flexion.

The C-arm was angled in a cephalad direction, to take an axial view and ensure the approach and entrance in the midpoint of the humeral head. We injected with local anesthetic the skin and subcutaneous tissues overlying the midpoint. A 15 cm bone needle is of 15-10G diameter was advanced through the humeral head.

At this point, the C arm was rotated to a lateral position, as the needle is advanced into the bony lesion [Figure 1]. The direction of the needle was rechecked after 2–3 cm of needle advancement and adjusted in order to remain axial [Figure 2].
Figure 2: Fluoroscopic tunnel view of the needle at the entrance point of the humeral head

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Once the tip of the needle reached the site of metastasis, a venography was performed to delimitate the tumoral activity and vascular drainage. Polymethyl methacrylate (PMMA) was injected in a “toothpaste” consistency, the amount of PMMA needed, in each patient, depended on the bone defect, state a medium of 20 ml (range 19-20 ml) was injected in the three cases.


  Results Top


A week after the procedure, the patient reported a pain reduction of >50%, as well as an improvement in arm mobility, with a Likert scale of 4/5, and a decrease in basal opioids.

During the follow-up at 1 and 4 months, he continued reporting improvement in pain in the right shoulder region, with an intensity of 3/10. Moreover, he is currently under treatment with tramadol 12.5 mg as rescue and pregabalin 150 mg daily to control chemotherapy-induced peripheral neuropathy. [Figure 3] demonstrates PMMA filling in a CT reconstruction.
Figure 3: Bone computed tomography reconstruction (a) Humerus in a coronal view, before bone cement injection, tumor is visible in the first two-thirds of the proximal humerus. (b) Computed tomography control post humeroplasty, Polymethyl methacrylate filling along the humerus is visible

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  Discussion Top


Even bone metastasis are initially asymptomatic, once they appear, they can potentially reduce the quality of life secondary to SREs. Treatment of bone pain secondary to metastases includes pharmacologic therapies, external radiotherapy, and surgery. In osteolytic metastases, bone cement augmentation has taken an important role in pain palliation.

Several systematic reviews have been published in order to determine long bone augmentation effectiveness and safety. Some modifications have been added to percutaneous osteoplasty as adding stainless needles or percutaneous fixation to the procedure. However, in this case, series patients reported good pain relief with percutaneous injection of PMMA alone.

Percutaneous humeroplasty could be an option in multiple myeloma patients with impending humeral fractures, especially when the osteolytic lesion is localized in the humeral head. The procedure provided good pain relief to the patient. However, more studies should be conducted to asses efficacy and complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Coleman RE. Skeletal complications of malignancy. Cancer 1997;80:1588-94.  Back to cited text no. 1
    
2.
Chen YC, Sosnoski DM, Mastro AM. Breast cancer metastasis to the bone: Mechanisms of bone loss. Breast Cancer Res 2010;12:215.  Back to cited text no. 2
    
3.
Saad F, Ivanescu C, Phung D, Loriot Y, Abhyankar S, Beer TM, et al. Skeletal-related events significantly impact health-related quality of life in metastatic castration-resistant prostate cancer: Data from PREVAIL and AFFIRM trials. Prostate Cancer Prostatic Dis 2017;20:110-6.  Back to cited text no. 3
    
4.
Mercadante S. Malignant bone pain: Pathophysiology and treatment. Pain 1997;69:1-8.  Back to cited text no. 4
    
5.
Mantyh PW. Pain due to Bone metastases: New research issues and their clinical implication. In: Leon-Casasola OA, editor. Cancer Pain: Pharmacological, Interventional and Palliative Care Approaches. 1st ed. Philadelphia: Saunders Elsevier; 2006. p. 75-84.  Back to cited text no. 5
    
6.
Milgrom DP, Lad NL, Koniaris LG, Zimmers TA. Bone pain and muscle weakness in cancer patients. Curr Osteoporos Rep 2017;15:76-87.  Back to cited text no. 6
    
7.
Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 1989;249:256-64.  Back to cited text no. 7
    
8.
Plancarte R, Guajardo J, Meneses-Garcia A, Hernandez-Porras C, Chejne-Gomez F, Medina-Santillan R, et al. Clinical benefits of femoroplasty: A nonsurgical alternative for the management of femoral metastases. Pain Physician 2014;17:227-34.  Back to cited text no. 8
    
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Feng H, Feng J, Li Z, Feng Q, Zhang Q, Qin D, et al. Percutaneous femoroplasty for the treatment of proximal femoral metastases. Eur J Surg Oncol 2014;40:402-5.  Back to cited text no. 9
    
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Botton E, Edeline J, Rolland Y, Vauléon E, Le Roux C, Mesbah H, et al. Cementoplasty for painful bone metastases: A series of 42 cases. Med Oncol 2012;29:1378-83.  Back to cited text no. 10
    
11.
Deschamps F, Farouil G, Hakime A, Teriitehau C, Barah A, de Baere T. Percutaneous stabilization of impending pathological fracture of the proximal femur. Cardiovasc Intervent Radiol 2012;35:1428-32.  Back to cited text no. 11
    
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Hernández-Porras C, Plancarte R. Regarding percutaneous augmented peripheral osteoplasty in long bones of oncologic patients for pain reduction and prevention of impeding pathologic fracture: The rebar concept. Cardiovasc Intervent Radiol 2016;39:477-8.  Back to cited text no. 12
    
13.
Jacquot F, Zbili D, Feron JM, Sautet A, Doursounian L, Masquelet AC. Balloon humeroplasty reconstruction for acute Hill-Sachs injury: A technical note. Hand Surg Rehabil 2016;35:250-4.  Back to cited text no. 13
    
14.
Sun G, Jin P, Liu XW, Li M, Li L. Cementoplasty for managing painful bone metastases outside the spine. Eur Radiol 2014;24:731-7.  Back to cited text no. 14
    
15.
Cazzato RL, Palussière J, Buy X, Denaro V, Santini D, Tonini G, et al. Percutaneous long bone cementoplasty for palliation of malignant lesions of the limbs: A systematic review. Cardiovasc Intervent Radiol 2015;38:1563-72.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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