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Localized Corticosteroid Injections for Malignant Joint Pain in the Oncologic Population: A Case Series

Rakesh, Neal MD, MS*; Magram, Yan Cui MD; Shah, Jay M. MD; Gulati, Amitabh MD

doi: 10.1213/XAA.0000000000000977
Case Reports
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Pain is a common issue that is present in cancer survivors as well as those with active malignant processes. Despite opioid analgesics and adjuvant therapies such as systemic corticosteroids, many patients have persistent localized pain. We describe a case series of 3 cancer patients who have concurrent hip- and greater trochanteric–related pain. We performed a single-insertion-site, ultrasound-guided injection to target both the intra-articular hip and greater trochanteric bursa for each patient. All patients reported an improvement in pain symptoms and function with no major complications. Targeted corticosteroid injections provide a potential for relief of malignant joint pain.

From the *Department of Rehabilitation and Regenerative Medicine, NewYork-Presbyterian Hospital - University Hospital of Columbia and Cornell, New York, New York

Weill Cornell Tri-Institutional Pain Medicine Program, Department of Anesthesiology, Weill Cornell Medicine, New York, New York

Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York.

Accepted for publication December 31, 2018.

Funding: None.

Conflicts of Interest: See Disclosures at the end of the article.

Address correspondence to Amitabh Gulati, MD, Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065. Address e-mail to gulatia@mskcc.org.

Pain affects between 30% and 50% of patients with early-stage cancer and up to 70%–90% of patients with more advanced stages.1 Bony metastases are a common cause of pain.2–4 Systemic corticosteroids are often used as an adjuvant therapy for neuropathic, visceral, and metastatic bone pain that is refractory to radiation and nerve ablations.5–7 However, oral steroids can have serious systemic side effects including proximal muscle weakness, osteoporosis, gastrointestinal bleeding, thromboembolisms, anxiety, and depression.7

The oncologic population is susceptible to joint pain from early osteoarthritis, primary malignancy, or metastatic disease. Exposure to radiation and chemotherapy has also been shown to predispose these patients to joint-related arthropathies.8,9 Primary hip osteoarthritis pain may be difficult to distinguish from pain secondary to metastatic lesions. Both pathologies present with groin and lateral hip pain, which worsen with standing and ambulation. However, patients with bone metastases tend to have hip pain even without movement of the hip joint. Furthermore, patients with lesions or masses in and around the pelvic bone, muscles, and nerves may present with similar pain in the groin or lateral hip. These symptoms tend to be constant and neuropathic in nature and may not be related to hip joint movement. A hip injection with local anesthetic may help differentiate intrinsic joint pain from oncologic referred hip pain. We describe 3 cases of cancer patients who presented with hip pain and responded to a combined intra-articular hip and greater trochanteric bursa injection administered with the patients lying in the lateral position.

A chart review of 3 patients with a history of oncologic disease and hip pain was performed. Written consent was obtained from each patient. We reviewed each patient’s pain symptomology, relevant medical history, and pre- and postprocedure pain.

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METHODS

The procedures were performed with each patient placed in the lateral decubitus position with the unaffected side on the table and both hips slightly flexed. The patients were prescanned with the ultrasound device (GE P9 with either 9 L linear or 1–5 Hz curvilinear probe; GE Healthcare, Waukesha, WI) to assess for anomalies in anatomy and for preprocedure planning. The transducer was positioned in the longitudinal coronal plane over the femoral shaft to visualize the acetabulum superiorly and greater trochanter inferiorly (Figures 1, 2A, 2B).

Figure 1.

Figure 1.

The patients were then cleaned and sterilely prepared. A 25-gauge needle with a syringe containing 1% lidocaine was used to anesthetize the insertion site. A 25-gauge 2- or 3.5-inch Quincke needle with a syringe containing a solution of either 80 mg triamcinolone acetonide (triamcinolone) with 6 mL of 0.25% bupivacaine or 80 mg of methylprednisolone acetate (methylprednisolone) with 6 mL of 0.25% bupivacaine was inserted under ultrasound guidance to the femoral neck (injectate varied due to different physician preferences) (Figure 2C). After negative aspiration, half of the solution was injected. The needle was then withdrawn toward the skin and redirected caudally and superficially into the greater trochanteric bursa and overlying muscular structures (Figure 2D). After a second negative aspiration, the remaining mixture was administered, and the needle was removed. Patient follow-up was conducted according to the standard protocol at Memorial Sloan Kettering Cancer Center.

Figure 2.

Figure 2.

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CASE PRESENTATION AND RESULTS

Case 1

A 57-year-old man with a history of mucosa-associated lymphoid tissue lymphoma presented with right hip and lower extremity pain for 6 weeks. The pain radiated into the right groin and was associated with numbness and tingling in the lateral aspect of the right leg and foot. Magnetic resonance imaging revealed a right hip intra-articular lesion with lumbar neuroforaminal stenosis (Figure 3C). An electromyography was conducted and was consistent with a right L4 radiculopathy. The patient was started on oxycodone extended-release 10 mg twice a day and duloxetine 60 mg daily, which initially decreased his overall pain score from 8 of 10 to 2 of 10. However, he reported a return of his pain and multiple exacerbations that required emergency department evaluations. He underwent a right-sided sacroiliac joint and a series of lumbar epidural steroid injections, which only led to the improvement of his foot pain. An ultrasound-guided intra-articular hip and greater trochanteric bursa injection was performed, resulting in a decrease of his pain from 8 of 10 to 2 of 10. At his follow-up visit 2 months after the procedure, the patient noted a continued 80% reduction in his right hip and groin pain, without any subsequent visits to the emergency department for pain exacerbations.

Figure 3.

Figure 3.

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Case 2

A 63-year-old woman with a history of metastatic endometrial cancer (status posthysterectomy and bilateral salpingo-oophorectomy, chemotherapy, and left iliac mass radiation therapy) and postradiation osteoarthritis of the right hip (status after total hip replacement) presented with progressively worsening left groin pain and radiating pain into the lateral hip. The patient had been taking hydrocodone 2 mg up to 4 times a day as needed. Her pain was reduced with her medication regimen but was still aggravated by prolonged standing and ambulation. A computed tomography pelvis revealed posterior osteophytes on the left femoral head and a left retroperitoneal soft tissue iliac mass (Figure 3A, B). She underwent an intra-articular hip and greater trochanteric bursa injection under ultrasound guidance and reported immediate pain relief with a decrease of her pain score from 5 of 10 to 2 of 10. The patient reported persistent relief for the next 5 months and an improvement in her ambulation.

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Case 3

A 54-year-old man with metastatic prostate cancer to the lymph nodes, lungs, and bone (status postradiation and chemotherapy) presented with right buttocks and thigh pain that radiated into the right groin. While hospitalized, he required a hydromorphone patient-controlled analgesia pump, fentanyl patch 200 µg/h, methadone 60 mg daily, gabapentin 300 mg 3 times a day, and lorazepam 0.5 mg 4 times a day as needed. This regimen provided only mild pain relief. A total spine magnetic resonance imaging revealed an increase in metastasis infiltrating the left L5 vertebral body and paraspinous area as well as a right iliac bone mass. A computed tomography pelvis showed a right trochanteric lytic lesion (Figure 3D). He then underwent an intra-articular hip and greater trochanteric bursa injection. The patient reported immediate postprocedure resolution of pain with a decrease of his pain score from 6 of 10 to 0 of 10. While the oral regimen did not significantly decrease his pain, he noted minimal right hip and groin pain for 2 months after the injection.

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DISCUSSION

Oncologic patients may present with various etiologies of hip- and groin-related pain that may be difficult to differentiate and diagnose. Localized corticosteroid injections not only provide diagnostic and therapeutic value but have a much lower incidence of systemic side effects as compared to conventional oral corticosteroids. In addition, given that hip osteoarthritis and greater trochanteric pain syndrome often coexist, targeting one may result in only partial pain relief. In these instances, performing a combined injection can be beneficial. It should be noted that in all the cases, the injection is not the primary treatment for the patients’ oncologic disease.

Case 1 demonstrates that patients with pain refractory to oral adjuvant therapies and single-site injections can significantly benefit from a combined intra-articular hip and greater trochanteric bursa injection. It should also be noted that select cancer patients with contraindications to intra-articular steroids or with pain that is refractory to this approach may be considered for an injection with viscosupplementation to help relieve intractable pain from multifactorial etiologies.10

Finally, cases 2 and 3 illustrate that metastatic disease and radiation of the pelvis or femur may result in pain and functional impairment similar to pain from hip osteoarthritis and greater trochanteric pain syndrome. Thus, it can be difficult to determine the etiology of the patient’s pain. We targeted both pain generators simultaneously for a better chance of providing pain relief. This may be a preferred approach when considering end-of-life situations in which diagnosis may not be as important as the need for improving quality of life as quickly as possible. In addition, we observed significant improvement in pain scores for the duration of the local anesthetic (hours to a day), with little or no benefit from the concurrently injected corticosteroids. In our experience, disease of the intrinsic hip (acetabular or femoral head/neck tumors) consistently improves with local anesthetic injections but has a highly variable response to corticosteroids.

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Limitations

As a retrospective review and technique article, the evidence presented here demonstrates the potential for a combined intra-articular hip and greater trochanteric bursa injection to be beneficial to the oncologic population. To determine the efficacy of this approach, a more thorough study and comparison would be needed. In addition, given the necessity for immediate pain relief in this population, it may be difficult to properly assess whether a patient’s pain stems from the hip joint or the greater trochanteric bursa.

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CONCLUSIONS

Symptoms like hip osteoarthritis and greater trochanteric pain syndrome may result from post–treatment-related degenerative disease or from malignant bone lesions. These often coexist, and oncologic patients may present with pain that is refractory to systemic opioids, oral adjuvant therapies, and injections of only 1 site. A concurrent injection of local anesthetic and steroids at both sites under ultrasound guidance offers an elegant solution to improve patients’ refractory pain.

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DISCLOSURES

Name: Neal Rakesh, MD, MS.

Contribution: This author helped design the case series and write the manuscript.

Conflicts of Interest: None.

Name: Yan Cui Magram, MD.

Contribution: This author helped perform the procedure and edit the manuscript.

Conflicts of Interest: None.

Name: Jay M. Shah, MD.

Contribution: This author helped perform the procedure and edit the manuscript.

Conflicts of Interest: None.

Name: Amitabh Gulati, MD.

Contribution: This author helped design the case series, perform the procedure, and write the manuscript.

Conflicts of Interest: Dr Gulati is a consultant for Medtronic, and a scientific advisor for Flowonix and EnsoRelief.

This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.

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