1317 - Multimodal Pain Management and Interventional Strategies in a Patient with Metastatic Rhabdomyosarcoma and Iliac Vein Obstruction

Case Diagnosis: Managing cancer-related pain is a significant challenge, as pain is often multifactorial and refractory to conventional therapies. High-dose opioids are frequently limited by side effects and tolerance. Alternative systemic infusions like ketamine and lidocaine offer limited, short-term benefits. This case aims to illustrates how integrating vascular and interventional pain procedures can achieve significant pain relief and functional improvement in palliative oncology.

Case Description: 40-year-old male with metastatic rhabdomyosarcoma to the prostate presented with severe abdominal and left lower extremity pain and edema. His pain was neuropathic and refractory to high-dose opioids and analgesic infusions, so a discussion was taking place regarding long-term opioid use vs. an intrathecal opioid pump. Imaging was consistent with iliac vein compression from pelvic tumor burden. Instead of opioids, a targeted L5/S1 interlaminar epidural steroid injection (LESI) was performed, producing rapid relief of neuropathic leg pain and enabling partial opioid tapering. Given ongoing pain and edema, iliac vein thrombectomy with angioplasty and stent placement was performed, leading to a marked reduction in swelling and compressive pain.

Discussions: These interventions allowed complete discontinuation of his Dilaudid patient-controlled analgesia pump, avoidance of an intrathecal opioid pump, and eventual discharge without systemic opioids. Importantly, by the time of discharge, the patient demonstrated independence in standing with assistance for gait, balance, and mobility, supporting a safe transition home and resumption of cancer-directed therapy.

Conclusions: The successful use of both a vascular intervention and an interventional pain procedure highlights a novel and effective strategy for managing complex cancer pain. The LESI enabled a meaningful de-escalation of his opioid regimen by targeting a specific neuropathic pain generator, while the iliac vein stent provided crucial functional improvement by reducing edema. This case underscores the pivotal role of interventional pain and PM&R specialists in a collaborative, multidisciplinary cancer care team.