Mattei Tobias A, Mendel Ehud, Bourekas Eric C
Department of Neurological Surgery, The Ohio State University Wexner Medical Center/The James Cancer Center, 410 W 10th Ave., N1037 Doan Hall, Columbus, OH 43210, USA.
Department of Neurological Surgery, The Ohio State University Wexner Medical Center/The James Cancer Center, 410 W 10th Ave., N1037 Doan Hall, Columbus, OH 43210, USA.
Spine J. 2014 Jun 1;14(6):e29-35. doi: 10.1016/j.spinee.2013.11.046. Epub 2013 Dec 6.
Denosumab (XGeva) is a receptor activator of nuclear factor-κB ligand (RANKL)-antibody that was approved by the Food and Drug Administration (FDA) in 2010 for the prevention of skeletal fractures in patients with bone metastases from solid tumors. Although there is a widespread use of such drug in patients under risk of pathological fractures, the compatibility of denosumab therapy with percutaneous vertebroplasty (an interventional procedure commonly used for pain control in such population) has not yet been established.
To present the serial imaging findings and technical report of an attempted percutaneous vertebroplasty in a patient with refractory pain and a lytic pathological vertebral fracture related to small cell lung cancer spinal metastasis and who was actively under medical treatment with denosumab.
Retrospective review and case report.
The authors present the imaging findings and technical report of an attempted percutaneous vertebroplasty in the only patient found to be actively under treatment with denosumab after a retrospective review of the databank of patients with pathological fractures referred to the Department of Radiology of the Ohio State University for percutaneous vertebroplasty (a total sample of 20 patients) since the FDA approval of denosumab (November 2010) until June 2013 (a 30-month period).
Although the computed tomography scan of the thoracic spine, performed 6 weeks after the initiation of the treatment with denosumab, presented a remarkable remodeling of the previously lytic vertebral lesion (which became markedly sclerotic in appearance), the clinical response in terms of pain improvement was not satisfactory. At the time of the percutaneous vertebroplasty (which was indicated for pain control), after advancing the 11-gauge needle through the pedicle with extreme difficulty, the needle repeatedly deviated laterally and, despite several attempts, it was not possible to penetrate the vertebral body and perform the cement injection.
This is the first report of the technical peculiarities of percutaneous vertebroplasty in patients under medical treatment with denosumab. According to our experience, because of its RANKL-mediated effects on osteoclasts activity, denosumab has been shown to induce a fast and marked sclerotic response on vertebral bodies that may not be accompanied by a satisfactory improvement in pain control (especially in patients with mechanical type of pain) and which may actually prevent the successful performance of percutaneous vertebroplasty. Therefore, it is of paramount importance that future studies evaluating patients with vertebral fractures under treatment with denosumab include long-term pain outcome measures. Additionally, further investigation is warranted to determine the optimal order of treatment and the best timeframe for combining percutaneous vertebroplasty and denosumab therapy in patients presenting with acute vertebral compression fractures and refractory axial pain.
地诺单抗（Xgeva）是一种核因子κB受体活化因子配体（RANKL）抗体，于2010年获美国食品药品监督管理局（FDA）批准，用于预防实体瘤骨转移患者的骨骼骨折。尽管此类药物在有发生病理性骨折风险的患者中广泛使用，但地诺单抗治疗与经皮椎体成形术（在此类患者中常用于控制疼痛的一种介入手术）的兼容性尚未确定。
介绍一名患有与小细胞肺癌脊柱转移相关的顽固性疼痛和溶骨性病理性椎体骨折且正在接受地诺单抗积极治疗的患者经皮椎体成形术尝试的系列影像表现及技术报告。
回顾性研究及病例报告。
作者在回顾自FDA批准地诺单抗（2010年11月）至2013年6月（30个月期间）转诊至俄亥俄州立大学放射科接受经皮椎体成形术的病理性骨折患者数据库（共20例患者样本）后，展示了唯一一名正在接受地诺单抗积极治疗的患者经皮椎体成形术尝试的影像表现及技术报告。
尽管在开始使用地诺单抗治疗6周后进行的胸椎计算机断层扫描显示，先前的溶骨性椎体病变有显著重塑（外观明显硬化），但疼痛改善方面的临床反应并不令人满意。在进行经皮椎体成形术（旨在控制疼痛）时，将11号穿刺针极其困难地推进椎弓根后，穿刺针多次向外侧偏斜，尽管多次尝试，仍无法穿透椎体并进行骨水泥注射。
这是关于正在接受地诺单抗治疗的患者经皮椎体成形术技术特点的首份报告。根据我们的经验，由于地诺单抗对破骨细胞活性的RANKL介导作用，已显示其可在椎体上诱导快速且显著的硬化反应，但这可能并未伴随疼痛控制方面的令人满意改善（尤其是机械性疼痛患者），且实际上可能妨碍经皮椎体成形术的成功实施。因此，未来评估接受地诺单抗治疗的椎体骨折患者的研究纳入长期疼痛结局指标至关重要。此外，有必要进一步研究确定急性椎体压缩骨折和顽固性轴向疼痛患者经皮椎体成形术与地诺单抗治疗联合的最佳治疗顺序和最佳时间框架。
