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Kundra A, Strand DS, Shami VM. Endoscopic Management of Pain due to Chronic Pancreatitis. Gastrointest Endosc Clin N Am 2024; 34:433-448. [PMID: 38796291 DOI: 10.1016/j.giec.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Pain secondary to chronic pancreatitis is a poorly understood and complex phenomenon. Current endoscopic treatments target pancreatic duct decompression secondary to strictures, stones, or inflammatory and neoplastic masses. When there is refractory pain and other treatments have been unsuccessful, one can consider an endoscopic ultrasound-guided celiac plexus block. Data on the latter are underwhelming.
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Affiliation(s)
- Arjun Kundra
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Daniel S Strand
- Department of Gastroenterology, University of Virginia, Charlottesville, VA, USA
| | - Vanessa M Shami
- Department of Medicine, University of Virginia, Charlottesville, VA, USA.
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Nagar SD, Nagar SJ, Jordan V, Dawson J. Sympathetic nerve blocks for persistent pain in adults with inoperable abdominopelvic cancer. Cochrane Database Syst Rev 2024; 6:CD015229. [PMID: 38842054 PMCID: PMC11154857 DOI: 10.1002/14651858.cd015229.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND Persistent visceral pain is an unpleasant sensation coming from one or more organs within the body. Visceral pain is a common symptom in those with advanced cancer. Interventional procedures, such as neurolytic sympathetic nerve blocks, have been suggested as additional treatments that may play a part in optimising pain management for individuals with this condition. OBJECTIVES To evaluate the benefits and harms of neurolytic sympathetic nerve blocks for persistent visceral pain in adults with inoperable abdominopelvic cancer compared to standard care or placebo and comparing single blocks to combination blocks. SEARCH METHODS We searched the following databases without language restrictions on 19 October 2022 and ran a top-up search on 31 October 2023: CENTRAL; MEDLINE via Ovid; Embase via Ovid; LILACS. We searched trial registers without language restrictions on 2 November 2022: ClinicalTrials.gov; WHO International Clinical Trials Registry Platform (ICTRP). We searched grey literature, checked reference lists of reviews and retrieved articles for additional studies, and performed citation searches on key articles. We also contacted experts in the field for unpublished and ongoing trials. Our trial protocol was preregistered in the Cochrane Database of Systematic Reviews on 21 October 2022. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) comparing any sympathetic nerve block targeting sites commonly used to treat abdominal pelvic pain from inoperable malignancies in adults to standard care or placebo. DATA COLLECTION AND ANALYSIS We independently selected trials based on predefined inclusion criteria, resolving any differences via adjudication with a third review author. We used a random-effects model as some heterogeneity was expected between the studies due to differences in the interventions being assessed and malignancy types included in the study population. We chose three primary outcomes and four secondary outcomes of interest. We sought consumer input to refine our review outcomes and assessed extracted data using Cochrane's risk of bias 2 tool (RoB 2). We assessed the certainty of evidence using the GRADE system. MAIN RESULTS We included 17 studies with 1025 participants in this review. Fifteen studies with a total of 951 participants contributed to the quantitative analysis. Single block versus standard care Primary outcomes No included studies reported our primary outcome, 'Proportion of participants reporting no worse than mild pain after treatment at 14 days'. The evidence is very uncertain about the effect of sympathetic nerve blocks on reducing pain to no worse than mild pain at 14 days when compared to standard care due to insufficient data (very low-certainty evidence). Sympathetic nerve blocks may provide small to 'little to no' improvement in quality of life (QOL) scores at 14 days after treatment when compared to standard care, but the evidence is very uncertain (standardised mean difference (SMD) -0.73, 95% confidence interval (CI) -1.70 to 0.25; I² = 87%; 4 studies, 150 participants; very low-certainty evidence). The evidence is very uncertain about the risk of serious adverse events as defined in our review as only one study contributed data to this outcome. Sympathetic nerve blocks may have an 'increased risk' to 'no additional risk' of harm compared with standard care (very low-certainty evidence). Secondary outcomes Sympathetic nerve blocks showed a small to 'little to no' effect on participant-reported pain scores at 14 days using a 0 to 10 visual analogue scale (VAS) for pain compared with standard care, but the evidence is very uncertain (mean difference (MD) -0.44, 95% CI -0.98 to 0.11; I² = 56%; 5 studies, 214 participants; very low-certainty evidence). There may be a 'moderate to large' to 'little to no' reduction in daily consumption of opioids postprocedure at 14 days with sympathetic nerve blocks compared with standard care, but the evidence is very uncertain (change in daily consumption of opioids at 14 days as oral milligrams morphine equivalent (MME): MD -41.63 mg, 95% CI -78.54 mg to -4.72 mg; I² = 90%; 4 studies, 130 participants; very low-certainty evidence). The evidence is very uncertain about the effect of sympathetic nerve blocks on participant satisfaction with procedure at 0 to 7 days and time to need for retreatment or treatment effect failure (or both) due to insufficient data. Combination block versus single block Primary outcomes There is no evidence about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks on the proportion of participants reporting no worse than mild pain after treatment at 14 days because no studies reported this outcome. There may be a small to 'little to no' effect on QOL score at 14 days after treatment, but the evidence is very uncertain (very low-certainty evidence). The evidence is very uncertain about the risk of serious adverse events with combination sympathetic nerve blocks compared with single sympathetic nerve blocks due to limited reporting in the included studies (very low-certainty evidence). Secondary outcomes The evidence is very uncertain about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks on participant-reported pain score and change in daily consumption of opioids postprocedure, at 14 days. There may be a small to 'little to no' effect, but the evidence is very uncertain (very low-certainty evidence). There is no evidence about the effect on participant satisfaction with procedure at 0 to 7 days and time to need for retreatment or treatment effect failure (or both) due to these outcomes not being measured by the studies. Risk of bias The risk of bias was predominately high for most outcomes in most studies due to significant concerns regarding adequate blinding. Very few studies were deemed as low risk across all domains for any outcome. AUTHORS' CONCLUSIONS There is limited evidence to support or refute the use of sympathetic nerve blocks for persistent abdominopelvic pain due to inoperable malignancy. We are very uncertain about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks. The certainty of the evidence is very low and these findings should be interpreted with caution.
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Affiliation(s)
- Sachin D Nagar
- Department of Hospital Palliative Care, North Shore Hospital, Te Whatu Ora - Waitemata, Auckland, New Zealand
| | - Sarah J Nagar
- Neurogenetics, Center for Brain Research, University of Auckland, Auckland, New Zealand
| | - Vanessa Jordan
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Jennifer Dawson
- Department of Hospital Palliative Care, Middlemore Hospital, Te Whatu Ora - Counties Manukau, Auckland, New Zealand
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Haraga I, Kosugi T, Sadashima E, Yumiba T, Kubo M, Ishikawa-Konishi A, Akiyoshi K. Effects of palliative intrathecal analgesia on patients with refractory cancer bone pain. J Anesth 2024; 38:405-411. [PMID: 38565691 DOI: 10.1007/s00540-024-03338-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 03/07/2024] [Indexed: 04/04/2024]
Abstract
This study examined the effects of intrathecal analgesia (ITA) using an extracorporeal pump with a subcutaneous port system in cancer patients with bone metastasis. Among the patients who died of cancer with bone metastasis at the palliative care unit of our institution, 11 who received ITA were selected. Changes in pain, opioid doses, the palliative prognostic index (PPI), and Eastern Cooperative Oncology Group Performance Scale after ITA were assessed. Pain, opioid doses, and PPI decreased after ITA (P = 0.002, 0.002, and 0.017). ITA for cancer patients with increased PPI due to refractory cancer bone pain decreased pain, opioid doses, and PPI.(100 words).
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Affiliation(s)
- Isao Haraga
- Department of Anesthesiology, Faculty of Medicine, Fukuoka University, 7-45-1, Nanakuma, Jonan-ku, Fukuoka-shi, Fukuoka, 814-0180, Japan.
- Department of Anesthesiology, Kitakyushu Municipal Medical Center, 2-1-1, Bashaku, Kokurakita-ku, Kitakyushu-shi, Fukuoka, 802-8561, Japan.
| | - Toshifumi Kosugi
- Department of Palliative Care, Saga-Ken Medical Center Koseikan, 400, Nakabaru, Kasemachi, Saga-shi, Saga, 840-8571, Japan
| | - Eiji Sadashima
- Medical Research Institute, Saga-Ken Medical Center Koseikan, 400Nakabaru, Kasemachi,, Saga-shi, Saga, 840-8571, Japan
| | - Tomoko Yumiba
- Department of Palliative Care, Saga-Ken Medical Center Koseikan, 400, Nakabaru, Kasemachi, Saga-shi, Saga, 840-8571, Japan
| | - Mayuko Kubo
- Department of Palliative Care, Saga-Ken Medical Center Koseikan, 400, Nakabaru, Kasemachi, Saga-shi, Saga, 840-8571, Japan
| | - Asako Ishikawa-Konishi
- Department of Palliative Care, Saga-Ken Medical Center Koseikan, 400, Nakabaru, Kasemachi, Saga-shi, Saga, 840-8571, Japan
- Tachikawa Home Care Clinic, 5-71-16, Saiwai-cho, Tachikawa-shi, Tokyo, 190-0002, Japan
| | - Kozaburo Akiyoshi
- Department of Anesthesiology, Faculty of Medicine, Fukuoka University, 7-45-1, Nanakuma, Jonan-ku, Fukuoka-shi, Fukuoka, 814-0180, Japan
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Rizzo GEM, Carrozza L, Rancatore G, Binda C, Fabbri C, Anderloni A, Tarantino I. The Role of Endoscopy in the Palliation of Pancreatico-Biliary Cancers: Biliary Drainage, Management of Gastrointestinal Obstruction, and Role in Relief of Oncologic Pain. Cancers (Basel) 2023; 15:5367. [PMID: 38001627 PMCID: PMC10670525 DOI: 10.3390/cancers15225367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/20/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Therapeutic endoscopy permits many and various treatments for cancer palliation in patients with bilio-pancreatic cancers, enabling different options, supporting patients during their route to oncologic treatments, and trying to improve their quality of life. Therefore, both endoscopic and endoscopic ultrasound (EUS)-guided techniques are performed in this scenario. We performed a literature review focusing on the role of endoscopy in the palliation of those advanced pancreatic and biliary cancers developing malignant biliary obstruction (MBO), gastric outlet obstruction (GOO), and pain unresponsive to medical therapies. Therefore, we explored and focused on the clinical outcomes of endoscopic procedures in this scenario. In fact, the endoscopic treatment is based on achieving biliary drainage in the case of MBO through endoscopic retrograde cholangiopancreatography (ERCP) or EUS-guided biliary drainage (EUS-BD), while GOO is endoscopically treated through the deployment of an enteral stent or the creation of EUS-guided gastro-entero-anastomosis (EUS-GEA). Furthermore, untreatable chronic abdominal pain is a major issue in patients unresponsive to high doses of painkillers, so EUS-guided celiac plexus neurolysis (CPN) or celiac ganglia neurolysis (CGN) helps to reduce dosage and have better pain control. Therefore, therapeutic endoscopy in the palliative setting is an effective and safe approach for managing most of the clinical manifestations of advanced biliopancreatic tumors.
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Affiliation(s)
- Giacomo Emanuele Maria Rizzo
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
- Ph.D. Program, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, 90133 Palermo, Italy
| | - Lucio Carrozza
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
| | - Gabriele Rancatore
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 48100 Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 48100 Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy;
| | - Ilaria Tarantino
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
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Okita M, Otani K, Matsui S. Efficacy of Endoscopic Ultrasound-guided Celiac Plexus Neurolysis for Abdominal Pain in Patients With Unresectable Pancreatic Cancer: Network Meta-analysis of Randomized Controlled Trials. J Clin Gastroenterol 2023; 57:1054-1062. [PMID: 36227001 DOI: 10.1097/mcg.0000000000001773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 05/10/2022] [Indexed: 12/10/2022]
Abstract
GOALS We conducted a systematic review and network meta-analysis to investigate the effect of endoscopic ultrasound-guided celiac plexus neurolysis added to medical management (EUS-CPN+MM) compared with MM, percutaneous CPN (P-CPN)+MM, or intraoperative CPN (I-CPN)+MM for abdominal pain associated with unresectable pancreatic cancer. BACKGROUND Many approaches to CPN have been proposed since 1919. EUS-CPN, which is less invasive and safer than traditional procedures, has been preferred recently, but the superiority of EUS-CPN+MM has not been fully investigated. STUDY We performed searches of PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) on March 16, 2021. We conducted the network meta-analysis using a frequentist weighted least-squares approach. We used a random-effects model to synthesize the primary outcome, defined as the mean difference between treatment groups in standardized pain intensity scores at 4 and 12 weeks. RESULTS We selected 10 RCTs involving 662 individuals. At 4 weeks, the estimated mean difference between the EUS-CPN+MM and MM groups was -1.30 (95% CI: -2.19 to -0.41) in favor of EUS-CPN+MM, and that between the EUS-CPN+MM and P-CPN+MM groups was -0.88 (95% CI: -1.82 to 0.06). At 12 weeks, the estimated mean difference between the EUS-CPN+MM and MM groups was -2.58 (95% CI: -3.68 to -1.48), and that between the EUS-CPN+MM and P-CPN+MM groups was -2.44 (95% CI: -4.03 to -0.84), both in favor of EUS-CPN+MM. CONCLUSIONS The combination of EUS-CPN+MM was effective at 4 and 12 weeks, although the risk of bias in synthesized studies was generally high, necessitating careful interpretation.
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Affiliation(s)
- Muneyori Okita
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Japan
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Capodanno Y, Hirth M. Targeting the Cancer-Neuronal Crosstalk in the Pancreatic Cancer Microenvironment. Int J Mol Sci 2023; 24:14989. [PMID: 37834436 PMCID: PMC10573820 DOI: 10.3390/ijms241914989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) represents one of the most aggressive solid tumors with a dismal prognosis and an increasing incidence. At the time of diagnosis, more than 85% of patients are in an unresectable stage. For these patients, chemotherapy can prolong survival by only a few months. Unfortunately, in recent decades, no groundbreaking therapies have emerged for PDAC, thus raising the question of how to identify novel therapeutic druggable targets to improve prognosis. Recently, the tumor microenvironment and especially its neural component has gained increasing interest in the pancreatic cancer field. A histological hallmark of PDAC is perineural invasion (PNI), whereby cancer cells invade surrounding nerves, providing an alternative route for metastatic spread. The extent of PNI has been positively correlated with early tumor recurrence and reduced overall survival. Multiple studies have shown that mechanisms involved in PNI are also involved in tumor spread and pain generation. Targeting these pathways has shown promising results in alleviating pain and reducing PNI in preclinical models. In this review, we will describe the mechanisms and future treatment strategies to target this mutually trophic interaction between cancer cells to open novel avenues for the treatment of patients diagnosed with PDAC.
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Affiliation(s)
- Ylenia Capodanno
- Institute of Pharmacology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 366, 69117 Heidelberg, Germany
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1–3, 68167 Mannheim, Germany
| | - Michael Hirth
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1–3, 68167 Mannheim, Germany
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Sekiguchi S, Ishida Y, Tomino M, Ohseto K. Two Cases of Splanchnic Nerve Block With Epidural Anesthesia in Patients Unable to Maintain Prone Position Due to Pancreatic Pain. Palliat Med Rep 2023; 4:274-277. [PMID: 37786485 PMCID: PMC10541929 DOI: 10.1089/pmr.2023.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 10/04/2023] Open
Abstract
Splanchnic nerve block is considered to be effective for abdominal visceral pain, and is performed for the purpose of controlling abdominal pain and back pain caused by upper abdominal cancer. The patients in this case report were candidates for splanchnic nerve block owing to cancer-associated pain. However, because they could not assume the prone position that is required for the block owing to their pain, combined epidural anesthesia was used, resulting in successful implementation of the splanchnic nerve block. Patients who are candidates for splanchnic nerve block often have advanced cancer, and it is hence often difficult to secure and maintain the position required for the procedure owing to their severe pain. The two patients presented here suggest the possibility that epidural anesthesia might be useful as an adjunct in such cases.
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Affiliation(s)
- Shunya Sekiguchi
- Department of Anesthesiology, Tokyo Medical University Hospital, Shinjuku-ku, Tokyo, Japan
| | - Yusuke Ishida
- Department of Anesthesiology, Tokyo Medical University Hospital, Shinjuku-ku, Tokyo, Japan
| | - Mikiko Tomino
- Department of Anesthesiology, Tokyo Medical University Hospital, Shinjuku-ku, Tokyo, Japan
| | - Kiyoshige Ohseto
- Department of Anesthesiology, Tokyo Medical University Hospital, Shinjuku-ku, Tokyo, Japan
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Mitsou JD, Tseveleki V, Dimitrakopoulos FI, Konstantinidis K, Kalofonos H. Radical Tumor Denervation Activates Potent Local and Global Cancer Treatment. Cancers (Basel) 2023; 15:3758. [PMID: 37568574 PMCID: PMC10417359 DOI: 10.3390/cancers15153758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/13/2023] Open
Abstract
This preliminary study seeks to determine the effect of R&P denervation on tumor growth and survival in immunocompetent rats bearing an aggressive and metastatic breast solid tumor. A novel microsurgical approach was applied "in situ", aiming to induce R&P denervation through the division of every single nerve fiber connecting the host with the primary tumor via its complete detachment and re-attachment, by resecting and reconnecting its supplying artery and vein (anastomosis). This preparation, known as microsurgical graft or flap, is radically denervated by definition, but also effectively delays or even impedes the return of innervation for a significant period of time, thus creating a critical and therapeutic time window. Mammary adenocarcinoma cells (HH-16.cl4) were injected into immunocompetent Sprague Dawley adult rats. When the tumors reached a certain volume, the subjects entered the study. The primary tumor, including a substantial amount of peritumoral tissue, was surgically isolated on a dominant artery and vein, which was resected and reconnected using a surgical microscope (orthotopic tumor auto-transplantation). Intending to simulate metastasis, two or three tumors were simultaneously implanted and only one was treated, using the surgical technique described herein. Primary tumor regression was observed in all of the microsurgically treated subjects, associated with a potent systemic anticancer effect and prolonged survival. In stark contrast, the subjects received a close to identical surgical operation; however, with the intact neurovascular connection, they did not achieve the therapeutic result. Animals bearing multiple tumors and receiving the same treatment in only one tumor exhibited regression in both the "primary" and remote- untreated tumors at a clinically significant percentage, with regression occurring in more than half of the treated subjects. A novel therapeutic approach is presented, which induces the permanent regression of primary and, notably, remote tumors, as well as, evidently, the naturally occurring metastatic lesions, at a high rate. This strategy is aligned with the impetus that comes from the current translational research data, focusing on the abrogation of the neuro-tumoral interaction as an alternative treatment strategy. More data regarding the clinical significance of this are expected to come up from a pilot clinical trial that is ongoing.
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Affiliation(s)
- John D. Mitsou
- Department of Plastic and Reconstructive Surgery, Athens Medical Center, 15125 Maroussi, Greece
| | - Vivian Tseveleki
- Laboratory of Molecular Genetics, Hellenic Pasteur Institute, 11521 Athens, Greece;
| | - Foteinos-Ioannis Dimitrakopoulos
- Molecular Oncology Laboratory, Division of Oncology, Medical School, University of Patras, 26504 Rio, Greece;
- Division of Oncology, Department of Medicine, University Hospital of Patras, 26504 Rio, Greece;
| | - Konstantinos Konstantinidis
- Department of General Robotic, Laparoscopic and Oncologic Surgery, Athens Medical Center, 15125 Maroussi, Greece;
| | - Haralabos Kalofonos
- Division of Oncology, Department of Medicine, University Hospital of Patras, 26504 Rio, Greece;
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Chauvet S, Hubert F, Mann F, Mezache M. Tumorigenesis and axons regulation for the pancreatic cancer: A mathematical approach. J Theor Biol 2023; 556:111301. [PMID: 36270328 DOI: 10.1016/j.jtbi.2022.111301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/23/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
The nervous system is today recognized to play an important role in the development of cancer. Indeed, neurons extend long processes (axons) that grow and infiltrate tumors in order to regulate the progression of the disease in a positive or negative way, depending on the type of neuron considered. Mathematical modeling of this biological process allows to formalize the nerve-tumor interactions and to test hypotheses in silico to better understand this phenomenon. In this work, we introduce a system of differential equations modeling the progression of pancreatic ductal adenocarcinoma (PDAC) coupled with associated changes in axonal innervation. The study of the asymptotic behavior of the model confirms the experimental observations that PDAC development is correlated with the type and densities of axons in the tissue. We study then the identifiability and the sensitivity of the model parameters. The identifiability analysis informs on the adequacy between the parameters of the model and the experimental data and the sensitivity analysis on the most contributing factors on the development of cancer. It leads to significant insights on the main neural checkpoints and mechanisms controlling the progression of pancreatic cancer. Finally, we give an example of a simulation of the effects of partial or complete denervation that sheds lights on complex correlation between the healthy, pre-cancerous and cancerous cell densities and axons with opposite functions.
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Affiliation(s)
- Sophie Chauvet
- Aix Marseille Univ, CNRS, IBDM (UMR 7288), Turing Centre for Living systems, Marseille, France
| | - Florence Hubert
- Aix Marseille Univ, CNRS, Centrale Marseille, I2M (UMR 7373), Turing Centre for Living systems, Marseille, France
| | - Fanny Mann
- Aix Marseille Univ, CNRS, IBDM (UMR 7288), Turing Centre for Living systems, Marseille, France
| | - Mathieu Mezache
- Aix Marseille Univ, CNRS, Centrale Marseille, I2M (UMR 7373), Turing Centre for Living systems, Marseille, France; Université Paris-Saclay, INRAE, MaIAGE (UR 1404), 78350 Jouy-en-Josas, France.
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Strand DS, Law RJ, Yang D, Elmunzer BJ. AGA Clinical Practice Update on the Endoscopic Approach to Recurrent Acute and Chronic Pancreatitis: Expert Review. Gastroenterology 2022; 163:1107-1114. [PMID: 36008176 DOI: 10.1053/j.gastro.2022.07.079] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/08/2022] [Accepted: 07/01/2022] [Indexed: 02/07/2023]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review is to provide practical, evidence-based guidance to clinicians regarding the role of endoscopy for recurrent acute and chronic pancreatitis. METHODS This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide guidance on a topic of clinical importance to the AGA membership, underwent internal peer review by the Clinical Practice Updates Committee (CPUC), and external peer review through standard procedures of Gastroenterology. This review is framed around the 8 best practice advice points agreed upon by the authors, based on the results of randomized controlled trials, observational studies, systematic reviews and meta-analyses, as well expert consensus in this field. Best Practice Advice Statements BEST PRACTICE ADVICE 1: After an unrevealing initial evaluation, endoscopic ultrasound is the preferred diagnostic test for unexplained acute and recurrent pancreatitis. Magnetic resonance imaging with contrast and cholangiopancreatography is a reasonable complementary or alternative test to endoscopic ultrasound, based on local expertise and availability. BEST PRACTICE ADVICE 2: The role of endoscopic retrograde cholangiopancreatography (ERCP) for reducing the frequency of acute pancreatitis episodes in patients with pancreas divisum is controversial, but minor papilla endotherapy may be considered, particularly for those with objective signs of outflow obstruction, such as a dilated dorsal pancreatic duct and/or santorinicele. There is no role for ERCP to treat pain alone in patients with pancreas divisum. BEST PRACTICE ADVICE 3: The role of ERCP for reducing the frequency of pancreatitis episodes in patients with unexplained recurrent acute pancreatitis and standard pancreatic ductal anatomy is controversial and should only be considered after a comprehensive discussion of the uncertain benefits and potentially severe procedure-related adverse events. When pursued, ERCP with biliary sphincterotomy alone may be preferable to dual sphincterotomy. BEST PRACTICE ADVICE 4: Surgical intervention should be considered over endoscopic therapy for long-term treatment of patients with painful obstructive chronic pancreatitis. Endoscopic intervention is a reasonable alternative to surgery for suboptimal operative candidates or those who favor a less invasive approach, assuming they are clearly informed that the best practice advice primarily favors surgery. BEST PRACTICE ADVICE 5: When ERCP is pursued, small (≤5mm) main pancreatic duct stones can be treated with pancreatography and conventional stone extraction maneuvers. For larger stones, extracorporeal shockwave lithotripsy and/or pancreatoscopy with intraductal lithotripsy may be required. BEST PRACTICE ADVICE 6: When ERCP is pursued, prolonged stent therapy (6-12 months) is effective for treating symptoms and remodeling main pancreatic duct strictures. The preferred approach is to place and sequentially add multiple plastic stents in parallel (upsizing); emerging evidence suggests that fully covered self-expanding metal stents may have a role for this indication, but additional research is necessary. BEST PRACTICE ADVICE 7: ERCP with stent insertion is the preferred treatment for benign biliary stricture due to chronic pancreatitis. FCSEMS placement is favored over multiple plastic stents whenever feasible, given similar efficacy but significantly reduced need for stent exchange procedures during the treatment course. BEST PRACTICE ADVICE 8: Celiac plexus block should not be routinely performed for the management of pain due to chronic pancreatitis. The decision to proceed with celiac plexus block in selected patients with debilitating pain in whom other therapeutic measures have failed can be considered on a case-by-case basis, but only after discussion of the unclear outcomes of this intervention and its procedural risks.
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Affiliation(s)
- Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Ryan J Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida.
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
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11
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Mercadante S. Commentary: Interpreting Data of Celiac Plexus Block in Patients with Pancreatic Pain: Timing, Patients, Survival. Pain Ther 2022; 11:747-751. [PMID: 35622239 PMCID: PMC9314495 DOI: 10.1007/s40122-022-00396-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/06/2022] [Indexed: 01/11/2023] Open
Abstract
Although celiac plexus block (CPB) is a well known technique that has been performed for years, only in the last 30 years controlled studies, demonstrated its efficacy and safety. A historical pathway of literature regarding CPB and a critical analysis may help understand some points which remain still controversial, for a better interpretation of data.
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Affiliation(s)
- Sebastiano Mercadante
- Chair of Anesthetics & Main Regional Center for Pain Relief & Palliative/Supportive Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146 Palermo, Italy ,Regional Home Palliative Care Program, SAMOT Palermo, Palermo, Italy
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12
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Okita M, Otani K, Gibo N, Matsui S. Systematic review and meta-analysis of celiac plexus neurolysis for abdominal pain associated with unresectable pancreatic cancer. Pain Pract 2022; 22:652-661. [PMID: 35748531 DOI: 10.1111/papr.13143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/08/2022] [Accepted: 05/09/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Celiac plexus neurolysis (CPN) has been developed as adjunctive therapy to medical management (MM) of abdominal pain associated with unresectable pancreatic cancer. We aimed to conduct a systematic review and meta-analysis to obtain updated and more accurate evidence on the efficacy of additional types of CPN, including endoscopic ultrasound-guided CPN (EUS-CPN). METHODS On March 16, 2021, we performed searches of PubMed, Web of Science, and CENTRAL for original randomized controlled trials (RCTs). We defined the primary outcome as a standardized pain intensity score with a range of 0-10, and evaluated the mean difference between the CPN + MM and MM groups at 4, 8, and 12 weeks after the initiation of treatment. We used a random-effects model to synthesize the mean differences across RCTs. RESULTS We selected 10 RCTs involving 646 individuals. The synthesized mean difference in the pain intensity score between the CPN + MM and MM groups was -0.58 (95% confidence interval [CI]: -1.09 to -0.07) (p = 0.034) in favor of CPN + MM at 4 weeks, -0.46 (95%CI: -1.00 to 0.08) (p = 0.081) at 8 weeks, and - 1.35 (95%CI: -3.61 to 0.92) (p = 0.17) at 12 weeks. CONCLUSIONS This updated meta-analysis of CPN demonstrates its efficacy for managing abdominal pain at 4 weeks. Although there are various limitations, when abdominal pain in patients with unresectable pancreatic cancer is poorly controlled with MM alone, CPN should be an option even if the duration of effect is short-lived, taking into account the absence of serious adverse events.
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Affiliation(s)
- Muneyori Okita
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuki Otani
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Noriaki Gibo
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shigeyuki Matsui
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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13
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Sympathetic Blocks for Visceral Pain. Phys Med Rehabil Clin N Am 2022; 33:475-487. [DOI: 10.1016/j.pmr.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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14
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Li X, Peng X, Yang S, Wei S, Fan Q, Liu J, Yang L, Li H. Targeting tumor innervation: premises, promises, and challenges. Cell Death Dis 2022; 8:131. [PMID: 35338118 PMCID: PMC8956600 DOI: 10.1038/s41420-022-00930-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/17/2021] [Accepted: 02/28/2022] [Indexed: 01/03/2023]
Abstract
A high intratumoral nerve density is correlated with poor survival, high metastasis, and high recurrence across multiple solid tumor types. Recent research has revealed that cancer cells release diverse neurotrophic factors and exosomes to promote tumor innervation, in addition, infiltrating nerves can also mediate multiple tumor biological processes via exosomes and neurotransmitters. In this review, through seminal studies establishing tumor innervation, we discuss the communication between peripheral nerves and tumor cells in the tumor microenvironment (TME), and revealed the nerve-tumor regulation mechanisms on oncogenic process, angiogenesis, lymphangiogenesis, and immunity. Finally, we discussed the promising directions of ‘old drugs newly used’ to target TME communication and clarified a new line to prevent tumor malignant capacity.
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Affiliation(s)
- Xinyu Li
- Department of General Surgery, The Fourth Affiliated Hospital, China Medical University, Shenyang, 110032, China
| | - Xueqiang Peng
- Department of General Surgery, The Fourth Affiliated Hospital, China Medical University, Shenyang, 110032, China
| | - Shuo Yang
- Department of General Surgery, The Fourth Affiliated Hospital, China Medical University, Shenyang, 110032, China
| | - Shibo Wei
- Department of General Surgery, The Fourth Affiliated Hospital, China Medical University, Shenyang, 110032, China
| | - Qing Fan
- Department of General Surgery, The Fourth Affiliated Hospital, China Medical University, Shenyang, 110032, China
| | - Jingang Liu
- Department of General Surgery, The Fourth Affiliated Hospital, China Medical University, Shenyang, 110032, China
| | - Liang Yang
- Department of General Surgery, The Fourth Affiliated Hospital, China Medical University, Shenyang, 110032, China.
| | - Hangyu Li
- Department of General Surgery, The Fourth Affiliated Hospital, China Medical University, Shenyang, 110032, China.
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15
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Jiang SH, Zhang S, Wang H, Xue JL, Zhang ZG. Emerging experimental models for assessing perineural invasion in human cancers. Cancer Lett 2022; 535:215610. [PMID: 35283209 DOI: 10.1016/j.canlet.2022.215610] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/23/2022] [Accepted: 02/26/2022] [Indexed: 12/13/2022]
Abstract
Cancer neuroscience has emerged as a burgeoning field for the investigation of cancer-nervous system interactions. Perineural invasion (PNI) is defined as the presence of cancer cells that surround and/or invade the nerves infiltrating the tumor microenvironment. PNI is closely associated with increased tumor recurrence and diminished survival in many cancer types. Based on diverse in vitro, ex vivo, and in vivo models, mounting evidence suggests that the reciprocal crosstalk between nerves and cancer cells drives PNI, which is mediated by several factors including secreted neurotrophins, chemokines, exosomes, and inflammatory cells. Typical in vitro models using dorsal root ganglia (DRG) cells cocultured with cancer cells or other cell types allow the study of isolated factors. Ex vivo PNI models created by cocultivating cancer cells with explanted vagus and sciatic nerves enable the study of neuroaffinity in a time-saving and cost-efficient manner. In vivo models such as genetically engineered mouse models (GEMMs) and the chicken embryo chorioallantoic membrane (CAM)-DRG model, provide the nerve microenvironment needed to recapitulate the complex pathophysiological processes of PNI. Here, we summarize the current methods commonly used for modeling PNI and discuss the inherent pros and cons of these approaches for understanding PNI biology.
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Affiliation(s)
- Shu-Heng Jiang
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200240, PR China.
| | - Shan Zhang
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200240, PR China
| | - Hao Wang
- Department of Oncology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200123, PR China
| | - Jun-Li Xue
- Department of Oncology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200123, PR China.
| | - Zhi-Gang Zhang
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200240, PR China.
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16
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Zylberberg HM, Nagula S, Rustgi SD, Aronson A, Kessel E, Kumta NA, DiMaio CJ, Lucas AL. Celiac Plexus Neurolysis Is Associated With Decreased Survival in Patients With Pancreatic Cancer: A Propensity Score Analysis. Pancreas 2022; 51:153-158. [PMID: 35404890 DOI: 10.1097/mpa.0000000000001992] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The aim of this study was to investigate survival in patients who received celiac plexus neurolysis (CPN) compared with patients who received opioids. METHODS The Surveillance, Epidemiology and End Results-Medicare database was used to identify patients older than 65 years diagnosed with pancreatic cancer between 2007 and 2015. We used claims data to identify patients with a history of CPN and opioid use within 1 year of diagnosis, and other demographic, clinical, and treatment variables. Kaplan-Meier analyses and inverse propensity-weighted adjusted Cox proportional hazard ratios were used to evaluate survival. RESULTS We identified 648 patients who underwent CPN (19.0%) compared with 2769 patients who received opioids (81.0%). The median survival and interquartile range for patients who received CPN was 4.0 months (2.0-8.0 months) compared with 7.0 months (3.0-12.0 months) for opioid users (P < 0.0001). After adjusting for confounders and propensity score, the patients who received CPN showed worsened survival (hazard ratio, 1.69; 95% confidence interval, 1.59-1.79). CONCLUSIONS Pancreatic cancer patients who underwent CPN had decreased survival compared with opioid users. This suggests that opioid sparing methods to reduce pancreatic cancer pain may actually be harmful. Future prospective studies should investigate whether other opioid sparing therapies impact pancreatic cancer survival.
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Affiliation(s)
| | - Satish Nagula
- Gastroenterology, Icahn School of Medicine at Mount Sinai
| | - Sheila D Rustgi
- Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, NY
| | - Anne Aronson
- Gastroenterology, Icahn School of Medicine at Mount Sinai
| | | | - Nikhil A Kumta
- Gastroenterology, Icahn School of Medicine at Mount Sinai
| | | | - Aimee L Lucas
- Gastroenterology, Icahn School of Medicine at Mount Sinai
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17
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Corn BW, Feldman DB, Hull JG, O'Rourke MA, Bakitas MA. Dispositional hope as a potential outcome parameter among patients with advanced malignancy: An analysis of the ENABLE database. Cancer 2022; 128:401-409. [PMID: 34613617 PMCID: PMC10008020 DOI: 10.1002/cncr.33907] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/25/2021] [Accepted: 08/16/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hopefulness, whether inherently present (dispositional hope) or augmented (by enhancement techniques), may affect outcomes. This study was performed to determine the association of dispositional hope with survival among patients diagnosed with advanced cancer. METHODS Data from ENABLE (Educate, Nurture, Advise, Before Life Ends), a palliative care intervention, were reanalyzed to determine the association of higher dispositional hope and patient survival. This was a secondary analysis of data combined from the ENABLE II and ENABLE III randomized controlled trials (RCTs) with respect to dispositional hope and survival. A dispositional hope index was created from 3 hope items from 2 validated baseline questionnaires. Dispositional hope and survival data were collected during the 2 RCTs. In ENABLE II, participants were randomly assigned to the ENABLE intervention or to usual care. In ENABLE III, participants were randomly assigned to receive the intervention immediately or 12 weeks after enrollment. RESULTS In all, 529 persons were included in Cox proportional hazards regression analyses to model the effects of dispositional hope on survival. An initial analysis without covariates yielded a significant effect of hope (Wald statistic, 8.649; hazard ratio, 0.941; confidence interval, 0.904-0.980; P = .003), such that higher dispositional hope was associated with longer survival. In a subsequent analysis that included all covariates, the effect of dispositional hope approached statistical significance (Wald statistic, 2.96; hazard ratio, 0.933; confidence interval, 0.863-1.010; P = .085). CONCLUSIONS Higher levels of dispositional hope were associated with longer survival in patients with advanced cancer. Prospective trials are needed to determine the effects of dispositional and augmented hope on the outcomes of patients with advanced cancer.
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Affiliation(s)
- Benjamin W Corn
- Department of Oncology, Shaare Zedek Cancer Center, Jerusalem, Israel
| | - David B Feldman
- Department of Counseling Psychology, Santa Clara University, Santa Clara, California
| | - Jay G Hull
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, New Hampshire
| | - Mark A O'Rourke
- Prisma Health Upstate Cancer Institute, Greenville, South Carolina
| | - Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama.,Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama
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18
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Hickman K, Godfrey E, Ajithkumar T. Endoscopic ultrasound-guided neurolysis in advanced pancreatic cancer: current status. BMJ Support Palliat Care 2021; 12:22-28. [PMID: 34635545 DOI: 10.1136/bmjspcare-2021-002905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 07/11/2021] [Indexed: 11/04/2022]
Abstract
Pancreatic cancer has a very poor prognosis with patients often presenting with locally advanced, inoperable or metastatic disease. A significant proportion of patients have visceral pain due to perineural infiltration or coeliac plexus involvement by the tumour. This pain is difficult to control and may become refractory to conventional pain management. Therefore, coeliac plexus neurolysis (CPN) has been proposed to ablate the neuronal transmission pathway of pain permanently. CPN is recommended for those who have uncontrolled pain, are experiencing unacceptable opioid adverse effects or are receiving escalating doses of analgesics. It is not known whether CPN performed at diagnosis as the first-line treatment ('early') would impact short-term and long-term pain control and quality of life. NICE has recommended (2018) a randomised trial comparing early endoscopic ultrasound-guided coeliac plexus neurolysis (EUS-CPN) with on-demand EUS-CPN in pancreatic cancer. In this context, we will review the current evidence on its clinical benefits.
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Affiliation(s)
- Katy Hickman
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Edmund Godfrey
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Thankamma Ajithkumar
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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19
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Neurolytic Splanchnic Nerve Block and Pain Relief, Survival, and Quality of Life in Unresectable Pancreatic Cancer: A Randomized Controlled Trial. Anesthesiology 2021; 135:686-698. [PMID: 34398950 DOI: 10.1097/aln.0000000000003936] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Neurolytic splanchnic nerve block is used to manage pancreatic cancer pain. However, its impact on survival and quality of life remains controversial. The authors' primary hypothesis was that pain relief would be better with a nerve block. Secondarily, they hypothesized that analgesic use, survival, and quality of life might be affected. METHODS This randomized, double-blind, parallel-armed trial was conducted in five Chinese centers. Eligible patients suffering from moderate to severe pain conditions were randomly assigned to receive splanchnic nerve block with either absolute alcohol (neurolysis) or normal saline (control). The primary outcome was pain relief measured on a visual analogue scale. Opioid consumption, survival, quality of life, and adverse effects were also documented. Analgesics were managed using a protocol common to all centers. Patients were followed up for 8 months or until death. RESULTS Ninety-six patients (48 for each group) were included in the analysis. Pain relief with neurolysis was greater for the first 3 months (largest at the first month; mean difference, 0.7 [95% CI, 0.3 to 1.0]; adjusted P < 0.001) compared with placebo injection. Opioid consumption with neurolysis was lower for the first 5 months (largest at the first month; mean difference, 95.8 [95% CI, 67.4 to 124.1]; adjusted P < 0.001) compared with placebo injection. There was a significant difference in survival (hazard ratio, 1.56 [95% CI, 1.03 to 2.35]; P = 0.036) between groups. A significant reduction in survival in neurolysis was found for stage IV patients (hazard ratio, 1.94 [95% CI, 1.29 to 2.93]; P = 0.001), but not for stage III patients (hazard ratio, 1.08 [95% CI, 0.59 to 1.97]; P = 0.809). No differences in quality of life were observed. CONCLUSIONS Neurolytic splanchnic nerve block appears to be an effective option for controlling pain and reducing opioid requirements in patients with unresectable pancreatic cancer. EDITOR’S PERSPECTIVE
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20
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Reassessing the Role for Sympathetic Neurolysis in Patients with Pancreatic Cancer. Anesthesiology 2021; 135:573-575. [PMID: 34499098 DOI: 10.1097/aln.0000000000003880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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21
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Aman MM, Mahmoud A, Deer T, Sayed D, Hagedorn JM, Brogan SE, Singh V, Gulati A, Strand N, Weisbein J, Goree JH, Xing F, Valimahomed A, Pak DJ, El Helou A, Ghosh P, Shah K, Patel V, Escobar A, Schmidt K, Shah J, Varshney V, Rosenberg W, Narang S. The American Society of Pain and Neuroscience (ASPN) Best Practices and Guidelines for the Interventional Management of Cancer-Associated Pain. J Pain Res 2021; 14:2139-2164. [PMID: 34295184 PMCID: PMC8292624 DOI: 10.2147/jpr.s315585] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/18/2021] [Indexed: 12/17/2022] Open
Abstract
Moderate to severe pain occurs in many cancer patients during their clinical course and may stem from the primary pathology, metastasis, or as treatment side effects. Uncontrolled pain using conservative medical therapy can often lead to patient distress, loss of productivity, shorter life expectancy, longer hospital stays, and increase in healthcare utilization. Various publications shed light on strategies for conservative medical management for cancer pain and a few international publications have reviewed limited interventional data. Our multi-institutional working group was assembled to review and highlight the body of evidence that exists for opioid utilization for cancer pain, adjunct medication such as ketamine and methadone and interventional therapies. We discuss neurolysis via injections, neuromodulation including targeted drug delivery and spinal cord stimulation, vertebral tumor ablation and augmentation, radiotherapy and surgical techniques. In the United States, there is a significant variance in the interventional treatment of cancer pain based on fellowship training. As a first of its kind, this best practices and interventional guideline will offer evidenced-based recommendations for reducing pain and suffering associated with malignancy.
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Affiliation(s)
- Mansoor M Aman
- Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Ammar Mahmoud
- Department of Anesthesiology, Division of Pain Medicine, Northern Light Health Eastern Maine Medical Center, Bangor, ME, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Dawood Sayed
- Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shane E Brogan
- Department of Anesthesiology, Division of Pain Medicine, University of Utah, Salt Lake City, UT, USA
| | - Vinita Singh
- Department of Anesthesiology, Division of Pain Medicine, Emory University, Atlanta, GA, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Jacqueline Weisbein
- Department of Anesthesiology, Chronic Pain Division, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Johnathan H Goree
- Interventional Pain Medicine, Napa Valley Orthopedic Medical Group, Napa, CA, USA
| | - Fangfang Xing
- Swedish Pain Services, Swedish Health Services, Seattle, WA, USA
| | - Ali Valimahomed
- Gramercy Pain Center, Holmdel, NJ, & Advanced Orthopedics Sports Medicine Institute, Freehold, NJ, USA
| | - Daniel J Pak
- Department of Anesthesiology, Division of Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA
| | - Antonios El Helou
- Department of Neurosciences, Division of Neurosurgery, The Moncton Hospital, Moncton, NB. Assistant Professor, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | | | - Krishna Shah
- Assistant Professor of Anesthesiology, Baylor St. Luke’s Medical Center, Baylor College of Medicine, Houston, TX, USA
| | - Vishal Patel
- Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Alexander Escobar
- Department of Anesthesiology and Pain Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Keith Schmidt
- AMITA Neurosciences Institute, Comprehensive Pain Management Program, St. Alexius Medical Center, Hoffman Estates, IL, USA
| | - Jay Shah
- SamWell Institute for Pain Management, Colonia, NJ, USA
| | - Vishal Varshney
- Department of Anesthesia, Providence Healthcare, Vancouver, BC, Canada & Department of Anesthesiology, Pharmacology, Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - William Rosenberg
- Center for the Relief of Pain, Midwest Neurosurgery Associates, Kansas City, Missouri, USA
| | - Sanjeet Narang
- Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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22
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Teo ZHT, Tey BLJ, Foo CW, Wong WY, Low JK. Intraoperative Celiac Plexus Block With Preperitoneal Infusion Reduces Opioid Usage in Major Hepato-pancreato-biliary Surgery: A Pilot Study. Ann Surg 2021; 274:e97-e99. [PMID: 33856374 DOI: 10.1097/sla.0000000000004883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Given the role of celiac plexus block (CPB) in the management of chronic pain, we sought to investigate the utility of CPB in the control of postoperative pain in major hepato-pancreato-biliary surgeries. SUMMARY BACKGROUND DATA CPB has been in practice for decades for the management of upper abdominal visceral pain, especially in cancer patients. Typically, in this group of patients with chronic pain, a neurolytic agent is injected to cause irreversible neural damage to achieve pain control. We apply this concept to postoperative pain control by injecting bupivacaine to the celiac plexus instead of a neurolytic agent. We aim to investigate if this novel technique decreases postoperative opioid usage, offers better pain relief and leads to earlier ambulation. METHODS A retrospective, single institution study comparing consecutive patients who received intraoperative CPB and preperitoneal infusion with patients who received only preperitoneal infusion in open hepato-pancreato-biliary surgery between the years 2016 and 2019 by a single surgeon. Patients with incomplete data on patient-controlled analgesia usage and postoperative ambulation information were excluded. RESULTS Patients with CPB used 31% less morphine on postoperative day 1 compared to patient without CPB and 42% less morphine on postoperative day 2. Overall average morphine usage was significantly lower in patients with CPB. Duration of patient-controlled analgesia was shorter for patient with CPB compared with patient without CPB. The dynamic visual analogue score was marginally better in patients with CPB. Time to ambulation was similar in both groups. CONCLUSIONS CPB can be considered as part of a multimodal approach for postoperative pain management in open hepato-pancreato-biliary surgeries.
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Affiliation(s)
- Zhe Hao T Teo
- Department of Hepatopancreatobiliary Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Boon Lim J Tey
- Department of Anesthesiology, Woodlands Health Campus, Woodlands, Singapore
| | - Chek Wun Foo
- Department of Anesthesiology, Woodlands Health Campus, Woodlands, Singapore
| | - Wan Yi Wong
- Department of Anesthesiology, Tan Tock Seng Hospital, Novena, Singapore
| | - Jee Keem Low
- Department of Hepatopancreatobiliary Surgery, Tan Tock Seng Hospital, Novena, Singapore
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23
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Coveler AL, Mizrahi J, Eastman B, Apisarnthanarax SJ, Dalal S, McNearney T, Pant S. Pancreas Cancer-Associated Pain Management. Oncologist 2021; 26:e971-e982. [PMID: 33885205 PMCID: PMC8176967 DOI: 10.1002/onco.13796] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 04/02/2021] [Indexed: 12/12/2022] Open
Abstract
Pain is highly prevalent in patients with pancreas cancer and contributes to the morbidity of the disease. Pain may be due to pancreatic enzyme insufficiency, obstruction, and/or a direct mass effect on nerves in the celiac plexus. Proper supportive care to decrease pain is an important aspect of the overall management of these patients. There are limited data specific to the management of pain caused by pancreatic cancer. Here we review the literature and offer recommendations regarding multiple modalities available to treat pain in these patients. The dissemination and adoption of these best supportive care practices can improve quantity and quality of life for patients with pancreatic cancer. IMPLICATIONS FOR PRACTICE: Pain management is important to improve the quality of life and survival of a patient with cancer. The pathophysiology of pain in pancreas cancer is complex and multifactorial. Despite tumor response to chemotherapy, a sizeable percentage of patients are at risk for ongoing cancer-related pain and its comorbid consequences. Accordingly, the management of pain in patients with pancreas cancer can be challenging and often requires a multifaceted approach.
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Affiliation(s)
- Andrew L Coveler
- Department of Medical Oncology, University of Washington, Seattle, Washington, USA
| | - Jonathan Mizrahi
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bory Eastman
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | | | - Shalini Dalal
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Shubham Pant
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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24
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Murphy D, Lester D, Clay Smither F, Balakhanlou E. Peripheral neuropathic pain. NeuroRehabilitation 2021; 47:265-283. [PMID: 32986619 DOI: 10.3233/nre-208002] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Neuropathic pain (NP) can have either central nervous system causes or ones from the peripheral nervous system. This article will focus on the epidemiology, classifications, pathology, non-invasive treatments and invasive treatments as a general review of NP involving the peripheral nervous system. NP has characteristic symptomatology such as burning and electrical sensations. It occurs in up to 10% of the general population. Its frequency can be attributed to its occurrence in neck and back pain, diabetes and patients receiving chemotherapy. There are a wide range of pharmacologic options to control this type of pain and when such measures fail, numerous interventional methods can be employed such as nerve blocks and implanted stimulators. NP has a cost to the patient and society in terms of emotional consequences, quality of life, lost wages and the cost of assistance from the medical system and thus deserves serious consideration for prevention, treatment and control.
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Affiliation(s)
- Douglas Murphy
- Regional Amputation Center, Central Virginia Veterans Health Center, Richmond, VA, USA.,Physical Medicine & Rehabilitation, VCU Medical Center, Richmond, VA, USA
| | - Denise Lester
- Physical Medicine & Rehabilitation, VCU Medical Center, Richmond, VA, USA.,Peripheral Nerve Stimulation and Interventional Pain Research, Central Virginia Veterans Health Center, Richmond, VA, USA.,Anesthesiology, VCU Medical Center, Richmond, VA, USA
| | - F Clay Smither
- Polytrauma and Amputation, MSK/Ultrasound Fellow, Department of Physical Medicine and Rehabilitation, Central Virginia Veterans Health Center, Richmond, VA, USA
| | - Ellie Balakhanlou
- Physical Medicine & Rehabilitation, VCU Medical Center, Richmond, VA, USA
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Geriatric assessment and intervention in older vulnerable patients undergoing surgery for colorectal cancer: a protocol for a randomised controlled trial (GEPOC trial). Ann Surg 2021; 21:88. [PMID: 33516195 PMCID: PMC7847583 DOI: 10.1097/sla.0b013e3181fd36a2 10.1186/s12877-021-02045-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The incidence of colorectal cancer (CRC) increases with age. Older patients are a heterogeneous group ranging from fit to frail with various comorbidities. Frail older patients with CRC are at increased risk of negative outcomes and functional decline after cancer surgery compared to younger and fit older patients. Maintenance of independence after treatment is rarely investigated in clinical trials despite older patients value it as high as survival. Comprehensive geriatric assessment (CGA) is an evaluation of an older persons' medical, psychosocial, and functional capabilities to develop an overall plan for treatment and follow-up. The beneficial effect of CGA is well documented in the fields of medicine and orthopaedic surgery, but evidence is lacking in cancer surgery. We aim to investigate the effect of CGA on physical performance in older frail patients undergoing surgery for CRC. METHODS GEPOC is a single centre randomised controlled trial including older patients (≥65 years) undergoing surgical resection for primary CRC. Frail patients (≤14/17 points using the G8 screening tool) will be randomised 1:1 to geriatric intervention and exercise (n = 50) or standard of care along (n = 50) with their standard surgical procedure. Intervention includes preoperative CGA, perioperative geriatric in-ward review and postoperative follow-up. All patients in the intervention group will participate in a pre- and postoperative resistance exercise programme (twice/week, 2 + 12 weeks). Primary endpoint is change in 30-s chair stand test. Assessment of primary endpoint will be performed by physiotherapists blinded to patient allocation. Secondary endpoints: changes in health related quality of life, physical strength and capacity (handgrip strength, gait speed and 6 min walking test), patient perceived quality of recovery, complications to surgery, body composition (Dual-energy X-ray absorptiometry and bioelectric impedance), serum biomarkers, readmission, length of stay and survival. DISCUSSION This ongoing trial will provide valuable knowledge on whether preoperative CGA and postoperative geriatric follow-up and intervention including an exercise program can counteract physical decline and improve quality of life in frail CRC patients undergoing surgery. TRIAL REGISTRATION Prospectively registered at Clinicaltrials.gov NCT03719573 (October 2018).
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Gupta R, Madanat L, Jindal V, Gaikazian S. Celiac Plexus Block Complications: A Case Report and Review of the Literature. J Palliat Med 2021; 24:1409-1412. [PMID: 33395560 DOI: 10.1089/jpm.2020.0530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Celiac plexus block (CPB) has been widely used as a treatment option for chronic intractable abdominal pain resulting from intra-abdominal malignancies as well as benign conditions. Complications resulting from CPB have been long reported and include diarrhea, back pain, paraplegia, postural hypotension, pneumothorax, and local anesthesia toxicity. Diarrhea and postural hypotension are two most common complications with studies reporting incidences occurring in 44% to 60% and 10% to 52% of patients, respectively. Diarrhea is most often transient, resolving within 48 hours; however, literature reports cases in which diarrhea was chronic, debilitating, and in some instances life threatening. Persistent diarrhea proves difficult to treat. We report a case of a 76-year-old male with unresectable pancreatic adenocarcinoma who underwent computed tomography-guided CBP complicated by persistent diarrhea and fecal incontinence. After conventional antidiarrheal failed to improve the symptoms, octreotide proved to be beneficial and the patient reported significant improvement in symptoms.
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Affiliation(s)
- Ruby Gupta
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Luai Madanat
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Vishal Jindal
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Susanna Gaikazian
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan, USA
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Hunt PJ, Kabotyanski KE, Calin GA, Xie T, Myers JN, Amit M. Interrupting Neuron-Tumor Interactions to Overcome Treatment Resistance. Cancers (Basel) 2020; 12:E3741. [PMID: 33322770 PMCID: PMC7762969 DOI: 10.3390/cancers12123741] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/04/2020] [Accepted: 12/04/2020] [Indexed: 12/19/2022] Open
Abstract
Neurons in the tumor microenvironment release neurotransmitters, neuroligins, chemokines, soluble growth factors, and membrane-bound growth factors that solid tumors leverage to drive their own survival and spread. Tumors express nerve-specific growth factors and microRNAs that support local neurons and guide neuronal growth into tumors. The development of feed-forward relationships between tumors and neurons allows tumors to use the perineural space as a sanctuary from therapy. Tumor denervation slows tumor growth in animal models, demonstrating the innervation dependence of growing tumors. Further in vitro and in vivo experiments have identified many of the secreted signaling molecules (e.g., acetylcholine, nerve growth factor) that are passed between neurons and cancer cells, as well as the major signaling pathways (e.g., MAPK/EGFR) involved in these trophic interactions. The molecules involved in these signaling pathways serve as potential biomarkers of disease. Additionally, new treatment strategies focus on using small molecules, receptor agonists, nerve-specific toxins, and surgical interventions to target tumors, neurons, and immune cells of the tumor microenvironment, thereby severing the interactions between tumors and surrounding neurons. This article discusses the mechanisms underlying the trophic relationships formed between neurons and tumors and explores the emerging therapies stemming from this work.
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Affiliation(s)
- Patrick J. Hunt
- Medical Scientist Training Program, Baylor College of Medicine, Houston, TX 77030, USA; (P.J.H.); (K.E.K.)
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Katherine E. Kabotyanski
- Medical Scientist Training Program, Baylor College of Medicine, Houston, TX 77030, USA; (P.J.H.); (K.E.K.)
| | - George A. Calin
- Translational Molecular Pathology, Division of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Tongxin Xie
- Department of Head and Neck Surgery, Division of Surgery, MD Anderson Cancer Center, Houston, TX 77030, USA; (T.X.); (J.N.M.)
| | - Jeffrey N. Myers
- Department of Head and Neck Surgery, Division of Surgery, MD Anderson Cancer Center, Houston, TX 77030, USA; (T.X.); (J.N.M.)
| | - Moran Amit
- Department of Head and Neck Surgery, Division of Surgery, MD Anderson Cancer Center, Houston, TX 77030, USA; (T.X.); (J.N.M.)
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Banh RS, Biancur DE, Yamamoto K, Sohn ASW, Walters B, Kuljanin M, Gikandi A, Wang H, Mancias JD, Schneider RJ, Pacold ME, Kimmelman AC. Neurons Release Serine to Support mRNA Translation in Pancreatic Cancer. Cell 2020; 183:1202-1218.e25. [PMID: 33142117 DOI: 10.1016/j.cell.2020.10.016] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 08/31/2020] [Accepted: 10/06/2020] [Indexed: 12/23/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) tumors have a nutrient-poor, desmoplastic, and highly innervated tumor microenvironment. Although neurons can release stimulatory factors to accelerate PDAC tumorigenesis, the metabolic contribution of peripheral axons has not been explored. We found that peripheral axons release serine (Ser) to support the growth of exogenous Ser (exSer)-dependent PDAC cells during Ser/Gly (glycine) deprivation. Ser deprivation resulted in ribosomal stalling on two of the six Ser codons, TCC and TCT, and allowed the selective translation and secretion of nerve growth factor (NGF) by PDAC cells to promote tumor innervation. Consistent with this, exSer-dependent PDAC tumors grew slower and displayed enhanced innervation in mice on a Ser/Gly-free diet. Blockade of compensatory neuronal innervation using LOXO-101, a Trk-NGF inhibitor, further decreased PDAC tumor growth. Our data indicate that axonal-cancer metabolic crosstalk is a critical adaptation to support PDAC growth in nutrient poor environments.
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Affiliation(s)
- Robert S Banh
- Department of Radiation Oncology, Perlmutter Cancer Center, New York University Medical Center, New York, NY 10016, USA
| | - Douglas E Biancur
- Department of Radiation Oncology, Perlmutter Cancer Center, New York University Medical Center, New York, NY 10016, USA
| | - Keisuke Yamamoto
- Department of Radiation Oncology, Perlmutter Cancer Center, New York University Medical Center, New York, NY 10016, USA
| | - Albert S W Sohn
- Department of Radiation Oncology, Perlmutter Cancer Center, New York University Medical Center, New York, NY 10016, USA
| | - Beth Walters
- Department of Microbiology and Perlmutter Cancer Center, New York University School of Medicine, New York, NY 10016, USA
| | - Miljan Kuljanin
- Division of Genomic Stability and DNA Repair, Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA; Hale Family Pancreatic Cancer Research Center, Dana-Farber Cancer Institute, Boston, MA 02215, USA
| | - Ajami Gikandi
- Division of Genomic Stability and DNA Repair, Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA; Hale Family Pancreatic Cancer Research Center, Dana-Farber Cancer Institute, Boston, MA 02215, USA
| | - Huamin Wang
- Department of Anatomical Pathology, M.D. Anderson Cancer Center, University of Texas, Houston, TX 77030, USA
| | - Joseph D Mancias
- Division of Genomic Stability and DNA Repair, Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA; Hale Family Pancreatic Cancer Research Center, Dana-Farber Cancer Institute, Boston, MA 02215, USA
| | - Robert J Schneider
- Department of Radiation Oncology, Perlmutter Cancer Center, New York University Medical Center, New York, NY 10016, USA; Department of Microbiology and Perlmutter Cancer Center, New York University School of Medicine, New York, NY 10016, USA
| | - Michael E Pacold
- Department of Radiation Oncology, Perlmutter Cancer Center, New York University Medical Center, New York, NY 10016, USA
| | - Alec C Kimmelman
- Department of Radiation Oncology, Perlmutter Cancer Center, New York University Medical Center, New York, NY 10016, USA.
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Sample J, Hammad F, Ghazaleh S, Burlen J, Nawras A. A Rare Complication of Ileus Following Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis: A Case Report. Cureus 2020; 12:e10963. [PMID: 33209522 PMCID: PMC7667610 DOI: 10.7759/cureus.10963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Pancreatic cancer patients experience debilitating pain, which makes pain management an integral part of the treatment plan. Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-guided CPN) is an alternative palliative therapy for patients with pain due to pancreatic cancer. We report a patient who developed paralytic ileus after undergoing EUS-guided CPN. A 77-year-old male patient presented with nausea, vomiting, and abdominal pain of one-day duration. He was diagnosed with stage IV pancreatic adenocarcinoma three weeks prior to presentation for which he underwent EUS-guided CPN. He had a 30-pack-year smoking history and quit 31 years ago. He reported moderate alcohol use and denied illicit drug use. In the emergency department, vital signs demonstrated normal blood pressure, heart rate, respiratory rate, and temperature. Abdominal exam was significant for minimal epigastric tenderness without guarding or rebound. Complete blood count (CBC), basic metabolic panel (BMP), and liver function tests were unremarkable. Computed tomography (CT) scan of the abdomen showed significant gastric distension. Esophagogastroduodenoscopy (EGD) showed large amounts of fluids within the gastric fundus and body. Upper gastrointestinal series showed delayed gastric emptying of the contrast, but contrast was seen in the third part of the duodenum and jejunum. Push enteroscopy showed no obstruction or mucosal abnormalities in the third or fourth parts of the duodenum. Small bowel obstruction was ruled out, and the diagnosis of ileus was made. The patient received ondansetron and polyethylene glycol as needed, and his diet was advanced slowly. His symptoms improved over the course of a few days, and he experienced a return of normal bowel activity. He eventually tolerated a regular diet and was discharged home in a stable condition. Although EUS-guided CPN is a safe procedure, the procedure resulted in an unexpected ileus that has rarely been reported in the literature. Future studies with large sample sizes are recommended to capture the occurrence of the rare side effects of EUS-guided CPN.
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Affiliation(s)
- Jack Sample
- Internal Medicine, University of Toledo, Toledo, USA
| | - Faris Hammad
- Internal Medicine, Saint Vincent Charity Medical Center, Cleveland, USA
| | - Sami Ghazaleh
- Internal Medicine, University of Toledo, Toledo, USA
| | - Jordan Burlen
- Gastroenterology and Hepatology, University of Toledo, Toledo, USA
| | - Ali Nawras
- Gastroenterology and Hepatology, University of Toledo, Toledo, USA
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Agarwal A, Gautam A, Rastogi S, Malviya D, Das PK, Harjai M. Effect of Celiac Plexus Neurolysis for Pain Relief in Patients with Upper Abdominal Malignancy: A Retrospective Observational Study and Review of Literature. Indian J Palliat Care 2020; 26:512-517. [PMID: 33623314 PMCID: PMC7888415 DOI: 10.4103/ijpc.ijpc_37_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 05/14/2020] [Accepted: 07/01/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Abdominal pain from primary cancer or metastatic disease is a significant cause of pain for patients undergoing treatment for the disease. Patient's pain may be resistant or non-responsive to the pharmacological management, hence minimal invasive pain intervention like celiac plexus neurolysis or splanchnic nerve rhizolysis may be required to relieve pain of such patients. Objective: The aim of this retrospective study is to assess the effect of celiac plexus neurolysis for pain relief in patients with upper gastro-intestinal malignancies. Study Design: This is a retrospective, observational study with short review. Methods: This retrospective observational study was done in the Pain Medicine unit from 2016 and November 2018. Ninety-four patients with upper abdominal malignancy and unrelenting pain, non-responsive or poorly responsive to pharmacological treatment as per WHO ladder of analgesics, received fluoroscopy-guided celiac plexus neurolysis (CPN). All the patients underwent celiac plexus neurolysis through Trans-Aortic approach and the primary outcome measure was pain as assessed with Visual Analogue Scale (VAS) ranging from 0 to 10; the secondary outcome measures were morphine consumption per day (M), quality of life (QOL) as assessed by comparing the percent of positive responses and complications, if any. These were noted and analyzed prior to intervention and then on day 1, and months 1, 2, 3, 4, 5, 6 following CPN. Results: Follow up was completed 6 months after the procedure. VAS score, daily morphine consumption, and the quality of life showed improvement for the duration of the study. There was some relapse in pain and deterioration in QOL during the fourth to sixth month of pain intervention due to disease progression. Some transient known side effects also occurred. Conclusion: Trans-Aortic celiac plexus neurolysis with low volume of alcohol is a safe procedure providing up to 6 months of pain relief and is an effective, well established, minimally invasive procedure for abdominal pain due to primary malignancy or metastatic spread.
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Affiliation(s)
- Anurag Agarwal
- Department of Anesthesiology, CCM and Pain Medicine, Dr RMLIMS, Lucknow, Uttar Pradesh, India
| | - Anuj Gautam
- Department of Anesthesiology, CCM and Pain Medicine, Dr RMLIMS, Lucknow, Uttar Pradesh, India
| | - Shivani Rastogi
- Department of Anesthesiology, CCM and Pain Medicine, Dr RMLIMS, Lucknow, Uttar Pradesh, India
| | - Deepak Malviya
- Department of Anesthesiology, CCM and Pain Medicine, Dr RMLIMS, Lucknow, Uttar Pradesh, India
| | - Praveen Kumar Das
- Department of Anesthesiology, CCM and Pain Medicine, Dr RMLIMS, Lucknow, Uttar Pradesh, India
| | - Mamta Harjai
- Department of Anesthesiology, CCM and Pain Medicine, Dr RMLIMS, Lucknow, Uttar Pradesh, India
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Comlek S. Pain Control with Splanchnic Neurolysis in Pancreatic Cancer Patients Unresponsive to Celiac Plexus Neurolysis. J Pain Res 2020; 13:2023-2031. [PMID: 32848449 PMCID: PMC7429208 DOI: 10.2147/jpr.s266689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/23/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/AIMS In most instances of abdominal pain associated with pancreatic cancer, pain may become refractory to increasing doses of narcotics. Celiac plexus neurolysis represents an option; however, altered celiac plexus anatomy may render this treatment infeasible or ineffective, where splanchnic nerve neurolysis may represent another option. This study aimed to investigate the outcomes of splanchnic neurolysis in pancreatic cancer patients not responsive to celiac plexus neurolysis. PATIENTS AND METHODS Among all 84 patients who underwent celiac plexus neurolysis for pancreatic cancer pain during the study period, 34 patients did not respond and underwent splanchnic nerve neurolysis under fluoroscopic guidance and thus included in this retrospective study. Stage IV, III, and II disease was present in 38.2%, 47.1%, and 14.7% of the patients. During the study, 88.2% were receiving chemotherapy, whereas none were on radiotherapy. Data for daily narcotic dose equivalents and Visual Analogue Scale (VAS) scores during outpatient visits at baseline, 2 weeks, 2 months, and 3 months were extracted. RESULTS Pain response rates were 76.5%, 84.4%, and 71.0%, at 2 weeks, 2 months, and 3 months, respectively. A significant and dramatic reduction was seen in VAS scores at 2 weeks (2.8±1.2 versus 6.3±1.1, p<0.001), and this significant decline was maintained for 3 months. Similarly, a significant and dramatic reduction was seen in daily narcotic need at 2 weeks (20.8±32.9 versus 93.4±86.2 mg, p<0.001), which was also maintained during the 3-month follow-up. The procedure was generally well tolerated. CONCLUSION Findings of this study suggest that splanchnic neurolysis represents a durable and effective option for pain control in pancreatic cancer patients in whom the neurolysis of the celiac plexus is ineffective. However, these conclusions refer to only preliminary single-center results in a selected patient group; thus, further large studies are warranted.
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Affiliation(s)
- Savas Comlek
- Gayrettepe Florence Nightingale Hospital, Department of Anesthesiology and Reanimation, Istanbul, Besiktas 34349, Turkey
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33
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Dumitrescu A, Aggarwal A, Chye R. A retrospective case series of patients who have undergone coeliac plexus blocks for the purpose of alleviating pain due to intra-abdominal malignancy. Cancer Rep (Hoboken) 2020; 3:e1265. [PMID: 32687682 DOI: 10.1002/cnr2.1265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/11/2020] [Accepted: 06/19/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Coeliac plexus block (CPB) is an interventional pain management option for patients with pancreatic or other upper abdominal malignancy. AIMS To assess the safety, utilization, and outcomes of CPBs in the local context. METHODS AND RESULTS We conducted a retrospective case series of all patients with cancer who underwent CPB at 4 Sydney teaching hospitals from March 2010 to February 2016. We recorded baseline demographic data, details of the injectate, procedural approach and survival, as well as pain scores and analgesic use at 4 time points of interest. Thirty-nine procedures were performed during the study period. Twenty-four were performed endoscopically, 14 were performed via a bilateral percutaneous posterior approach by Pain Specialists or Radiologists and 1 was performed intraoperatively by a Surgeon. Patients had experienced pain for a mean of 17 weeks prior to CPB. Prior to CPB, the mean pain score was 8.8 out of 10. The mean pain score was reduced at 48 hours, 2 weeks, and 4 weeks following CPB (P < .01). The mean oral morphine equivalent daily dose prior to CPB was 362 mg which was reduced at 48 hours and 2 weeks but increased at the 4 weeks following CPB. One patient developed a bacteremia but otherwise no complications were observed. CONCLUSION CPB is performed by a number of approaches and is well tolerated. The approach selected appears to depend on patient anatomy, preference, and availability of local expertise. Local clinicians could consider CPB earlier in the management of malignant epigastric pain.
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Affiliation(s)
- Alix Dumitrescu
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Arun Aggarwal
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Central Clinical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Richard Chye
- St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
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Demir IE, Reyes CM, Alrawashdeh W, Ceyhan GO, Deborde S, Friess H, Görgülü K, Istvanffy R, Jungwirth D, Kuner R, Maryanovich M, Na'ara S, Renders S, Saloman JL, Scheff NN, Steenfadt H, Stupakov P, Thiel V, Verma D, Yilmaz BS, White RA, Wang TC, Wong RJ, Frenette PS, Gil Z, Davis BM. Clinically Actionable Strategies for Studying Neural Influences in Cancer. Cancer Cell 2020; 38:11-14. [PMID: 32531270 DOI: 10.1016/j.ccell.2020.05.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Neuro-glial activation is a recently identified hallmark of growing cancers. Targeting tumor hyperinnervation in preclinical and small clinical trials has yielded promising antitumor effects, highlighting the need of systematic analysis of neural influences in cancer (NIC). Here, we outline the strategies translating these findings from bench to the clinic.
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Affiliation(s)
- Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany; Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany; CRC 1321 Modelling and Targeting Pancreatic Cancer, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany.
| | - Carmen Mota Reyes
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany; CRC 1321 Modelling and Targeting Pancreatic Cancer, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Wasfi Alrawashdeh
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
| | - Güralp O Ceyhan
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Sylvie Deborde
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany; CRC 1321 Modelling and Targeting Pancreatic Cancer, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Kivanc Görgülü
- Comprehensive Cancer Center Munich, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Rouzanna Istvanffy
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany; CRC 1321 Modelling and Targeting Pancreatic Cancer, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - David Jungwirth
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany; CRC 1321 Modelling and Targeting Pancreatic Cancer, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Rohini Kuner
- Department of Molecular Pharmacology, Institute of Pharmacology, Heidelberg University, Heidelberg, Germany
| | - Maria Maryanovich
- Ruth L. and David S. Gottesman Institute for Stem Cell and Regenerative Medicine Research, Albert Einstein College of Medicine, Bronx, NY 10461, USA; Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Shorook Na'ara
- Department of Otolaryngology, Head and Neck Surgery, and the Laboratory for Applied Cancer Research, Rappaport Institute of Medicine and Research, The Technion, Israel Institute of Technology, Haifa, Israel; Head and Neck Center, Rambam Healthcare Campus, Haifa, Israel
| | - Simon Renders
- Division of Stem Cells and Cancer, German Cancer Research Center (DKFZ) and DKFZ-ZMBH Alliance, 69120 Heidelberg, Germany; Heidelberg Institute for Stem Cell Technology and Experimental Medicine (HI-STEM gGmbH), 69120 Heidelberg, Germany; Department of Internal Medicine V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jami L Saloman
- Department of Medicine, Division of Gastroenterology, Hepatology, & Nutrition, Center for Neuroscience at the University of Pittsburgh, Pittsburgh Center for Pain Research and Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nicole N Scheff
- Hillman Cancer Center and Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Hendrik Steenfadt
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany; CRC 1321 Modelling and Targeting Pancreatic Cancer, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Pavel Stupakov
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany; CRC 1321 Modelling and Targeting Pancreatic Cancer, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Vera Thiel
- Division of Stem Cells and Cancer, German Cancer Research Center (DKFZ) and DKFZ-ZMBH Alliance, 69120 Heidelberg, Germany; Heidelberg Institute for Stem Cell Technology and Experimental Medicine (HI-STEM gGmbH), 69120 Heidelberg, Germany; Department of Internal Medicine V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Divij Verma
- Ruth L. and David S. Gottesman Institute for Stem Cell and Regenerative Medicine Research, Albert Einstein College of Medicine, Bronx, NY 10461, USA; Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Bengi Su Yilmaz
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany; CRC 1321 Modelling and Targeting Pancreatic Cancer, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Ruth A White
- Division of Hematology and Oncology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Timothy C Wang
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Richard J Wong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul S Frenette
- Ruth L. and David S. Gottesman Institute for Stem Cell and Regenerative Medicine Research, Albert Einstein College of Medicine, Bronx, NY 10461, USA; Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461, USA; Department of Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Ziv Gil
- Department of Otolaryngology, Head and Neck Surgery, and the Laboratory for Applied Cancer Research, Rappaport Institute of Medicine and Research, The Technion, Israel Institute of Technology, Haifa, Israel; Head and Neck Center, Rambam Healthcare Campus, Haifa, Israel
| | - Brian M Davis
- Center for Neuroscience at the University of Pittsburgh, Pittsburgh Center for Pain Research and Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Kanno Y, Koshita S, Masu K, Ogawa T, Kusunose H, Murabayashi T, Sakai T, Kozakai F, Ito K. Efficacy of EUS-guided celiac plexus neurolysis compared with medication alone for unresectable pancreatic cancer in the oxycodone/fentanyl era: a prospective randomized control study. Gastrointest Endosc 2020; 92:120-130. [PMID: 31953188 DOI: 10.1016/j.gie.2020.01.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 01/02/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The efficacy of celiac plexus neurolysis (CPN) with EUS guidance (EUS-CPN) has not been confirmed in the era of developed opioids. The aim of this study was to evaluate the efficacy of EUS-CPN for patients with pancreatic cancer-associated pain to compare medication using oxycodone and/or fentanyl with and without EUS-CPN. METHODS In this randomized control study involving patients who underwent EUS-CPN and those who did not, pain, quality of life (QOL), and opioid consumption were compared. Standard medicinal treatment using oxycodone and/or fentanyl was performed for both groups. The primary endpoint was defined as the pain evaluated by using a visual analog scale (VAS) rated from a 0 to 10, 4 weeks after the baseline. RESULTS For 48 registered patients, the outcomes of 24 patients in the EUS-CPN group and 22 patients in the control group were analyzed. EUS-CPN was successfully performed and did not induce severe procedure-related adverse events for all patients in the EUS-CPN group. Although the average pain VAS scores for both groups significantly decreased in comparison with baseline, scores were not statistically different between the groups at week 4 (1.3 ± 1.3 for the EUS-CPN group vs 2.3 ± 2.3 for the control group, P = .10). There was no statistical difference or tendency in favor of EUS-CPN at evaluation points of weeks 1, 2, 8, and 12. Moreover, the average VAS scores for QOL and the average opioid consumption between the groups were not different at all evaluation points. CONCLUSIONS EUS-CPN for patients with pancreatic cancer-associated pain did not appear to improve pain, QOL, or opioid consumption compared with those who did not undergo EUS-CPN and medicated with oxycodone/fentanyl. Although EUS-CPN can be an option, it was not found to have a large enough impact to be routinely performed for all patients with pain. (Clinical trial registration number: UMIN 000037172.).
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Affiliation(s)
- Yoshihide Kanno
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Shinsuke Koshita
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Kaori Masu
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Takahisa Ogawa
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Hiroaki Kusunose
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Toji Murabayashi
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Toshitaka Sakai
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Fumisato Kozakai
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Kei Ito
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
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Pain Relieving Effect of Intraoperative Chemical Splanchnicectomy of Celiac Ganglions in Patients with Resectable Pancreatic or Gastric Masses: A Randomized Clinical Trial. Pain Res Manag 2020; 2020:2675940. [PMID: 32300382 PMCID: PMC7132578 DOI: 10.1155/2020/2675940] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 02/27/2020] [Indexed: 11/17/2022]
Abstract
Background Trials of intraoperative chemical splanchnicectomy during resection of pancreatic and gastric masses resulted in significant difference in a patient's postoperative pain. This study aims to determine if splanchnicectomy by alcohol neurolysis can relieve postoperative pain after gastrectomy and Whipple surgery. The study explores differences in outcomes at first four months after surgery. Methods Fifty-eight patients with gastric and 60 patients with pancreatic resectable masses were included (28 were lost to follow-up). Each randomized in control and intervention subgroups. Intervention subgroups underwent chemical blockage of celiac ganglions by ethanol injection at both sides of suprapancreatic aorta. Participants were asked to report their pain intensity according to the Visual Analogue Scale (VAS) at specific times. Result The overall postoperative pain of injected Whipple and gastrectomy subgroups was lower than the noninjected Whipple and gastrectomy subgroups (p < 0.001). The pain-modifying effect of the injection was not different between Whipple and gastrectomy groups (p=0.125). Conclusion Splanchnicectomy is recommended for pain reduction after abdominal operations. Perspective. This article presents positive effect of intraoperative chemical splanchnicectomy during resection of pancreatic and gastric masses on postoperative pain. This is an easy, effective, safe, and inexpensive procedure recommended for all operable gastric or pancreatic masses to palliate the pain degree.
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Abstract
The contribution of nerves to the pathogenesis of malignancies has emerged as an important component of the tumour microenvironment. Recent studies have shown that peripheral nerves (sympathetic, parasympathetic and sensory) interact with tumour and stromal cells to promote the initiation and progression of a variety of solid and haematological malignancies. Furthermore, new evidence suggests that cancers may reactivate nerve-dependent developmental and regenerative processes to promote their growth and survival. Here we review emerging concepts and discuss the therapeutic implications of manipulating nerves and neural signalling for the prevention and treatment of cancer.
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Affiliation(s)
- Ali H Zahalka
- Ruth L. and David S. Gottesman Institute for Stem Cell and Regenerative Medicine Research, Albert Einstein College of Medicine, New York, NY, USA
- Department of Cell Biology, Albert Einstein College of Medicine, New York, NY, USA
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul S Frenette
- Ruth L. and David S. Gottesman Institute for Stem Cell and Regenerative Medicine Research, Albert Einstein College of Medicine, New York, NY, USA.
- Department of Cell Biology, Albert Einstein College of Medicine, New York, NY, USA.
- Department of Medicine, Albert Einstein College of Medicine, New York, NY, USA.
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Wong T, Georgiadis PL, Urman RD, Tsai MH. Non-Operating Room Anesthesia: Patient Selection and Special Considerations. Local Reg Anesth 2020; 13:1-9. [PMID: 32021414 PMCID: PMC6956865 DOI: 10.2147/lra.s181458] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 11/25/2019] [Indexed: 12/18/2022] Open
Abstract
Non-operating room anesthesia (NORA) represents a growing field of medicine with an increasing trend in the number of cases performed over the previous decade. As a result, anesthesia providers will need to enhance their familiarity with the resources, personnel, and environment outside of the operating room. Anesthesia delivery in NORA settings should be held with the same high-quality standards as that within the operating room. This review looks at special considerations in patient selection and the preoperative, intraoperative, and postoperative periods. In addition, there is a discussion on the unique aspects of specific NORA areas and the considerations that come with them.
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Affiliation(s)
- Timothy Wong
- University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Paige L Georgiadis
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mitchell H Tsai
- Department of Anesthesiology, Department of Orthopaedics and Rehabilitation (by Courtesy), Department of Surgery (by Courtesy), University of Vermont Larner College of Medicine, Burlington, VT, USA
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Interventional Techniques to Management of Cancer-Related Pain: Clinical and Critical Aspects. Cancers (Basel) 2019; 11:cancers11040443. [PMID: 30934870 PMCID: PMC6520967 DOI: 10.3390/cancers11040443] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/14/2019] [Accepted: 03/26/2019] [Indexed: 01/20/2023] Open
Abstract
Interventional techniques to manage cancer-related pain may be efficient treatment modalities in patients unresponsive or unable to tolerate systemic opioids. However, indication and selection of the right technique demand knowledge, which is still incipient among clinicians. The present article summarizes the current evidence regarding the five most essential groups of interventional techniques to treat cancer-related pain: Neuraxial analgesia, minimally invasive procedures for vertebral pain, sympathetic blocks for abdominal cancer pain, peripheral nerve blocks, and percutaneous cordotomy. Furthermore, indication, mechanism, drug agents, contraindications, and complications of the main techniques of each group are discussed.
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Levy MJ, Gleeson FC, Topazian MD, Fujii-Lau LL, Enders FT, Larson JJ, Mara K, Abu Dayyeh BK, Alberts SR, Hallemeier CL, Iyer PG, Kendrick ML, Mauck WD, Pearson RK, Petersen BT, Rajan E, Takahashi N, Vege SS, Wang KK, Chari ST. Combined Celiac Ganglia and Plexus Neurolysis Shortens Survival, Without Benefit, vs Plexus Neurolysis Alone. Clin Gastroenterol Hepatol 2019; 17:728-738.e9. [PMID: 30217513 DOI: 10.1016/j.cgh.2018.08.040] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pancreatic cancer produces debilitating pain that opioids often ineffectively manage. The suboptimal efficacy of celiac plexus neurolysis (CPN) might result from brief contact of the injectate with celiac ganglia. We compared the effects of endoscopic ultrasound-guided celiac ganglia neurolysis (CGN) vs the effects of CPN on pain, quality of life (QOL), and survival. METHODS We performed a randomized, double-blind trial of patients with unresectable pancreatic ductal adenocarcinoma and abdominal pain; 60 patients (age 66.4±11.6 years; male 66%) received CPN and 50 patients (age 66.8±10.0 years; male 56%) received CGN. Primary outcomes included pain control and QOL at week 12 and survival (overall median and 12 months). Secondary outcomes included morphine response, performance status, secondary neurolytic effects, and adverse events. RESULTS Rates of pain response at 12 weeks were 46.2% for CGN and 40.4% for CPN (P = .84). There was no significant difference in improvement of QOL between the techniques. The median survival time was significantly shorter for patients receiving CGN (5.59 months) compared to (10.46 months) (hazard ratio for CGN, 1.49; 95% CI, 1.02-2.19; P = .042), particularly for patients with non-metastatic disease (hazard ratio for CGN, 2.95; 95% CI, 1.61-5.45; P < .001). Rates of survival at 12 months were 42% for patients who underwent CPN vs 26% for patients who underwent CGN. The number of adverse events did not differ between techniques. CONCLUSION In a prospective study of patients with unresectable pancreatic ductal adenocarcinoma and abdominal pain, we found CGN to reduce median survival time without improving pain, QOL, or adverse events, compared to CPN. The role of CGN must be therefore be reassessed. Clinicaltrials.gov no: NCT01615653.
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Affiliation(s)
- Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota.
| | - Ferga C Gleeson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Mark D Topazian
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | - Felicity T Enders
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Joseph J Larson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Kristin Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | - William D Mauck
- Department of Pain Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Bret T Petersen
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Rajan
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | - Santhi S Vege
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth K Wang
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
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Bang JY, Sutton B, Hawes RH, Varadarajulu S. EUS-guided celiac ganglion radiofrequency ablation versus celiac plexus neurolysis for palliation of pain in pancreatic cancer: a randomized controlled trial (with videos). Gastrointest Endosc 2019; 89:58-66.e3. [PMID: 30120957 DOI: 10.1016/j.gie.2018.08.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/04/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Although EUS-guided celiac plexus neurolysis (EUS-CPN) is frequently performed, its efficacy for palliation of pain in pancreatic cancer is suboptimal. Recently, EUS-guided radiofrequency ablation (EUS-RFA) has been proposed as a palliative treatment option for pancreatic neoplasms. We performed a single-blind, randomized trial to compare the effectiveness of EUS-CPN and EUS-RFA for palliation of pain in pancreatic cancer. METHODS Patients with abdominal pain because of locally advanced or metastatic pancreatic cancer underwent EUS-CPN (n = 14) or EUS-RFA (n = 12). EUS-RFA was performed using a 1F monopolar probe passed via a 19-gauge FNA needle, by targeting the area of celiac plexus or visualized ganglia. Primary outcome was pain severity as measured by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire pancreatic cancer module (PAN26) administered pretreatment and at 2 and 4 weeks post-treatment. Secondary outcome measures were comparison of quality of life as determined by the PAN26 and EORTC Quality of Life Questionnaire core questionnaire (C30) and opioid analgesia use between the 2 groups. RESULTS Both the PAN26 (49.0 vs 57.0, P < .001) and C30 (51.9 vs 64.4, P = .032) revealed less pain for EUS-RFA than for EUS-CPN. Also, the EUS-RFA cohort experienced significantly less-severe GI symptoms, were able to plan more for the future, and had better emotional functioning compared with the EUS-CPN group. CONCLUSIONS Compared with EUS-CPN, EUS-RFA provided more pain relief and improved the quality of life for patients with pancreatic cancer. (Clinical trials registration number: NCT03152487.).
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Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Bryce Sutton
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Robert H Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
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Evans MT, Wigmore T, Kelliher LJS. The impact of anaesthetic technique upon outcome in oncological surgery. BJA Educ 2018; 19:14-20. [PMID: 33456849 DOI: 10.1016/j.bjae.2018.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2018] [Indexed: 11/17/2022] Open
Affiliation(s)
- M T Evans
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - T Wigmore
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - L J S Kelliher
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
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Abstract
Palliative care is the multidisciplinary focus on patient symptoms and quality of life. The emphasis of minimally invasive surgery on reduced pain and faster recovery aligns well with the goals of palliative care. Minimally invasive approaches can be safely and effectively used to address several common complications of solid organ malignancies as well as the complications of cytotoxic therapy. A patient-centered, minimally invasive approach will not only help alleviate disabling symptoms and improve patient quality of life but will also minimize the pain and adverse effects of the intervention itself.
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Affiliation(s)
- Jordan M Cloyd
- Department of Surgery, The Ohio State University, 410 West 10th Avenue, N-907, Columbus, OH 43210, USA.
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Abstract
Pain is often associated with chronic pancreatitis and pancreatic cancer. Often times opioids are used to treat pain; however, the use of opioids is frequently difficult. Endoscopic ultrasound-guided celiac plexus block and celiac plexus nuerolysis are safe and effective modalities used to alleviate pain. Celiac plexus block is a transient interruption of the plexus by local anesthetic, while celiac plexus neurolysis is prolonged interruption of the transmission of pain from the celiac plexus using chemical ablation. Celiac plexus block is generally performed in the unilateral position, while celiac plexus neurolysis is performed in the unilateral or bilateral position.
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Affiliation(s)
- Amit H Sachdev
- Division of Digestive and Liver Diseases, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY 10032, USA.
| | - Frank G Gress
- Division of Digestive and Liver Diseases, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY 10032, USA
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Perioperative Immunosuppression and Risk of Cancer Progression: The Impact of Opioids on Pain Management. Pain Res Manag 2018; 2018:9293704. [PMID: 30327708 PMCID: PMC6169211 DOI: 10.1155/2018/9293704] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/05/2018] [Accepted: 08/19/2018] [Indexed: 12/21/2022]
Abstract
Opioids comprise an important group of drugs used in cancer pain pharmacotherapy. In recent years, more and more studies have emerged indicating the potentially immunosuppressive effects of opioid analgesics and their serious consequences, including the risk of cancer progression. The identification of these risks has prompted a search for other effective, and most importantly, safer methods of perioperative analgesic management. Regional analgesia techniques, which allow for a significant reduction in opioid dosing and thus diminish the risk of immunosuppression associated with these drugs, seem to offer substantial hope in this respect. A number of studies available in the literature assess the effects of regional analgesia techniques on cancer progression; however, it is often difficult to interpret their results owing to several perioperative factors (such as surgical trauma, inadequate pain and stress relief, and hypothermia) which are also attributed immunosuppressive effects and tend to be implicated in increased risk of cancer progression. Further research is needed to verify the available data on both the potential adverse effects of opioids and the possible protective effects of regional analgesia techniques on cancer patients.
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Anghelescu DL, Guo A, Morgan KJ, Frett M, Prajapati H, Gold R, Federico SM. Pain Outcomes After Celiac Plexus Block in Children and Young Adults with Cancer. J Adolesc Young Adult Oncol 2018; 7:666-672. [PMID: 30113244 DOI: 10.1089/jayao.2018.0035] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: The use of celiac plexus block (CPB) for abdominal pain has been extensively reported in adults. However, pediatric literature is limited to three single case reports and a series of three cases. This study evaluated the effectiveness of CPB in children and young adults (aged 8-20 years) with abdominal malignancies. Methods: Pain outcomes after CPB were evaluated in four children and young adults with cancer. Mean daily pain score (PS, 0-10) and morphine consumption (intravenous morphine equivalent daily [MED], mg/kg/day) before and after CPB were used to assess effectiveness. Results: Mean daily PS reduced after CPB in all patients. In one patient, this reduction was sustained up to 6 months of follow-up, and analgesics were discontinued 1 week after CPB. The other three patients had limited survival (6, 16, and 37 days) after CPB. One patient had a PS of 0 over the last few days of life, but the MED was escalated from 0.74 before the block to 5.4 mg/kg/day at the end of life. In the other two patients, MED was lower during the first week after CPB than that before CPB (4.55 vs. 1.59 and 2.88 vs. 1.51 mg/kg/day, respectively). As these two patients had disease progression during their last days of life, the MED was increased to 4.75 and 263.9 mg/kg/day, respectively. Conclusions: Our results suggest that CPB may contribute to reducing PS and MED. We observed the use of CPB rather late in the disease trajectory.
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Affiliation(s)
- Doralina L Anghelescu
- Division of Anesthesiology, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Andy Guo
- Division of Anesthesiology, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Kyle J Morgan
- Division of Anesthesiology, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Michael Frett
- Division of Anesthesiology, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Hasmukh Prajapati
- Division of Anesthesiology, Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Robert Gold
- Division of Anesthesiology, Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Sara M Federico
- Division of Anesthesiology, Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
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Saloman JL, Singhi AD, Hartman DJ, Normolle DP, Albers KM, Davis BM. Systemic Depletion of Nerve Growth Factor Inhibits Disease Progression in a Genetically Engineered Model of Pancreatic Ductal Adenocarcinoma. Pancreas 2018; 47:856-863. [PMID: 29975347 PMCID: PMC6044729 DOI: 10.1097/mpa.0000000000001090] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES In patients with pancreatic ductal adenocarcinoma (PDAC), increased expression of proinflammatory neurotrophic growth factors (eg, nerve growth factor [NGF]) correlates with a poorer prognosis, perineural invasion, and, with regard to NGF, pain severity. We hypothesized that NGF sequestration would reduce inflammation and disease in the KPC mouse model of PDAC. METHODS Following biweekly injections of NGF antibody or control immunoglobulin G, beginning at 4 or 8 weeks of age, inflammation and disease stage were assessed using histological, protein expression, and quantitative polymerase chain reaction analyses. RESULTS In the 8-week anti-NGF group, indicators of neurogenic inflammation in the dorsal root ganglia (substance P and calcitonin gene-related peptide) and spinal cord (glial fibrillary acidic protein) were significantly reduced. In the 4-week anti-NGF group, TRPA1 mRNA in dorsal root ganglia and spinal phosphorylated ERK protein were elevated, but glial fibrillary acidic protein expression was unaffected. In the 8-week anti-NGF group, there was a 40% reduction in the proportion of mice with microscopic perineural invasion, and no macrometastases were observed. CONCLUSIONS Anti-NGF treatment beginning at 4 weeks may increase inflammation and negatively impact disease. Treatment starting at 8 weeks (after disease onset), however, reduces neural inflammation, neural invasion, and metastasis. These data indicate that NGF impacts PDAC progression and metastasis in a temporally dependent manner.
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Affiliation(s)
- Jami L. Saloman
- Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Aatur D. Singhi
- University of Pittsburgh Cancer Institute, Pittsburgh, PA
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Douglas J. Hartman
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Daniel P. Normolle
- University of Pittsburgh Cancer Institute, Pittsburgh, PA
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kathryn M. Albers
- Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Brian M. Davis
- Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
- University of Pittsburgh Cancer Institute, Pittsburgh, PA
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Burrell SA, Yeo TP, Smeltzer SC, Leiby BE, Lavu H, Kennedy EP, Yeo CJ. Symptom Clusters in Patients With Pancreatic Cancer Undergoing Surgical Resection: Part II. Oncol Nurs Forum 2018; 45:E53-E66. [PMID: 29947350 DOI: 10.1188/18.onf.e53-e66] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To explore the relationship between 16 symptom clusters (SCs), clinical and demographic influencing factors, and clinical outcomes over time in patients with pancreatic cancer (PC) undergoing surgical resection. SAMPLE & SETTING 143 patients with stage II PC undergoing surgical resection were recruited to participate in this longitudinal, exploratory study conducted at Thomas Jefferson University Hospital, a National Cancer Institute-designated cancer center. METHODS & VARIABLES Quality of life was measured preoperatively and at three, six, and nine months postoperatively. Statistical methods included simple linear and Cox proportional hazard regression. RESULTS Preoperative pain was significantly associated with the pain-gastrointestinal SC, and preoperative worry was significantly associated with the mood SC. The strongest negative association with emotional well-being across all study time points was found with the preoperative mood SC. The insomnia-digestive problems SC and the nutritional problems SC demonstrated a trend toward poor survival. IMPLICATIONS FOR NURSING Findings provide evidence that preoperative worry and pain are associated with SC severity and that SCs may have a detrimental effect on quality of life and survival in patients with PC undergoing surgical resection.
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Pain in pancreatic ductal adenocarcinoma: A multidisciplinary, International guideline for optimized management. Pancreatology 2018; 18:446-457. [PMID: 29706482 DOI: 10.1016/j.pan.2018.04.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023]
Abstract
Abdominal pain is an important symptom in most patients with pancreatic ductal adenocarcinoma (PDAC). Adequate control of pain is often unsatisfactory due to limited treatment options and significant variation in local practice, emphasizing the need for a multidisciplinary approach. This review contends that improvement in the management of PDAC pain will result from a synthesis of best practice and evidence around the world in a multidisciplinary way. To improve clinical utility and evaluation, the evidence was rated according to the GRADE guidelines by a group of international experts. An algorithm is presented, which brings together all currently available treatment options. Pain is best treated early on with analgesics with most patients requiring opioids, but neurolytic procedures are often required later in the disease course. Celiac plexus neurolysis offers medium term relief in a substantial number of patients, but other procedures such as splanchnicectomy are also available. Palliative chemotherapy also provides pain relief as a collateral benefit. It is stressed that the assessment of pain must take into account the broader context of other physical and psychological symptoms. Adjunctive treatments for pain, depression and anxiety as well as radiotherapy, endoscopic therapy and neuromodulation may be required in selected patients. There are few comparative studies to help define which combination and order of these treatment options should be applied. New pain therapies are emerging and could for example target neural transmitters. However, until better methods are available, management of pain should be individualized in a multidisciplinary setting to ensure optimal care.
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