Image-Guided Percutaneous Lipiodol-Pingyangmycin Suspension Injection Therapy for Sacral Chordoma
A 74-year-old man presented with a progressively worsening pain in sacrum in January, 2004. MRI showed a mass lesion in the sacrum. In May, 2004, sacral pain was intolerable and accompanied with uroclepsia. Routine laboratory tests including blood routine, liver function and renal function all showed within normal limits. MRI showed the lesion increased in size and compressed the urinary bladder. The contrast-enhanced CT showed a 5-cm mass without enhancements (). An additional puncture biopsy was confirmed for the histologic diagnosis of chordoma. The patient refused to undergo surgical resections of the tumor. Percutaneous intratumoral injection with LPS was therefore suggested as an alternative treatment. In China, the usage of LPS for the treatment of solid tumors had to be approved by Institutional Review Boards. The patient thus gave his written informed consent.\nAccording to the CT images, the entry point of the skin was located on the left side of the 1st sacral vertebra with an 8-cm distance from the spine, and the direction of needle inserted into the tumor was a horizontal angle of 30°. The procedure was performed using a 15-cm-long, 21-gauge needle with a closed conical tip and three terminal side holes (Hakko, Tokyo, Japan) and under C-arm fluoroscopy (Axiom-Artis-dTA Angiographic System, Siemens Medical Systems, Germany) guidance.\nThe patient was put in prone position. Local anesthesia with 2% lidocaine was administered after local disinfections of the skin. The needle was inserted into the tumor under C-arm fluoroscopy, and the position of the needle tip was confirmed by anteroposterior and lateral fluoroscopy. Then, a 3 mL kermesinus liquid was aspirated from the tumor followed by injecting 3 mL of contrast medium (Iopamilon 300; Schering, Berlin, Germany) directly into the tumor. CT scan was immediately tested and showed that the contrast medium was accumulated within the tumor.\nThe procedure of intra-tumoral injection with LPS was performed afterwards. LPS was made as follows: pingyangmycin (PYM, Northern China Pharmaceutical Factory, Shijiazhuang, Hebei, China) 16 mg was dissolved in 5 mL of contrast medium and then mixed into a suspension with 5 mL lipiodol (LP, Laboratoire Guerbet, Roissy, France), and total LPS was about 10 mL in volume. Sequentially, LPS was manually injected slowly under simultaneous fluoroscopy until the vein drainage appeared. Then the needle was retracted 1-2 cm or adjusted to the direction of needling route. After the tip of needle within the lesion was confirmed by C-arm anteroposterior and lateral fluoroscopy, the additional injections were continued so that the LPS could be distributed throughout the entire tumor (). Three days after the procedure, an X-ray radiography was taken and showed that the LPS deposited well within the sacrum tumor ().\nFollow-up CT scan showed that LP deposited well within the tumor 2 months after the first procedure. Surveillances of CT/MRI scans were required every 6 months thereafter. However, as a lack of compliance, the patient obtained follow-up CT scans again 28 months after the first procedure because of severe sacroiliac pains. It showed that the lesion obviously increased in size measuring 8.7 × 5.4 × 8.1 cm and LP thinly retained in the tumor (). From September to October in 2006, the intratumoral injection with LPS was repeated in the same method 3 times under fluoroscopy guidance within the interval of one week, and the volume of LPS was respectively as follows: 20 mL (16 mg PYM, 10 mL LP, and 10 mL contrast medium), 10 mL (12 mg PYM, 5 mL LP, and 5 mL contrast medium), and 10 mL (12 mg PYM, 5 mL LP, and 5 mL contrast medium). LPS were distributed throughout the upper lesion after the first and second injections and the lower one after the third injection.\nIn April 2009, the patient was readmitted to our hospital, because he had experienced symptoms for more than one month, including severe sacroiliac pains, frequency and urgency of micturition, and weakness in lower limbs with greater severity on the right side. CT scan revealed that the sacrum tumor increased significantly and LP was deposited poorly in some regions. Intratumoral injection with LPS was repeated twice under CT guidance aimed to the region with only a little LP deposition in the interval of one week, with 20 ml of LPS (24 mg PYM, 10 mL LP, and 10 mL contrast medium) each time. In order to uniform the LPS distributions in the entire tumor mass, the third injection are required two weeks after being released from the hospital.\nRoutine laboratory tests were rechecked 3-7 days after the procedures, including blood routines, liver functions, and renal functions.\nThere were three sessions of treatments for the patient, and the intratumoral injection with LPS was repeated altogether 6 times with a total of 90 mL of LPS (PYM: 104 mg and LP: 45 mL) under fluoroscopy guidance (n = 4) and CT guidance (n = 2). The operation time ranged from 5 to 10 minutes (mean, 6.5 minutes) under fluoroscopy guidance, and it was 22 minutes and 31 minutes under CT guidance, respectively.\nAfter the first procedure, the pain in sacrum gradually diminished. The patient demonstrated significant improvements in quality of life. CT scan showed that the tumor lesion decreased from 5 cm to 3 cm in diameter and the residual LP deposited well within the tumor 2 months after this procedure (). Three days after the second procedure, CT scan showed that the tumor was filled fully with LPS (). Symptoms were relieved and then vanished 3 weeks after the third procedure.\nThe patient did not experience adverse reactions after each procedure, such as fever, nausea, and vomiting. Nevertheless, 3-7 days after the procedure, his routine laboratory tests including blood routine, liver function and renal function showed within normal limits. There were only some LP depositions in gluteus after the second procedure without any discomfort (). In the third procedure, disappointedly, the patient was not readmitted to the hospital to receive the third injection. No complications were observed during the follow-up period, such as skin necrosis, pelvic visceral injury, and neurological deficits.\nIn July, 2010, the patient presented with a severe pain in sacrum again. CT scan obtained in the local hospital revealed that the sacrum tumor increased significantly again, and lung metastasis appeared. The patient rejected further treatments and was unavailable for follow-ups. During a 6-year follow-up period, the patient demonstrated significant improvement in quality of life with a Karnofsky Performance Score above 80 points.