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Original research
CT-guided cryoablation for palliation of secondary trigeminal neuralgia from head and neck malignancy
  1. Suhail A Dar1,
  2. Zachary Love2,
  3. John D Prologo2,
  4. Daniel Pierce Hsu3
  1. 1School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
  2. 2Department of Radiology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
  3. 3Department of Interventional Neuroradiology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
  1. Correspondence to Suhail A Dar, School of Medicine, Case Western Reserve University, 2109 Adelbert Rd, Cleveland, OH 44106, USA; sad26{at}case.edu

Abstract

Background Facial pain is a common presentation secondary to tumoral invasion, rendering an individual unable to perform basic activities such as eating and talking. Cryotherapy may be appropriate in patients seeking immediate pain relief for trigeminal neuralgia (TN) near the end of life with its minimal invasiveness and procedural morbidity. While cryosurgery has been effectively demonstrated in the treatment of primary TN, this study is unique as it is the first documented use of CT guidance and treatment of secondary TN using percutaneous cryoablation.

Aim To perform and report experience with CT-guided percutaneous cryoablation, a palliative treatment for TN secondary to recurrent invasive head and neck carcinoma, in patients previously treated with chemotherapy, radiotherapy and/or surgery with the goal of improving functional status and quality of life.

Methods Palliative cryoablation procedures performed under CT guidance on recurrent head and neck malignancy between September 2010 and June 2011 were retrospectively analyzed. The procedure was performed under general anesthesia or conscious sedation. For each patient, 1–2 cryoprobes were placed in the tumor and two or four freeze-thaw cycles were performed. Patients were evaluated for facial pain relief immediately after treatment by telephone follow-up.

Results Three patients underwent treatment for three masses using CT-guided percutaneous cryoablation. On imaging, technical success was achieved in all cases with hypodense ice formation encompassing symptomatic lesions on the CT scan. No procedural complications were encountered with post-procedure pain relief and reduction in required pain medication noted in all patients. One patient had 1 month of pain relief before the symptoms returned.

Conclusion CT-guided percutaneous cryoablation is an efficient minimally invasive method for the palliative treatment of TN secondary to recurrent invasive head and neck carcinoma as a result of direct tumoral invasion of the extracranial divisions of the trigeminal nerve. Patients meeting the therapeutic criteria of individuals treated for musculoskeletal metastatic lesions may benefit from this treatment. The results suggest it may not currently be a curative technique as one patient's symptoms returned, but it could prove useful as an adjunct to current palliative therapies with minimal invasiveness and procedural morbidity, especially in patients seeking pain palliation, improved functional status and improved quality of life near the end of life.

  • Aneurysm
  • coil
  • neoplasm
  • vascular malformation
  • metastatic
  • artery
  • temporal bone
  • MRI
  • CT
  • subarachnoid

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Introduction

Head and neck cancer accounts for approximately 2.4% of new cancer cases in the USA every year.1 Facial pain is a common presentation secondary to tumorous invasion. Of the estimated 15 000 patients diagnosed each year with trigeminal neuralgia (TN) (a subset of facial pain) in the USA, tumors account for 1–11.6% of the cases.2–5 Patients with TN have frequent episodes of severe facial pain confined to the root or branches of the trigeminal nerve on one side of the face.6 It can be associated with shock-like pains which are abrupt in onset and termination and limited to certain distributions of the trigeminal nerve.7 Pain can be elicited by everyday stimuli such as eating, shaving, talking and brushing teeth or have no discernible inciting event to make such functional activities unbearable. It can be classified as either primary or idiopathic TN and secondary or symptomatic TN.6 While primary or idiopathic TN has no clear cause, secondary TN has a presenting cause that can include etiologies such as tumor, multiple sclerosis or neurovascular compression.

In this paper we review our experience using CT-guided percutaneous cryoablation in the palliative treatment of three patients affected with TN secondary to recurrent head and neck cancer after previously undergoing chemoradiotherapy, radiotherapy and/or open surgery to treat initial lesions. Our primary goal was to provide immediate pain relief and improve functional status and quality of life in patients near the end of life. It was expected our method would provide immediate pain relief with minimal invasiveness and procedural morbidity, congruent with our stated goals. Cryosurgery has previously been reported in the use of primary TN, but our experience is unique as it is the first documented use of percutaneous cryoablation performed under CT guidance for the treatment of secondary TN.

Materials and methods

We performed a retrospective review of three patients with recurrent head and neck cancer presenting with intractable TN treated with percutaneous cryoablation performed under CT guidance for pain palliation. The initial clinical diagnosis of TN was made by the treating otolaryngologist. Patients were selected for treatment if they were referred with intractable pain consistent with TN in conjunction with imaging findings of tumor in the expected location of the symptomatic division of the trigeminal nerve and who were unable to receive external beam radiation therapy due to previous external beam radiation therapy or issues of non-compliance.

Two patients had recurrent squamous cell carcinoma (SCC) and one had recurrent mucoepidermoid carcinoma.

Patient 1 had stage IV SCC of the left maxillary sinus and presented for salvage surgery and re-irradiation after initial surgical resection and radiation therapy. After retreatment the patient experienced extreme weight loss and left jaw and face pain to the point that oral intake was no longer possible. Diagnostic MRI disclosed extensive recurrence at the skull base with enhancing soft tissue within the left foramen ovale and foramen rotundum and thickened maxillary (V2) and mandibular (V3) divisions of the left trigeminal nerve, respectively. This tumor involvement was felt to be responsible for the clinically apparent V2 and V3 TN (figure 1).

Figure 1

(A–D) Contrast-enhanced fat saturated T1-weighted imaging of the skull base showing enhancing tumor (asterisk) extending into the second (arrowhead) and third (arrow) divisions of the trigeminal nerve.

Patient 2 had recurrent stage IV T2 N2c M0 supraglottic laryngeal SCC recurrent to the right masticator space, with local extension shown on MRI to the right infraorbital fissure and foramen ovale causing intractable V3 TN after initial treatment with radiation and chemotherapy.

Patient 3 had resection of a T2 N2b M0 high-grade mucoepidermoid carcinoma of the right parotid gland with positive microscopic margins following radical right parotidectomy 8 years previously with recurrence to the right nasolabial fold, cheek and submental area. After wide local excision and re-irradiation, the patient re-presented with right V2 distribution TN with loss of soft tissue planes within the right masticator space and associated enlargement of the right foramen rotundum and pterygopalatine fissure with associated enhancing soft tissue.

Our institution in the past has used glycerol for treating primary TN and radiofrequency ablation either for tumors or primary TN, but neither modality for TN secondary to tumorous invasion. Due to our experience with cryoablation in the treatment of neoplasms and for the purposes of pain palliation, it was felt that it would be a reasonable modality for our patients. The procedure was performed under conscious sedation for patient 1. While conscious sedation was the first-line option, patients 2 and 3 were given general anesthesia because of claustrophobia and an inability to tolerate previous diagnostic imaging examinations. For each patient, 1–2 cryoprobes were placed in the tumor and two or four freeze-thaw cycles were performed (10 min freeze; 6–8 min thaw). Hypodensity was confirmed surrounding the cryoprobe(s) in order to confirm ice formation at the end of each freeze cycle (figure 2). Two patients presented with right trigeminal nerve involvement and one patient with left trigeminal nerve involvement.

Figure 2

(A) Non-enhanced axial and (B) off sagittal >coronal multiplanar reconstruction CT images through the cryoablation probe (arrow) obtained at the end of the freeze cycle showing ice formation (arrowheads) extending adjacent to the foramen rotundum. (C) Non-enhanced axial CT image showing placement of a second cryoprobe (arrow) with ice ball (arrowhead) in contact with the foramen ovale.

All preprocedure imaging confirmed enhancing soft tissue along the expected courses of the clinically involved trigeminal nerve distribution. Patients were discharged following the procedure and a telephone follow-up was made to note post-procedural pain relief. Chart review was also performed.

Results

Three patients with intractable TN secondary to recurrent head and neck carcinoma not controlled with oral and intravenous pain medications were treated with percutaneous cryoablation under CT guidance. Patients ranged in age from 54 to 73 years at the time of cryotherapy. Cancer staging prior to treatment was as follows: one patient had stage IV and two patients had T2 N2 M0 recurrent head and neck cancer.

Clinical examination/history disclosed TN involving the V2 and V3 in one patient, V2 alone in one patient and V3 alone in one patient. Imaging confirmed the presence of an enhancing soft tissue mass with extension to the expected anatomic location of the affected divisions of the trigeminal nerve in all cases.

A total of three lesions were treated with four cryoablation probes. Patient 1 had placement of two separate probes and a total of four treatment cycles with a 17-gauge probe (IceSeed, Galil). Patient 2 underwent two freeze/thaw cycles after placement of two probes (IceSphere, Galil Medical Ltd., Yokneam, Israel). Patient 3 underwent two freeze/thaw cycles after placement of a single probe (IceSphere, Galil Medical Ltd., Yokneam, Israel).

All probes were placed within the abnormal soft tissue lesions and in contact with the presumptive symptomatic division of the trigeminal nerve at its exit through the appropriate skull base foramen. For V2, placement was in the pterygopalatine fossa as close to the foramen rotundum as possible (figure 3). Placement was within abnormal soft tissue at the level of the foramen ovale (figure 4).

Figure 3

(A) Contrast-enhanced coronal and (B) axial MRI with enhancing tumor in the right masticator space (asterisk) with extension to the right foramen rotundum (circle). (C) CT scan with bone windows showing the tip of the cryopobe in the inferior right pterygopalatine fossa. (D) Coronal multiplanar reconstruction CT scan showing the probe and hypodense ice in the right masticator space extending into the right inferior orbital fissure (circle).

Figure 4

(A) Fused positron emission tomographic (PET)/CT image showing a fluorodeoxyglucose-avid lesion involving the right masticator space extending into the right foramen ovale (arrow). (B) Corresponding contrast-enhanced coronal T1 MRI showing a mass lesion in the infratemporal fossa (asterisk). (C) CT scan with bone windows showing enlargement of the right foramen ovale (arrowhead) and permeative destruction of the adjacent lesser wing sphenoid bone (arrow). (D) Coronal multiplanar reconstruction from treatment CT showing the tip of the cryoablation probe and extension of hypodense ice (arrowheads) into the foramen ovale (arrow).

Ice formation was identified extending to the skull base foramina of interest on all interventions. No procedural or immediate postprocedural complications were encountered including infection, hemorrhage or new sensory disturbance. Immediate postprocedure examination and report of pain was no different from the preprocedural assessment.

Twenty-four hours after the procedure, telephone interviews with the patients disclosed a decrease in pain in all three patients with complete pain resolution of symptoms in two patients and near complete reduction in pain in the third patient reported in telephone interviews during the 2 weeks following the procedures.

Patient 1 had pain relief for 4 months before return of symptoms and eventual hospice placement and death. Patient 2 reported pain relief by telephone interview 2 weeks after the procedure and died approximately 1 month after the procedure. Patient 3 had 1 month of pain relief before return of symptoms.

Discussion

Cryotherapy is one of the oldest techniques of tissue ablation with documented use dating back as early as 1851 when iced saline solutions were used to treat carcinomas of the breast and cervix.8 ,9 Open surgical tumor exposure was a prerequisite to cryotherapy due to equipment limitations before the 1990s, but improvements in minimally invasive percutaneous techniques, devices and imaging have overcome this challenge.9 Potential therapeutic advantages over other surgical interventions include a targeted treatment zone, minimal scarring, less procedural trauma and treatment management through image guidance.9–12 The advances in minimally invasive techniques have enabled the development of image-guided percutaneous cryoablation, and this study is the first documented use of it in patients with secondary TN. Our patients benefited from its advantages in their final stages of life when it was prudent to limit complications that could not be avoided with other options, as the primary goal was to provide immediate pain relief and improve functional status and quality of life.

While our results show that cryoablation is not a curative treatment for TN, it is gaining prominence as a primary treatment modality of various other neoplasms. Percutaneous cryoablation has already been well described in patients treated for primary neoplastic and metastatic disease to various organs, most notably the kidney, liver and prostate.11–15 It is also being used in the treatment of renal neoplasms amenable to ablation because of less opioid analgesia, decreased morbidity and shorter recovery time compared with partial and radical nephrectomy.16 Finley et al found it to be so effective in the treatment of small renal neoplasms in patients with or at high risk of renal insufficiency that it has become their primary treatment modality regardless of the circumstances.15 It is our hope that percutaneous cryoablation under image guidance can eventually become a primary treatment option in TN, even if it is employed in conjunction with chemotherapy, radiotherapy and/or surgery.

Cryotherapy is now increasingly used in pain palliation, most notably in patients with metastases to the musculoskeletal system.9 ,17 ,18 As these patients have a shortened life expectancy and poorer quality of life, the treatment is aimed at pain palliation and improving functional status,18 similar to the aim in treating our patients. Callstrom and Charboneau,17 Masala et al 18 and Ullrick et al 9 in their respective studies report a rapid significant reduction in pain in patients treated with CT-guided percutaneous cryoablation of bone lesions. It should be noted that Callstrom and Charboneau selected patients provided they met the following three requirements: (1) moderate to severe pain (as mild pain can be managed with oral analgesics); (2) focal pain limited to one or two sites (as systemic pain is best treated with a systemic approach); and (3) painful metastatic lesions amenable to the use of percutaneous ablative devices.17 These criteria were generally applicable to our patients, making durable pain relief a more likely outcome.

Our results indicate that, if the criteria outlined by Callstrom and Charboneau are met in patients with secondary TN, percutaneous cryoablation can prove useful as an adjunctive therapy even if it is not yet considered a primary treatment modality. It has already been described in the treatment of other head and neck tumors such as adenoid cystic carcinoma, recurrent thyroid carcinoma and circumscribed solitary fibrous tumors.11 ,12

The management and treatment of patients with invasive head and neck malignancy is complex and varies according to clinical presentation and clinician expertise.19 For example, radiotherapy and/or surgery is used in patients with stage I and most stage II SCC of the head and neck as cure is the primary objective.20 However, most patients with SCC of the head and neck present with stage III or IV disease.21 Conventional treatment for these patients has been chemotherapy, radiotherapy or a combination (chemoradiotherapy).19 ,20 Nevertheless, these conventional treatments do have some adverse effects. Pain, swelling and dysphagia are side effects of chemotherapy (cisplatin/5-fluorouracil)22 and mucositis, xerostomia, dysphagia, pain, weight loss and deterioration in performance status are side effects of radiotherapy.23 ,24 The danger of toxicity can impede advances in standard treatment, including chemoradiotherapy.20 CT-guided percutaneous cryoablation avoids these unfavorable side effects and is an alternative approach in patients with TN secondary to end-stage head and neck cancer where the primary goals are immediate pain palliation, improved functional status and improved quality of life.

Since the effects of carbamazepine as a first-line treatment for TN may be short-lived,2 cryosurgery has been used in the past but has often involved surgical exposure of the affected peripheral nerve branches of the trigeminal nerve.25 ,26 The nerve is exposed surgically under general or local anesthesia and a cryoprobe is applied directly on to the exposed nerve for several freeze-thaw cycles.25 ,26 Pradel et al 27 reported transmucosal cryosurgery under nerve block at the infraorbital foramen and/or mental foramen by an intraoral approach. The results of these studies were favorable as most patients had immediate pain relief and were free from pain within 10–14 days.27 ,28 Pain recurrence was common, however, with only 27–32% of patients being pain-free after 1 year.27 ,28 This corroborates our conclusion that cryoablation may not currently be curative but is, at best, an adjunctive therapy in the treatment of primary or secondary TN since patient 3 in our study had 1 month of pain relief before the symptoms returned. Nevertheless, our study demonstrates that CT-guided percutaneous cryoablation is a potential option to treat tumorous TN, providing pain relief in patients near the end of life. While not currently curative, this treatment can easily be re-administered should the pain return.

While there is a risk to external carotid artery branches when performing cryoablation in the head and neck region, it was felt to be low as we made no direct communication with the upper aerodigestive tract or the airway. Although not desirable, an expanding hematoma or pseudoaneurysm could be treated by endovascular embolization.

The limitations of this study include the small number of patients, short follow-up period and follow-up without clear objective measures. A future prospective study could be performed to assess the TN more systematically including its impact on daily living and correlation with pain medication intake as well as the effectiveness and duration of pain control following treatment. Nevertheless, this study does show that percutaneous cryoablative therapy under image guidance is feasible and can be used safely with promising preliminary results.

Conclusions

CT-guided percutaneous cryoablation is an efficient minimally invasive method for the palliative treatment of TN secondary to recurrent invasive head and neck carcinoma as a result of direct tumorous invasion of the extracranial divisions of the trigeminal nerve. Patients meeting the therapeutic criteria of individuals treated for musculoskeletal metastatic lesions may benefit from this treatment. Our results suggest that it may not currently be a curative technique as one patient's symptoms returned, but it could prove useful as an adjunct to current palliative therapies with minimal invasiveness and procedural morbidity, especially in patients seeking pain palliation, improved functional status and improved quality of life near the end of life.

References

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Footnotes

  • Competing interests None.

  • Ethics approval Ethics approval was provided by University Hospitals of Case Medical Center.

  • Provenance and peer review Not commissioned; externally peer reviewed.