Background Forequarter amputation (FQA), involving the removal of the upper extremity, scapula and clavicle, is a safe and reliable procedure for palliation of intractable pain, lymphoedema and limb dysfunction in patients with metastatic disease of the shoulder girdle.¹ Although first reported in 1836, use of FQA remains controversial due to the radical nature of the procedure. However, some authors argue it is a justified last resort to provide substantial relief and improve quality of life.²

In this report, we discuss the use of FQA for intractable pain in metastatic carcinoma and considerations involved in ensuring patient-centred care.

Methodology A 70 year old right-hand dominant male farmer presented with intractable pain from shoulder girdle metastases of laryngeal squamous cell carcinoma. The management of the primary tumour involved laryngectomy, right hemi-thyroidectomy and neck dissection but the patient declined radiotherapy. He later developed a right shoulder mass over 6 months, progressively increasing in size, causing intractable pain, lymphoedema and limb dysfunction, leading to hospital admission. His metastases was too extensive for radiotherapy, thus referred to a quartenary hospital for FQA.

His medical history include congenital albinism with partial blindness, Takusubo cardiomyopathy and large incisional hernia from previous laparotomy for perforated diverticulum. He communicated via the laryngectomy stoma, had a nasogastric tube for dysphagia, and Australia-modified Karnofsky Peformance Scale (AKPS) 40. Furthermore, he had low health literacy and relied on his wife to oversee his health issues.

Staging PET and MRI confirmed large metastases, 21cm, eroding the right humerus with extensive muscle and brachial plexus involvement. He had pulmonary metastases and synchronous colorectal tumour. Prognosis was thought to be less than 3 months.

There were clinical and ethical concerns regarding the potential morbidity and mortality of performing major amputation on a debilitated patient with metastatic disease, low AKPS and short life expectancy. However, pain control and quality of life were imperative, compounded by the fact that he found the heavy non-functioning arm burdensome even if it became pain-free.

The risks and benefits of amputation was discussed with the patient and his family to provide realistic expectations. The patient was keen to undergo FQA, burdened physically and psychologically by the arm, aware of complications and prognosis.

Results Multiple agents (lignocaine, hydromorphone, methadone, clonidine, dexamethasone, mirtazapine and ketamine) were used concurrently with limited effect and increasing side effects. Interventional strategies met with varying levels of success. Although brachial plexus block provided good relief, it was not sustained beyond 24 hours as interscalene catheter was repeatedly dislodged.

Patient underwent FQA with significant pain relief and opioid reduction. There was also psychological relief with removal of the burdensome arm. The complications of pulmonary embolism and mild phantom limb pain had minimal effect on the patient. Patient was transferred to his local hospital where he died less than one month later from complications of his malignancy.

Conclusion FQA for metastatic carcinoma can significantly improve pain and quality of life. This case highlights the importance of thorough informed discussion to ensure patient-centred care whilst navigating complexities in shared decision making.

References

1. Wittig JC, Bickels J, Kollender Y, et al. Palliative forequarter amputation for surgical technique, and results. J Surg Oncol. 2001;77(2):105–113.

2. Merimsky O, Kollender Y, Inbar M, et al. Is forequarter amputation justified for palliation of intractable cancer symptoms?. Oncology 2001;60(1):55–59.