Pancoast Tumor

[clubdeac]

So I was sent a 64 y/o gentleman from oncology with intractable RUE brachial plexitis secondary to pancoast tumor. Neuropathic pain in the ulnar/C7/8 distribution as you would expect. Refractory to high doses of opiates and neuropathic meds. I tried one stellate on him w/o success. Not sure if it was my block vs the pathology. What would you recommend next? Try another stellate followed by stellate RFA if short term relief? C7/T1 DRG PRFA? Stim trial? Thoughts....

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[drf]

Michael Gofeld told me of his US guided C7 or C8 ablation for a pancoast tumorr. I believe he published it as a case report.

Spinal nerves are easy to find with US. Drop a couple of ccs around the nerve. If pain goes away follow with a couple of ccs of alcohol or do cRF.

Only if he has intractable pain and/or loss of function of those nerve roots of course.

Personal experience is for mets to shoulder with mostly shoulder pain but also extreme Lymphedema of entire arm due to cancer. No motor function remained. My plan was to do c4-c8 sequentially to see what I had to ablate. I used US and blocked one spinal nerve at a time. Unfortunately once I blocked 4 and 5 which hurt the most she still had intractable pain in the rest. Only a complete plexus block made her happy. I was too chicken to inject that much alcohol so I had my surgeon cut them all.

Now she still complained of intercostobrachial pain but overall was much better.

 

[joshmir]

I had a patient with a similar tumor with predominantly shoulder pain

I blocked the suprascapular nerve under flouro with 1cc and it helped a lot; I think killed the nerve with alcohol or phenol, I forget which; it helped a lot

A shoulder surgeon buddy of mine told me the suprascapular artery is "over-rated" FWIW, if you are worried about damaging it

I think MD Anderson presented or published a case series regarding SCS for cancer pain

 

[joshmir]

DrF-

In retrospect do you think the intercostobrachial nerve should have been clipped, or do you think its more complex than that?

 

[drf]

Basically anything past the shoulder hurt. We killed everything except that one nerve. She was better but medial upper arm still hurt. Not sure where I'm gonna find a surgeon to cut that one, except for accidental during mastectomy. She was much better so I didn't pursue it.

 

[lovebailey2001]

We had a patient with upper back and shoulder pain d/t pancoast tumour, not controlled by Morphine and anti-neuropathic drugs. Did a supra-scacular nerve block, only partial, short lasting relief. Went for High Cervical Cordotomy at C1-2 level, 80% relief for one month and well managed with Ultracet TID doses. After a month, relief decreased to 50%, In last 3 days of his life of abt 8 weeks post cordotomy, his pain increased he took up to 8 tabs of Ultracet. per day.

 

[Ducttape]

We had a patient with upper back and shoulder pain d/t pancoast tumour, not controlled by Morphine and anti-neuropathic drugs. Did a supra-scacular nerve block, only partial, short lasting relief. Went for High Cervical Cordotomy at C1-2 level, 80% relief for one month and well managed with Ultracet TID doses. After a month, relief decreased to 50%, In last 3 days of his life of abt 8 weeks post cordotomy, his pain increased he took up to 8 tabs of Ultracet. per day.

as a fellow, i remember recommending DREZ lesioning for brachial plexus related terminal pain conditions...

 

[Ducttape]

so now i have a patient, with tumor extension abutting the neuroforamen at C45, C56 and C67.

already on opioids, gabapentin, TCA.

any injections that someone would recommend? anyone have experience with subarachnoid neurolytic of the cervical nerve roots???