INTRODUCTION: Multimodal treatment of cancer with optimized systemic therapy does not reach adequate pain control in 5-14 % of patients. About 8-11 % could benefit from interventional procedures. This report has been made on the severe pain case while NBP treatment with invasive interventions applied.
CASE REPORT: A 50-year-old female has been admitted to The Thoracic Surgery Unit due to breast cancer progressed. CT scan has showed a 12x6 cm chest wall infiltration in contact with a brachial plexus (Picture 1). She has suffered from burning hand pain (7 points of NRS) with progressed hand swelling (picture 2) and motor weakness till motoric absence, hyperesthesia, allodynia. Elective chest wall tumorectomy has been made. Histology has showed metastatic breast carcinoma. Surgery has aggravated pain to 10 points of NRS despite maximum tolerated medical treatment with nonsteroidal anti-inflammatory drugs, paracetamol, tricyclic antidepressants, antiepileptic drugs, opioids, intravenous ketamine and lidocaine as it has proved to be totally ineffective. Interventional pain treatment by ultrasound-guided (UG) plexus brachialis block in supraclavicular and interscallene approach with 20 mL 0,5 % bupivacaine and 40 mg methyl-prednisolone has been fulfilled by blocking three times in total. It has resulted in subsequent prolonged pain relief to 8 points with no more benefits from block repeating (chart). The causalgia has been diagnosed under diagnostic criteria. For sympathetically maintained pain the UG stellate ganglion block (SGB) with 1 % lidocaine and 40 mg methyl-prednisolone has been applied. It has resulted in constant pain relief to 2 points and significant decrease in pain medication demand. After SGB decreasing of hand edema lasting for weeks (picture 3) and decreased temperature difference between hands (picture 4) have also been seen. 
The SGB has been repeated twice after the first block has been made. Due to pain increase and carcinoma progression UG brachial plexus neurolysis with 6 ml 60% ethanol in supraclavicular way and 1 week later with 5 ml 70 % ethanol in interscallene way has been applied. It has resulted in loss of any sensations in the whole hand and the absence of need for pain medication. Nonetheless, after a month the patient felt intermittent pain associated with a stressful situation. Paint was totally responsive to daily clonidine 0,15 mg tabs.  
CONCLUSION: Malignant invasion of brachial plexus occurs in less than 0,5% of breast cancers with 31% intractable pain. Our patient’s pain decrease after brachial block has not been satisfactory due to the combined various neuropathic and nociceptive origin of pain. Sympathetic blockade by SBG and brachial plexus neurolysis has been required. 


04 / The stellate ganglion block and plexus brachialis ethanolic neurolysis given the neoplastic brachial plexopathy (NBP)
Vidas Jankus, Renata Paškeviciute, Geda Klimaviciute
Klaipeda University Hospital, Anesthesiology and Intensive Care Clinic, Lithuania

04 / The stellate ganglion block and plexus brachialis ethanolic neurolysis given the neoplastic brachial plexopathy (NBP) Vidas Jankus, Renata Paškeviciute, Geda Klimaviciute Klaipeda University Hospital, Anesthesiology and Intensive Care Clinic, Lithuania