Inoperable Sacral Giant Cell Tumor: Therapeutic Options and Pain Control

Viana, Eneida de Mattos Brito Oliveira; Batista, Katia Torres; Carneiro, José Leite

doi:10.1055/s-0039-1692450

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Case Report • Rev. bras. ortop. 54 (03) • May-Jun 2019 • https://doi.org/10.1055/s-0039-1692450 copy

Inoperable Sacral Giant Cell Tumor: Therapeutic Options and Pain Control^* * Work performed at Rede Sarah de Hospitais de Reabilitação, Brasília, DF, Brazil, and presented at the Instituto de Ensino e Pesquisa from the Hospital Sírio Libanês to obtain the certification as a specialist in the care of patients with pain.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Sacral giant cell tumor (GCT) is a rare condition. Its treatment is complex, since surgical removal is difficult and the response to other therapeutic options is low. The control of its growth and pain is an additional challenge. The present paper reports a case of inoperable sacral GCT, with embolization and radiotherapy for pain control as therapeutic options. The patient, a 39-year-old male, presented pain in the sacral region with lower limb irradiation due to an inoperable sacral giant cell tumor. The patient was submitted to embolization, radiotherapy, pain management with opioids and other drugs, and a rehabilitation program. Despite the difficulty in tumor growth and pain control during the follow-up, the outcome is stable after 9 years.

Keywords:
giant cell tumors; orthopedics; chronic pain

Month	Complication	Treatment
1^st month, admissionIntra-arterial embolization in the tumoral territory irrigated by the left lateral sacral artery	PainPain intensified (score 10/10)	Morphine, 10 mg every 6 hoursAmitriptyline, 50 mg/dayReplacement with transdermal fentanyl (200 mcg) and gabapentin (1,200 mg/day)
3^rd month, unchanged tumoral volumeTumoral embolizationInterferon alfa 2A (1.1MU/m²)	Pain flare-up	Gabapentin, 600 mg every 8 hoursTransdermal fentanyl (200 µcg), Tenoxicam, 20 mg/dayParacetamol, 750 mg every 6 hoursAmitriptyline, 75 mg/day
4^th month	Pain when walking. Difficulty in using transdermal fentanyl patches due to profuse sweating.	Intrathecal catheter placement with fentanyl PCA pump (5 µcg; blocking interval: 30 minutes; continuous infusion: 0.5 µcg/h; total continuous dose: 12 µcg/day)
5^th month, interferon alfa 2A (2.2MU/m²)	Fentanyl withdrawal syndromeStabbing pain throughout the lower right limb due to L4 spondylolysis, grade I L4-L5 listhesis and neural foramen stenosis.	Synchromed II intrathecal pump placement, approximately at L3/L4 level. Fentanyl infusion started at a continuous daily dose of 10 µcg.Intrathecal fentanyl dose was progressively adjusted; latter, fentanyl was replaced with morphine.Increased intrathecal drug infusion, with tramadol addition and morphine maintenance for salvage therapy.Bilateral L4/L5 periradicular block with bupivacaine and methylprednisolone. Second bilateral L4/L5 periradicular block with bupivacaine and methylprednisolone.
10^th month, tumoral growthInterferon alfa 2A (4.4MU/m²)	Severe pain and burning sensation from the buttock to the posterior region of the lower right limb; profuse sweating, weight loss, moaning and pressure sore at the ulnar region due to load support.	Amitriptyline, 75 mg/dayGabapentin, 2,400 mg/day; intrathecal morphine, 2.5 mg/day; Bupivacaine, 1.25 mg/day (Pain score went from 9/10 to 4/10).
11^th month, Radiotherapy – 4,500 cGy at the tumoral bed	Severe burning sensation at the left plantar area, unable to touch the floor with the foot. Catheter in the subarachnoid space.	Clonidine, 42 µcg/day; intrathecal morphine solution; Gabapentin, 2,700 mg/day.The catheter was replaced; it was intact, but it rolled under the pump.
12^th to 14^th month – hydrotherapy and physical therapy	The patient is unstable and requiring assistance in all daily life activities.	Morphine (3.5 mg/day); bupivacaine; amitriptyline, 125 mg/day; gabapentin, 2,400 mg/day; tizanidine, 6 mg/day; methadone, 15mg/day; and naproxen, 1 g/day.
29^th month – ankle-foot orthosis	Pain relapse	Increase intrathecal morphine dose to 2 mg/day; methadone, 5 mg every 12 hours; amitriptyline, 25 mg/night; naproxen, 250 mg every 12 hours.
87^th month	End of PCA pump working time	PCA pump replaced
91^st month	PCA pump exteriorization	Intrathecal injection system removal; continuous venous infusion of morphine, 4 mg/hour, and methadone, 10 mg every 8 hours, reduced to 5 mg every 8 hours for 1 year; gabapentin, 300 mg 12 hours, and amitriptyline, 25 mg/night.
96^th month, tumoral growth stabilization		With no specific oncologic treatment, no pain or any analgesic medication, the patient resumed his daily life activities and returned to work

Sociedade Brasileira de Ortopedia e Traumatologia Al. Lorena, 427 14º andar, 01424-000 São Paulo - SP - Brasil, Tel.: 55 11 2137-5400 - São Paulo - SP - Brazil
E-mail: rbo@sbot.org.br

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[1] Address for correspondence
Katia Torres Batista, Rede Sarah de Hospitais de Reabilitação, SMHS Qd 301 Bloco A, Brasília, DF, CEP: 70335-901, Brasil (e-mail: katiatb@terra.com.br; 203911@sarah.br).