QOL-19. Complete pain response following MRI-guided anterior cingulotomy with concurrent LITT ablation of a refractory painful skull base metastasis

Abstract BACKGROUND Patients with metastatic cancer often experience intractable pain despite aggressive multimodal therapies. A 55-year-old woman with T3N2a rectal adenocarcinoma developed widespread osseous and skull base metastases, including a large and painful right sphenoid lesion extending into the middle cranial fossa. Despite fractionated SBRT, the mass remained symptomatic with persistent right-sided headache and facial pain, diplopia, facial droop, and tinnitus-like auditory disturbance. She was a poor surgical candidate and even palliative resection was deemed high-risk and futile. METHODS She underwent a single-session stereotactic procedure combining MRI-guided laser interstitial thermal therapy (MRIg-LITT) for biopsy and lesion ablation with bilateral anterior cingulotomies for affective pain control. The patient was first brought to the operating room for trajectory planning. Using a frameless image-guided stereotactic neuronavigation system, two frontal cranial bolts were placed using pre-planned trajectories to target standard coordinates for disconnection of the anterior cingulate gyri. A third temporal trajectory targeting the right sphenoid lesion was likewise devised and used for needle biopsy. Next, all three trajectories were confirmed using intraoperative MRI and sequentially ablated under real-time MRI guidance. RESULTS In the immediate postoperative period, the patient reported some residual preoperative pain but was noted to be in significantly less emotional distress, consistent with the expected effect of cingulotomy. At close outpatient follow-up on postoperative day four, she experienced a complete pain response, with full resolution of pain symptoms and associated distress. The patient self-discontinued all analgesic medications, including morphine, gabapentin, and methadone. CONCLUSIONS This case demonstrates that combined MRIg-LITT ablation and anterior cingulotomy can be safely and effectively performed in a single session to address both structural tumor burden and refractory cancer-related pain. Minimally invasive neuroablative strategies such as cingulotomy may offer meaningful improvements in symptom control and quality of life in selected patients with metastatic disease and refractory cancer-related pain.