Disclosures: Thomas Chai, MD: No financial relationships or conflicts of interest

Case Diagnosis: 22-year-old male with oncologic history of metastatic clear cell sarcoma of the left thigh, status post trimodality oncologic treatment, presented with severe pain of the lower limbs due to widespread disease progression.

Case Description or Program Description: On hospital admission, pain management consisted of aggressive pain pharmacotherapy (including intravenous patient-controlled analgesia and ketamine continuous infusion), physical therapy, and ultimately the implantation of an intrathecal drug delivery system infusing hydromorphone and bupivacaine. Despite these measures, the patient’s pain remained unremitting. The patient was therefore deemed a candidate for cingulotomy to manage inextirpable cancer-related pain.

Setting: Tertiary Care Center

Assessment/Results: The patient underwent cingulotomy via laser interstitial thermal therapy (LITT) of the bilateral cingulate gyrus. By post-op day 2, patient reported a marked improvement in pain and was able gradually to wean off a significant amount of pain medication.

Discussion (relevance): Bilateral anterior cingulotomy is a neurosurgical, neuroablative approach that targets the anterior cingulate cortex, which is involved in controlling the integration of feelings and emotions. Cingulotomy has therefore been performed historically for psychiatric disorders, and then was recognized as a treatment for both malignant and benign pain conditions. A consequence of cingulotomy is reduced pain, or the patient may be habituated to ignore the pain. A spectrum of cognitive side effects may occur postoperatively, such as executive and attention impairments.

Conclusions: Neurosurgical, neuroablative approaches to pain, such as bilateral anterior cingulotomy, should be considered for severe cancer-related pain when traditional medical, surgical, and pharmacologic methods are unsuccessful.

Level of Evidence: Level V

« Back to AAPM&R Annual Assembly 2022

PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/unremitting-lower-extremity-cancer-pain-due-to-metastatic-clear-cell-sarcoma-of-the-thigh-relieved-with-bilateral-anterior-cingulotomy-a-case-report/