Table 1 describes demographics, oncologic diagnoses and treatments, pain regimen, functional status, disposition, and survival.
Table 1: Patient characteristics
Subject
|
1
|
2
|
3
|
4
|
5
|
6
|
Age
|
55
|
59
|
69
|
62
|
50
|
33
|
Gender
|
Female
|
Male
|
Male
|
Male
|
Male
|
Female
|
Race
|
White
|
White
|
White
|
Black or African American
|
White
|
White
|
Insurance
|
Private/ Commercial
|
Medicare
|
Medicare
|
Private/ Commercial
|
Private/ Commercial
|
Private/ Commercial
|
Cancer Type
|
Renal Cell Carcinoma
|
Merkel Cell Carcinoma of External Auditory Canal
|
Renal Cell Carcinoma
|
Ampullary Carcinoma
|
Renal Cell Carcinoma
|
Rectal Adenocarcinoma
|
Sites of Metastasis
|
Bone, viscera
|
Lymph
|
Bone, viscera, lymph
|
Bone, viscera, lymph
|
Bone, viscera, lymph
|
Viscera, lymph
|
Cancer Treatments
|
Chemotherapy, immunotherapy, radiation, surgical resection
|
Chemotherapy, immunotherapy, radiation
|
Chemotherapy, immunotherapy, radiation, surgical resection
|
Chemotherapy, surgical resection
|
Chemotherapy, immunotherapy, radiation
|
Chemotherapy, immunotherapy, radiation, surgical resection
|
Pain Medications 48h Pre-op
|
Opioid, muscle relaxant, steroid, acetaminophen
|
Opioid, neuropathic agent, muscle relaxant
|
Opioid, neuropathic agent, steroid, acetaminophen, NMDA-receptor antagonist
|
Opioid, neuropathic agent, steroid, acetaminophen
|
Opioid, neuropathic agent, steroid, muscle relaxant
|
Opioid, steroid, acetaminophen, neuropathic agent, NMDA-receptor antagonist, muscle relaxant
|
Interventional Pain Procedures?
|
Yes (radial nerve neurolysis)
|
No
|
Yes (trigger point injections, thoracic medial branch blocks, radiofrequency ablation)
|
No
|
Yes (kyphoplasty, cordotomy)
|
No
|
Referral Source (Location)
|
Orthopedic Surgery (Outpatient)
|
Oncology (Inpatient)
|
Anesthesiology (Outpatient)
|
Oncology (Inpatient)
|
Oncology (Inpatient)
|
Oncology (Inpatient)
|
ECOG 3 Months Prior to Procedure
|
2
|
2
|
3
|
3
|
3
|
3
|
ECOG at Discharge
|
3
|
3
|
3
|
3
|
4
|
4
|
Number of Procedures
|
1
|
1
|
1
|
1
|
2
|
1
|
Complications
|
Affect change
|
None reported
|
None reported
|
None reported
|
None reported
|
Headache
|
Hospital Length of Stay (Days)
|
33
|
4
|
15
|
16
|
80
|
14
|
Time to Discharge from Procedure (Days)
|
6
|
4
|
3
|
2
|
43
|
4
|
Discharge Services
|
Home hospice
|
Home without new services
|
Home hospice
|
Home hospice
|
Home hospice
|
Home hospice
|
Survival Post-op (Days)
|
49
|
23
|
11
|
27
|
26
|
Alive at 90 days
|
ECOG = Eastern Cooperative Oncology Group Performance Status Scale
A total of six unique patients had seven total procedures performed. One patient (subject 5) underwent cingulotomy twice due to inadequate pain relief following the initial procedure. The age of the patients in our cohort ranged from 33 to 69. 67% (4/6) were male. Five patients were white, and one patient was black.
50% (3/6) of our cohort was diagnosed with renal cell carcinoma. The three remaining patients had diagnoses of Merkel cell carcinoma of external auditory canal, ampullary adenocarcinoma, and rectal adenocarcinoma. All patients had metastatic cancer, with only one patient having metastasis limited to the lymphatic system (subject 2). The remainder had a combination of lymphatic, visceral, and bony metastases. Prior to cingulotomy, all patients had received chemotherapy, and all but one (subject 4) received immunotherapy and radiation.
50% (3/6) of our cohort had received some type of interventional pain procedure prior to pursuing cingulotomy, such as cordotomy and/or nerve blocks. Pain for all patients in our cohort was treated with an average of three adjuvant medications in addition to an opioid. 67% (4/6) of patients were referred for a cingulotomy procedure while inpatient status. 67% (4/6) were referred for cingulotomy by oncology specialists.
83% (5/6) of patients discharged home with hospice services. One patient (subject 2) discharged home with home health services and at next outpatient follow-up transitioned to home hospice. Prior to procedure, 67% (4/6) of patients had an ECOG score of 3, and 33% (2/6) had an ECOG score of 2. Post procedure, 67% (4/6) had an ECOG score of 3, and 33% (2/6) had an ECOG score of 4.
67% (4/6) of patients in our cohort had a survival time post-procedure of less than 30 days. One patient died 49 days post-procedure, and one patient was alive at 90 days.
There were no major complications in our cohort. Minor complications included affect change (subject 1) and headache (subject 6).
Table 2 describes average daily patient reported pain (ADPRP) scores and daily OME dose three months prior to cingulotomy, 48 hours prior to procedure, and at discharge. Average daily OME dose three months prior to cingulotomy, 48 hours prior to procedure, and at discharge were 367 mg, 4411 mg, and 250 mg, respectively.
Table 2: Pain Scores and Opioid Dosing
Subject
|
Pain Score 3 Months Pre-op
|
Pain Score 48 Hours Pre-op
|
Pain Score at Discharge
|
Daily OMEs 3 Months Pre-op
|
Daily OMEs 48 Hours Pre-op
|
Daily OMEs at Discharge
|
1
|
7
|
7
|
3
|
480
|
1174
|
60
|
2
|
5
|
6
|
1
|
90
|
480
|
0
|
3
|
8
|
6
|
6
|
540
|
1776
|
22.5
|
4
|
7
|
6
|
4
|
293
|
1683
|
140
|
51
|
7
|
2.5
|
1
|
200
|
1470
|
676
|
6
|
8
|
8
|
6
|
600
|
19882
|
600
|
Average
|
7
|
6
|
4
|
367
|
4411
|
250
|
OME = oral morphine equivalent
1Patient 5 – listed pain scores and OME dose averaged from both procedures
Table 3 lists daily OME dose by post-operative day (POD) and percent change of daily OME dose. There was a 43% reduction in ADPRP score from 48 hours prior to procedure to discharge, with a concomitant reduction in average daily OME dose of 89%. The greatest reduction in average OME dose occurred on POD 1 with a 68% reduction in average daily OME dose as compared to 48 hours prior to procedure. Average LOS in our cohort was 27 days. Average time to discharge post-procedure was 10 days.
Table 3: Post-operative Changes
Subject
|
Daily OMEs 48 Hours Pre-op
|
Daily OMEs POD 1
|
Daily OMEs POD 2
|
Prescribed Daily OMEs at Discharge
|
% Change OMEs POD1 vs 48 hr prior
|
% Change OMEs POD2 vs POD1
|
% Change OMEs at Discharge vs 48 hr prior
|
% Change Pain Score at Discharge compared to 48 hr prior
|
1
|
1174
|
790
|
404
|
60
|
-33
|
-49
|
-95
|
-57
|
2
|
480
|
38
|
8
|
0
|
-92
|
-80
|
-100
|
-83
|
3
|
1776
|
50
|
53
|
23
|
-97
|
5
|
-99
|
0
|
4
|
1683
|
240
|
200
|
140
|
-86
|
-17
|
-92
|
-33
|
51
|
1470
|
1333
|
1500
|
676
|
-9
|
13
|
-54
|
-60
|
6
|
19882
|
1440
|
960
|
540
|
-93
|
-33
|
-97
|
-25
|
Average
|
4411
|
648
|
521
|
240
|
-68
|
-20
|
-89
|
-43
|
1Patient 5 – listed pain scores and OME dose averaged from both procedures