Continuous epidural analgesia and interscalene brachial plexus block as postoperative analgesia for Pancoast tumor resection: a case report

Introduction

A Pancoast tumor is usually resected with the upper lobe via thoracotomy along with the chest wall of the apex. The surgical procedure involves the brachial plexus. In these cases, patients complain of severe pain of the shoulder or upper limb due to brachial plexus injury, as well as postoperative pain of the chest wall. For such pain, epidural analgesia alone is insufficient, and a request for pain control was made by surgeons. In response, we proposed a combination of continuous epidural analgesia and interscalene brachial plexus block. A case of Pancoast tumor resection in which it was possible to achieve good pain control with this method is reported. We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-24-7/rc).

Case presentation

A 58-year-old man (170 cm, 57.8 kg) came to the hospital complaining mainly of left back pain. He was diagnosed with a left Pancoast tumor (Figure 1) after investigation. Although the tumor had invaded the chest wall of the left apex on imaging, there were no neurological symptoms and findings related to the upper limbs, which suggested that the brachial plexus was preserved. Upper lobectomy with chest wall resection was scheduled after chemotherapy and radiation therapy.

Figure 1 Computed tomography images [sagittal (A) & horizontal (B) section]. The tumor in the left pulmonary apex invades the surrounding chest wall (red arrows).

He had hypertension that was well-controlled by drug therapy. He had a smoking history of 20 cigarettes a day until 1 year earlier. The preoperative examination did not identify any other serious complications.

Continuous interscalene brachial plexus block was planned for the pain of the dorsal scapular, axillary nerve dominant regions and the left upper extremity because continuous epidural analgesia alone could not fully cover the chest wall of the apex and damage to the brachial plexus.

After the patient entered the operating room, epidural catheter insertion was performed at thoracic intervertebral space 7/8. General anesthesia was induced with fentanyl, propofol and sevoflurane, and a supraglottic airway (SGA) was inserted. A left interscalene brachial plexus block under the dual guidance of ultrasound and a nerve stimulator (Stimuplex^® HNS12, B. Braun Medical, Melsungen, Germany) was performed with catheter insertion 3 cm caudad after administration of 15 mL of 0.2% ropivacaine. Remifentanil and rocuronium were then added. Following interscalene procedures, the SGA was replaced with a 37-Fr left-sided double-lumen endotracheal tube. We use both a nerve stimulator and an ultrasound device to perform nerve blocks after general anesthesia, but in order to use the nerve stimulator, induction must be performed without muscle relaxants. For this reason, we used a two-step anesthesia induction procedure: first SGA, then nerve block, followed by muscle relaxants and double-lumen tube insertion. An arterial catheter was placed at the right radial artery, and the patient was placed in the right lateral position. Intraoperative anesthesia was maintained with remifentanil 0.15 µg/kg/min and sevoflurane 1.5%. For epidural anesthesia, 8 mL of 0.375% ropivacaine were administered before the start of surgery, and 4 mL of 0.375% ropivacaine were administered every 2 hours thereafter. The surgery was completed without any complications. The surgical procedure consisted of resection of the upper lobe of the left lung and a combined resection of the chest wall, including the first to third ribs. The tumor and brachial plexus were dissected during the surgical operation. The operative time was 3 hours and 28 minutes, anesthesia time was 5 hours and 16 minutes, fluid volume was 2,320 mL, blood loss was 130 mL, and urine volume was 400 mL. Since the patient complained of severe pain in the left shoulder immediately after emerging from anesthesia, 6 mL of 0.25% ropivacaine were additionally administered via the brachial plexus catheter, and analgesia was obtained after 15 minutes, followed by continuous administration of 3 mL/h of 0.15% ropivacaine. For epidural analgesia, 0.15% ropivacaine + fentanyl was administered continuously (patient-controlled analgesia setting: bolus 3 mL, lockout time 30 minutes, infusion device; Toray Bessel-Fuser^®, Toray Medical Co., Ltd., Tokyo, Japan) at 4 mL/h (fentanyl 8 µg/h). Continuous infusion through both catheters continued for 1 week. In addition, as an auxiliary analgesic, intravenous acetaminophen (1,000 mg) was administered at the end of the surgery then repeatedly administered every 6 hours until postoperative day 1 (POD1). From POD1, 37.5 mg tramadol hydrochloride, 325 mg acetaminophen, and 60 mg loxoprofen sodium were taken regularly for 10 days.

Perioperative pain around the shoulder and incision were evaluated by a Numerical Rating Scale (NRS) (Figure 2). Due to sufficient analgesia, the range of motion of the left upper limb was able to reach 90 degrees of anterior elevation and abduction, respectively, even on POD1. The patient was discharged ambulatory on POD14, but left upper limb pain remained.

Figure 2 Changes of postoperative NRS. NRS, Numerical Rating Scale; POD, postoperative day; IAS, immediately after surgery; 15 min, 15 minutes after bolus injection of 0.25% ropivacaine 6 mL for brachial plexus block.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

A Pancoast tumor is a cancer that originates in the apex of the lung and invades the chest wall, brachial plexus, and lower cervical sympathetic ganglia (1). Chemotherapy and radiation therapy are usually given to shrink the tumor, and then surgery is planned (2), but in many cases, surgery is not indicated. When surgery is indicated, the major problem is that it is a highly invasive procedure involving resection of the upper lobe of the lung, resection of the surrounding chest wall, and brachial plexus dissection and preservation (3). Although epidural analgesia can control pain in the thoracotomy incision site to some extent, pain at the chest wall resection site around the apex of the lung and around the shoulder joint, and neuropathic pain due to brachial plexus injury caused by surgical manipulation are very severe and can interfere with weaning. At the same time, the range of motion of the upper extremities is restricted. In the past, there have been reports of continuous interscalene brachial plexus block for cancer pain control in patients with a Pancoast tumor (4-6), but there have been no reports of this method for postoperative pain control. The interscalene brachial plexus block is an effective method for postoperative analgesia in shoulder joint surgery (7,8), and we have performed it for postoperative analgesia in shoulder joint surgery, complex fractures of the upper arm, and joint replacement. The insertion of a catheter into the brachial plexus is thought to have a high risk of causing neuropathy due to the narrow space for placement, but we always try to perform the procedure under the dual guidance of ultrasound and a nerve stimulator. We have not had any cases of nerve damage, and we believe that the procedure can be performed safely. Reports to date indicate that 0–0.1% of cases have sensory deficits lasting longer than 6 months (9,10), with no reports of severe deficits. Only one case has been reported since the ultrasound device-guided procedure was introduced (11). In the present study, it was necessary to consider the amount of fluid to be administered when performing a continuous brachial plexus block.

We usually administered 0.2% ropivacaine at a dose of 3–5 mL/h for postoperative analgesia for shoulder surgery, but if the same amount of ropivacaine was to be added for epidural analgesia, we were concerned that the risk of local anesthetic poisoning would be high. To avoid this, fentanyl was added to the epidural analgesia, and acetaminophen was administered regularly (1,000 mg/6 h) as supplementary analgesia. This resulted in satisfactory analgesia (NRS: 2–3 in the shoulder, 0–1 in the wound), and this analgesic method was considered to be effective.

Later, the same analgesic method was used in another case (58-year-old man, 170 cm, 70 kg, left Pancoast tumor), and although analgesia for the chest area was good, the pain in the shoulder area and upper arm was severe; therefore, the dose of the continuous brachial plexus block was increased from 3 to 5 mL/h on POD3. With this, the NRS of 4–5 became 1–2, and satisfactory analgesia was obtained. Both catheters were removed on POD7, as in the previous case.

Postoperative analgesia following Pancoast tumor resection could be achieved with this analgesic method, but it is difficult to say that it was sufficiently effective for the neuropathic pain as a subsequent issue. Both patients had residual neuropathic pain due to intercostal nerve injury from rib resection and brachial plexus injury from surgical manipulation. Many reports have shown that brachial plexus injury often causes severe neuropathic pain that becomes chronic pain and is difficult to treat; recently, the usefulness of peripheral nerve stimulation therapy for such cases has been reported (12). In the future, in addition to this analgesic method, we would like to consider measures to prevent or relieve neuropathic pain.

In recent years, it has been advocated that in the management of pneumonectomy, preoperative evaluation of respiratory function and cardiac function, etc., should be performed by specialists in each of these areas, and as a multidisciplinary team (13). As the role of anesthesiologist, postoperative analgesia is also considered to have an impact on postoperative quality of life, and its coordination is considered important. We believe that this case report demonstrates the importance of such evaluation.

Conclusions

We have found that continuous brachial plexus block in addition to continuous epidural analgesia for postoperative analgesia after Pancoast tumor resection provided effective analgesia.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-24-7/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-24-7/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-24-7/coif). I.K. serves as an unpaid editorial board member of AME Case Reports from May 2023 to April 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Davis GA, Knight SR. Pancoast tumors. Neurosurg Clin N Am 2008;19:545-57. v-vi. [Crossref] [PubMed]
2. Pitz CC, de la Rivière AB, van Swieten HA, et al. Surgical treatment of Pancoast tumours. Eur J Cardiothorac Surg 2004;26:202-8. [Crossref] [PubMed]
3. Davis GA, Knight S. Pancoast tumor resection with preservation of brachial plexus and hand function. Neurosurg Focus 2007;22:E15. [Crossref] [PubMed]
4. Vranken JH, van der Vegt MH, Zuurmond WW, et al. Continuous brachial plexus block at the cervical level using a posterior approach in the management of neuropathic cancer pain. Reg Anesth Pain Med 2001;26:572-5. [Crossref] [PubMed]
5. Vranken JH, Zuurmond WW, de Lange JJ. Continuous brachial plexus block as treatment for the Pancoast syndrome. Clin J Pain 2000;16:327-33. [Crossref] [PubMed]
6. Zinboonyahgoon N, Vlassakov K, Abrecht CR, et al. Brachial Plexus Block for Cancer-Related Pain: A Case Series. Pain Physician 2015;18:E917-24. [Crossref] [PubMed]
7. Ullah H, Samad K, Khan FA. Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery. Cochrane Database Syst Rev 2014;2014:CD007080. [Crossref] [PubMed]
8. Tamosiūnas R, Gudas R, Karbonskiene A, et al. Bupivacaine for continuous interscalene brachial plexus analgesia after shoulder surgery. Medicina (Kaunas) 2004;40:351-7. [PubMed]
9. Wiegel M, Gottschaldt U, Hennebach R, et al. Complications and adverse effects associated with continuous peripheral nerve blocks in orthopedic patients. Anesth Analg 2007;104:1578-82. table of contents. [Crossref] [PubMed]
10. Borgeat A, Dullenkopf A, Ekatodramis G, et al. Evaluation of the lateral modified approach for continuous interscalene block after shoulder surgery. Anesthesiology 2003;99:436-42. [Crossref] [PubMed]
11. Shio H, Sakura S, Motooka A, et al. Severe and persistent nerve palsy after ultrasound-guided continuous interscalene brachial plexus block in a teenager undergoing shoulder surgery: a case report. JA Clin Rep 2020;6:15. [Crossref] [PubMed]
12. Kim JH, Shin SH, Lee YR, et al. Ultrasound-guided peripheral nerve stimulation for neuropathic pain after brachial plexus injury: two case reports. J Anesth 2017;31:453-7. [Crossref] [PubMed]
13. Della Rocca G, Vetrugno L, Coccia C, et al. Preoperative Evaluation of Patients Undergoing Lung Resection Surgery: Defining the Role of the Anesthesiologist on a Multidisciplinary Team. J Cardiothorac Vasc Anesth 2016;30:530-8. [Crossref] [PubMed]