Attending/Staff Physician Cleveland Clinic Foundation Cleveland, Ohio, United States
Case Diagnosis: Pain related to Advanced Sigmoid Colon Adenocarcinoma
Case Description: 51-year-old female with stage IV sigmoid colon adenocarcinoma, previously treated with resection, experienced metastatic recurrence. She had radiation therapy to the abdominal wall and sacrum. Recurrent bowel obstructions status-post radiation and surgery necessitated sigmoid colon stent placement.
She presented to us with excruciating burning rectal pain following stent placement. Diagnostic superior hypogastric plexus block was performed, offering 75% pain relief for one month. Months later, she was hospitalized with severe abdominal pain, revealing stenosis within the stent with tumor ingrowth, subsequently managed with stent-in-stent prosthesis placement.
She returns with pain due to stent-in-stent placement. Intrathecal pump for drug delivery was offered, but she deferred. Instead, a repeat superior hypogastric plexus block was performed without complications. However, days later, she presented with gastrointestinal bleeding, with imaging revealing stent migration and rectal pseudoaneurysm. Despite intervention, the patient's advanced metastatic cancer and poor prognosis led to a decision for comfort care and hospice.
Discussions: This case underscores the challenges of managing pain in complex malignancies, emphasizing the importance of patient-centered decision-making, particularly in advanced stages. Effective pain management strategies like the superior hypogastric plexus block can transiently impact patients' quality of life, but not without complications. Intrathecal drug delivery systems should be discussed with patients with advanced stages of cancer as a longer lasting option for their pain management and could limit need for repeat procedural interventions.
Conclusions: In the management of this patient, pain control through superior hypogastric plexus blocks offered temporary relief. However, complications related to stent placement and advanced disease ultimately led to a transition to comfort care and hospice, highlighting the complex nature of advanced cancer care. This case emphasizes the necessity of holistic, patient-focused approaches and discussions surrounding invasive interventions, especially in patients with complicated medical history, advanced malignancies, and poor prognoses.
