Case Study Orthopaedics

Dr.Ravi Sautha orthopaedic surgeon in gurgaon

Case History

Mrs Shalini is a 58 years old mother of two. She stays in Shimla with her husband & their son & daughter live in Delhi.

Mrs Shalini was diagnosed of ‘Carcinoma Papillary Thyroid’ on February 2006. During the initial phases of treatment the Radio Active Iodine Whole Body Scan (RAI WBC) showed significant functioning tissue in neck and chest, with a focus of distant functioning metastasis in the right side of pelvis.

During the course of further radiotherapy & treatmet, the PT scan suggested ONLY Iliac Bone Metastasis. The PT scan done in due course after administration of Iodine-131 suggested concentration in right Iliac bone and no additional lesion.

During the 7th year in treatment, the Triglyceride (TG) level in patient’s blood increased alarmingly to over 3000 ng/mL. The patient started experiencing acute pain in right leg (hip) and difficulty in walking. The local orthopaedician at Shimla was regularly consulted for growing pain, he prescribed Mega bone and Tapal ER-50 but that provided no relief to the patient.

It had been over 8 years of intense treatment/radiotherapy for the patient, but relief from pain was no where in sight for her.

Disease Timeline

For 8 long years the patient had been receiving medical treatment at PGIMER (Chandigarh), AIIMS (Delhi & from a local orthopeadician in Shimla, until the patient finally went to Dr. Ravi Sauhta where she received the most accurate diagnosis & best treatment.

Details of treatments done during these 8 years have been elaborated as follows:

February 2006

Hemi-thyroidectomy (23/02/2006) done at Shimla (Siri Ram Hospital, New Shimla). Static imaging of the neck region was performed (after i.v. injection of the radiotracer on 25/03/2006 by Department of Nuclear medicine, PGIMER Chandigarh). The report suggest for complete thyroidectomy followed by whole body I-131 scan (after 6 weeks). Completethyroidectomy (08/05/2006) was conducted (PGIMER Chandigarh) and Department of Histopathology of PGIMERChandigarh, diagnosed ‘Carcinoma Papillary’. The Micro report read as under:

“Section show a circumscribed tumour nodule showing papillary arrangement of tumour cells. Papillae have central fibrovascluar core and tumour cells shows nuclear overlapping, clearing (Orphan Annie Nuclei), nulear grooves and few pseudo inclusions. Overall features are of papillary carcinoma thyroid. Adjacent thyroid tissue shows features of goitrous changes in the form of varying sized follicles lined by flattened follicular cells and filled with colloid. Parathyroid tissue is also identified.”

May 2006

RAI WBC (Radio Active Iodine Whole Body Scan, 1.5 mCi ofI131) performed by the Department of Nuclear Medicine, PGIMER, Chandigarh , showed significant functioning ( I-131-avid) tissue in neck (residual thyroid) and chest (indicative of bilateral lung metastasis), with a focus of distant functioning metastasis in the right side of pelvis (? Struma ovarii).
It was suggested to give High dose radioiodine therapy for ablation of metastatic tissue, followed by a post-therapy scan.

AIIMS, Delhi: July, 2006 – till present

July 2006

Further treatment till date is being taken from All India Institute of Medical Sciences, (AIIMS) New Delhi.
First dose of I131100 mCi was given on 3rd July 2006
PT scan revealedRt Chest Wall + Rt Pelvic uptake.

January 2007- April 2009

Second dose of I131130 mCiwas given and thereafter the PT scan suggested ONLY Iliac Bone Metastasis.

April 2010 – August 2011

FDG PET CT was done which was suggestive of active disease involving Rt acetabular roof and thus Radiotherapy, (8Gy in 1 fraction) to Rt. hemi pelvic was given on 16th April 2010.
PT scan done after administration of I131 suggested concentration in Rt. Iliac bone and no additional lesion.
In total 1030 mCi of I131, since 2006 to 2011 after an interval of 6 months and 1 year, was administered till August 2011 (18/08/2011) and its further administration stopped.

October 2012

The TGlevels continue to increase, 92ng/mL during February 2012 and 139 during October 2012.The patient was put on drugs, “Graffe X-20” ( 13CisRetionoic Acid) for six months i.e., up to April 2013.

April 2013

Weight loss of 4 Kg was noticed and the TG level increased to 454 ng/mL. Doctors advised to stop “GraffeX-20 as patient was not responding to this medicine and changed the medicine to “Sodium Valproate” and thereafter to “Thalix 300mg”.
On asking the reason for increasing TG level and gradual increasing pain in right leg (hip) ,case doctor at AIIMs suggests that their main object is to contain the decease and pain is unavoidable. Doctors at Dharamshila, and Rajiv Gandhi Cancer Hospital, Delhi were also consulted but they suggested the treatment at AIIMS is in right direction.

December 2013

The TG level increased to over 3000 ng/mL. The patient started experiencing acute pain in right leg (hip) and difficulty in walking.
Local orthopaedician at Shimla was consulted from time to time, for growing pain, and prescribed Mega bone and Tapal ER-50 but not of any relief.

Awareness about Dr Ravi Sauhta

The patient was introduced to Dr Ravi Sauhta through a personal reference.

Challenges faced by Dr. Ravi Sauhta

The pain in the right leg had become unbearable for the patient. Various diagnosis tests showed acetabular roof superoposterior margin and lower part of iliac bone occupied by soft tissue density. Bilateral (Sacroiliac) SI joint appeared sclerotic. Right hip joint space was slightly reduced. PET CT showed evidence of enhancing lesion in right acetabulum, right (Sacroiliac) SI joint and right head/neck of femur suggestive of Metastasis.

The X-Ray report findings suggested ‘ill-defined soft tissue density lesion in the right pelvic outlet region causing corrosion of the right ilium and bilateral hip joints showing early degenerative changes’.

The CT report suggested ‘Destructive lesion of right pelvic bone with soft tissue involving ilium bone starting below the right SI joint and extending to acetabular margin.

Further extension was also seen into the right ischial spine and rest of pelvic bone as normal’. The comparison with CT done during September 2014 indicated that the destructive pelvic lesion as same with organized soft tissue component.

Treatment Plan / Innovative Strategies adopted by Dr Ravi Sauhta

On the basis of CT and MRI reports/films, it was suggested by Dr Ravi Sauhta that Radiofrequency Ablation + Cementoplasty was feasible. Prognosis of this treatment was reported to be short term to be followed by major surgery of removal/replacement of effected bone.

Excision of supra acetabular, metastasis using radiofrequency wand and reconstruction of effect of roof of acetabulum and supra acetabular region by tracbcular matter, bone graft and bone cement, Hybrid total hip replacement (cemented acetabulum and non-cemented femoral component) was done by Dr Ravi.

Healing Phase / Outcome

X-ray of hip joint – AP & LAT, post operation reported successful implantation.

Treatment Timeline

Mrs Shalini’s treatment under Dr Ravi Sauhta started in September 2014. In less than a year, Mrs Chander is now pain free & leads a healthy life.

Details of treatments done under the supervision of Dr Ravi Sauhta have been elaborated as follows:

September 2014

As the pain in right leg, near hip became unbearable consultation with Dr Ravi Sauhta was done. Blood tests and X-ray hip joint, Ultrasound Neck, CT Pelvis and PET CT was done. The CT Pelvisreport showed acetabular roof superoposterior margin and lower part of iliac bone and occupied by soft tissue density. Bilateral SI joint appeared sclerotic. Right hip joint space was slightly reduced. PET CT showed evidence of enhancing lesion in right acetabulum, right SI joint and right head/neck of femur suggestive of Metastasis.

It was suggested to undertake Stereotactic Body Radiotherapy (SBRT) and accordingly 30Gy in 6 fractions on 15/09/2014 to 23/09/2014 were given

December 2014

Review was done on 30/12/2014. X-Rays and CT-Abdomen-Pelvis/Lower Abdomen with Contrast was done by Dr Ravi Sauhta. The X-Ray report findings suggested ‘ill-defined soft tissue density lesion in the right pelvic outlet region causing corrosion of the right ilium and bilateral hip joints showing early degenerative changes’. The CT report suggested ‘Destructive lesion of right pelvic bone with soft tissue involving ilium bone starting below the right SI joint and extending to acetabular margin. Further extension was also seen into the right ischial spine and rest of pelvic bone as normal’. The comparison with CT done during September 2014 indicated that the destructive pelvic lesion as same with organized soft tissue component.

April 2015

On the basis of CT and MRI reports/films, it was suggested that Radiofrequency Ablation + Cementoplasty was feasible. Prognosis of this treatment was reported to be short term to be followed by major surgery of removal/replacement of effected bone.

May 2015

Fresh CT scan and tests were undertaken on 11/05/2015. Excision of supra acetabular, metastasis using radiofrequency wand and reconstruction of effect of roof of acetabulum and supra acetabular region by tracbcular matter, bone graft and bone cement, Hybrid total hip replacement (cemented acetabulum and non-cemented femoral component) was done on 12/05/2015.

X-ray of hip joint – AP & LAT, post operation reported successful implantation

*name of the patient has been changed