A 42-year-old woman was referred to the Pain Unit of the Galdakao Hospital from the Pathophysiology Department.
As a personal history of interest, it was diagnosed as an acclimatized and ectomised in his youth, two eutocic births and one curettage due to miscarriage.
Patient was admitted to the emergency department due to a nodule in the right breast diagnosed as ductal carcinoma with moderate differentiation grade II.
A quadrantectomy with right axillary lymphadenectomy was performed and subsequently treated with chemotherapy.
The bone scan showed no signs of bone metastases.
After one year, the patient had low back pain radiating to the left inguinal region.
Control bone scintigraphy showed lytic bone metastases in the left iliac pala and sacroiliac joint on the same side.
Magnetic resonance imaging (MRI) confirmed the diagnosis of multiple bone metastases in the left hemipelvis with a large lesion in iliac bone affecting the sacroiliac joint and above the acetabulum conserved cortical bone.
Treatment was initiated with radiotherapy and chemotherapy cycles.
At the time of consultation with the Pain Unit, the patient presented continuous moderate-severe pain, with difficulty sleeping.
It was located in the lumbar region and pelvis, located by left inguinal region.
Pain is characteristic and the patient did not complain of paresthesia or lancinating pain in the extremities.
It was accompanied by a feeling of loss of strength in the left limb.
Pain increased in intensity with walking and was assessed on the visual analog scale (VAS) of 9/10.
The examination showed negative Lassegue and Bragard, osteotendinous reflexes present and preserved strength.
Treatment was initiated with controlled morphine sulfate 15 mg.12 h-1, lysine acetyl salicylate 1.800 mg.8 h-1, dexamethasone 2 mg.8 h-1, metamizole release as rescue analgesic.24 h-1, prophylaxis
At the beginning of the treatment, pain at rest was controlled without significant side effects, but this persisted with movements.
Gradually, over three months, it was necessary to increase opioids reaching the dose of 260 mg of morphine sulfate day, along with immediate-release oral morphine 20 mg.4 hmitrip-1 for pain control incidentally associated 25 mg.24
Pain intensity according to the VAS was 8/10 with movements, so a new MRI was requested, which showed progression of the bone lesion in the left sacroiliac joint with respect to the previous study.
The lesion overflowed cortical margins and produced a mass of soft tissues affecting the left middle gluteus muscle.
Multiple bone lesions were also observed in the dorsal and lumbar vertebrae, compatible with metastasis, without occupation of the canal or foramina.
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Because of the increased number of bone metastases and the difficulty in controlling pain, it was decided to refer the patient to the Nuclear Medicine Department to assess the possibility of palliative treatment with samarium-153 (Sm-153) (Q).
The patient had a previous laboratory test without alterations.
95 millicuries (mCi) of Sm-153 were administered intravenously in a single injection without complications.
Prior hydration is recommended when this treatment is initiated to promote urinary excretion of the fraction of Sm-153 that does not bind to bone.
Treatment does not require hospitalization, but the patient should remain in the hospital for at least 6 hours for urine collection in special cells because it is contaminated by a radioisotope.
At the successive visit, the patient reported significant pain improvement within 24-48 hours and on the following days, both at rest and walking, with a VAS of 2/10.
Analgesics were progressively decreasing, and currently 10 mg.12 h-1 of morphine sulfate and metamizole were sufficient on demand.
In subsequent controls, leukopenia was observed after 4 weeks 2,200/mm3 with normal formula and platelet count was normal at 9300mm3 at 8 weeks, platelets normalized and persisted.
After 3 months, an increase in the levels of tumor marker CA 15.3 = 53.3 U.ml-1 was observed, and in the posterior abdominal ultrasound showed a discrete image in the liver suggestive of metastasis. In the left hemisphere there was also a decrease in the
At the last visit, the patient was undergoing chemotherapy due to the progression of breast carcinoma, but pain control was satisfactory, without requiring an increase in the dose of opioids in 6 months.
