patients on these medications endure exacerbating side effects and complications. Additionally, due to opioid tolerance, or reduced responsiveness, 10-fold increases in opioid doses are common in chronic pain management (2). This rapid increase in dosages is problematic due to the narrow therapeutic range of opioids and their high-risk side effects, such as nausea/vomiting, constipation, sedation, drowsiness, and neurological effects such as neuroexcitation, myoclonus, and urinary retention (3,4). The need for non-opioid treatment options for patients undergoing acute, chronic and obstinate pain is of great importance; one alternative is low-dose ketamine (LDK) infusion.

Background: Bony metastases are often seen in advanced cancers and lead to deterioration in patient quality of life with common complications of pain, bone fractures, and hypercalcemia. While most sites of metastasis to bone are observed in the axial skeleton from patients with a primary lung, breast or prostate cancer, metastases to the calvarium from lung cancer are less common, and thus less likely to be identified and managed.Case Description: A 69-year-old Caucasian female with advanced non-small cell lung cancer (NSCLC) presented with worsening symptoms of widespread body pain, fatigue, and weight loss. Physical examination was remarkable for a palpable protrusion on the patient's head. Imaging revealed a parieto-occipital calvarial lesion, a likely metastasis from her lung cancer. A previously performed CT-guided lung biopsy was evaluated for actionable tumor markers to allow for more specific and efficacious line of treatments; the patient's tumor had lacked any notable gene mutations. The treatment plan included radiotherapy, combined immunotherapy and chemotherapy consisting of pembrolizumab, pemetrexed, and carboplatin. Despite the treatment, the patient's skull lesion had continued to grow, and her overall condition deteriorated to the point where she required hospice.Conclusions: Given the unique location of calvarial metastases, early detection appears to correlate with improving patient outcomes and quality of life. A multimodal approach with a high index of suspicion is essential for diagnosing and managing rare presentations of metastatic disease.