Metastatic Breast Cancer Causing Severe Shoulder and Arm Pain

What happened, in summary

A 54-year-old woman sought care for severe right-shoulder pain, numbness, and tingling in her right arm. Twelve years earlier, she had been diagnosed with inflammatory breast cancer and multiple bone metastases. First-line chemotherapy was followed by radical mastectomy and axillary dissection. Residual cancer remained in the breast and lymph-node specimens. Three successive endocrine therapies then maintained prolonged disease control.

Seven years later, biopsy confirmed metastatic lymph nodes above and below the collarbone. External radiation and 2 chemotherapy regimens produced a good response. Three years afterward, the shoulder pain and arm swelling worsened. Despite additional chemotherapy, lymph-node masses behind the chest muscles and around the collarbone enlarged, while other metastatic sites remained stable. The masses involved the brachial plexus and thoracic inlet, producing profound arm weakness and Pancoast syndrome.

A pain team treated the neuropathic pain with acetaminophen, opioids, pregabalin, corticosteroids, buprenorphine, and indomethacin. When medicines were insufficient, an intrathecal catheter delivered morphine and ziconotide with good pain relief. A cerebrospinal-fluid leak caused headache and vomiting and was treated with an epidural blood patch. She died about 3 months later.