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Therapy of a Patient with a Solitary Vertebral Metastasis

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Question

I have a patient who had a 3.5 cm follicular carcinoma reoccur as a solitary vertebral met 13 years later..Thyrogobulin rose to max of 63 during the reoccurrence-we treated with local externall radiation and high dose I131–one year later the thyroglobulin is 7 clinically she feels well- no major pain and neurologically intact-(it is lowest lumbar body)–What are my options?-the neurosurgeons say resection would be a fairly large surgery because the vertebral body resection would require pelvic restructuring–The literature on vertebral embolization is largely from the Netherlands-do you have good US experience with this procedure? Is simple follow-up enough at this point? What is your experience with solitary vertebral mets?

Thanks,

Jeffrey Sanfield, M.D, F.A.C.P.
Ann Arbor Endocrinology
Ann Arbor, Michigan.

Response

Solitary mets are of course rare. The two that I cared for involved lung (resected and cured) and the humerus (treated with 131-I then resected, and cured). I believe that embolization has been used in patients with large tumor deposits, which I think your patientdoes not have, and helps, but does not cure the lesion. One option would be to re-treat with 131-I, and this seems the most probably useful.I presume the maximum radiotherapy was given.The TG of 7 (on T4?) is low enough to mean that growth is not rapid. After repeat 131-I it may be logical to follow the situation on suppressive doses of T4 and wait for a sign of growth by increasing TG. This might take years. I have never been involved in resection of a vertebrae, so I can not comment on that approach. I have installed Harrington rods in a few patients to stabilize their spine when multiple vertebrae had mets, and some contemporary version of this procedure may also be useful.

Leslie J De Groot, MD