Options for Pancoast tumor pain

[drrosenrosen]

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One of the local family docs called me - his 100 year old patient was having arm pain and Horner's syndrome, and lo and behold we found a huge Pancoast tumor invading into brachial plexus, with bony mets in the cervical spine as well. He's sending her to hospice, but wants to know if I have any palliative procedures I can do first. Would any of you try a neurolysis? Anatomy seems too messy to try a brachial plexus catheter. Any other ideas? Should I just let hospice do what they can with meds? I haven't seen or examined her yet

 

[Baron S]

I think in a 100 year old your options will be really limited.

I had a 60 year old patient with a pancoast tumor in fellowship. We threaded an intrathecal catheter up to T3 and used sufentanil with pretty good results.

In an inpatient setting I have also used a tunneled epidural catheter pretty high up the thoracic spine and kept them hooked up to an external pump.

I've read of some folks targeting the suprascapular nerve, but that would obviously depend on the distribution of pain symptoms.

 

[drrosenrosen]

I was concerned that anything I could try for this would be super aggressive for a 100 year old patient, just wanted to confer with the group before I told him no.

 

[buddababa]

in fellowship, i did a cesi for this with a theracath, entering at t2-3, riding up to c5-6 and injection on the way down and out - got great relief for a few months

 

[drrosenrosen]

in fellowship, i did a cesi for this with a theracath, entering at t2-3, riding up to c5-6 and injection on the way down and out - got great relief for a few months

Interesting. I thought about a CESI, but couldn't see how it would help for a plexus level lesion, although there's obviously stuff going on in the spine as well.

 

[buddababa]

Interesting. I thought about a CESI, but couldn't see how it would help for a plexus level lesion, although there's obviously stuff going on in the spine as well.

yeah i was surprised too when my attending brought it up. i did it, it worked, i presented a case report at a conference and i think i won top 2 or 3

 

[Agast]

Interesting. I thought about a CESI, but couldn't see how it would help for a plexus level lesion, although there's obviously stuff going on in the spine as well.

I did the opposite. CESI with 0 relief in arm pain and then found metastatic breast cancer.

 

[lobelsteve]

100 yrs old: Norco 5, consider 12. 5mcg fentanyl and titrate at a week.
Would not offer procedures as complication could be fatal and less invasive modalities make more sense.
Based on imaging we are beyond advanced spread of disease. Tumor, that's a THREEmor

 

[Ducttape]

if hospice, no injection, med management.

if she is not going to hospice, and initial round of medications arent helping, id consider a brachial plexus block.

 

[drrosenrosen]

Thanks for your input, y'all. I spoke with her PCP and advised let her go to hospice and be managed there.