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Case Reports
Case 1
A 35-year-old man with metastatic melanoma was hospitalized because of pain in the right leg. Melanoma of the right lower leg had been diagnosed 7 years earlier, and the patient underwent multimodal therapy, including surgery, radiation therapy, and chemotherapy. Beginning 3 months before this hospitalization, increasing pain developed in the right lower extremity, associated with significant soft-tissue tumor involvement (Fig. 1). His pain was especially difficult to control during wound dressing changes. During this hospitalization, the patient's pain was not controllable with opioids, including 5000 μg per day of intravenous fentanyl in addition to 480 mg per day MEDD for other opioids. The neurosurgical service was consulted, and the patient underwent a percutaneous cordotomy (Fig. 2) without complication; 3 days later, he was discharged to home hospice care. Pain control was excellent, and pain intensity score during dressing changes went from a 10 of 10 preoperatively to 2 of 10 postcordotomy. In addition, his MEDD was reduced by 75%. However, because of disease progression, the patient died on postcordotomy Day 10.
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Figure 1.
Case 1. Scout view CT image of the lower extremities, demonstrating extensive soft-tissue disease in the right lower extremity.
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Figure 2.
Case 2. Axial CT image at the level of C1–2, demonstrating the radiofrequency cordotomy electrode positioned within the left lateral spinothalamic tract.
Case 2
A 48-year-old woman with progressive stage IIIC ovarian carcinoma was hospitalized because of intractable left abdominal and leg pain. The cancer had been diagnosed 4 years earlier, and the patient had undergone surgery, radiation therapy, and chemotherapy. Her current pain was attributed to a mass in her left psoas muscle. As a supportive care service patient, she received multimodal supportive care, including management with opioids. Despite optimal medical management, which included hydromorphone with an MEDD of 300 mg, she reported a pain intensity of 9/10. At the request of the medical oncologist, the patient underwent a percutaneous cordotomy. After the procedure, the patient did not experience significant pain relief and she was transitioned to hospice care. Her hydromorphone was changed to the subcutaneous route at the same MEDD. She died at home 1 month later.
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