Interventional modalities to treat cancer-related pain

Principles of Palliative and Supportive Care in Pancreatic Cancer: A Review

Pancreatic adenocarcinoma (PDAC) is well known for its poor survival time. Clinical symptoms are painless jaundice or abdominal or back pain. Less specific symptoms often appear that make diagnosis difficult, e.g., weight loss, loss of appetite, nausea and vomiting, and general weakness. Only 10-20% of patients are diagnosed at an early stage. A cure is practically only possible with a radical surgical operation. In the case of locally advanced findings, neoadjuvant therapy is administered. Among the therapeutic options offered are chemotherapy, radiotherapy (including stereotactic radiotherapy-SBRT), targeted treatment, or immunotherapy. In the case of metastatic disease, of which more than half are present at diagnosis, the goal is to relieve the patient of problems. Metastatic PDAC can cause problems arising from the localization of distant metastases, but it also locally affects the organs it infiltrates. In our review article, we focus on the largest group of patients, those with locally advanced disease and metastatic disease-symptoms related to the infiltration or destruction of the pancreatic parenchyma and the growth of the tumor into the surrounding. Therefore, we deal with biliary or duodenal obstruction, gastric outlet syndrome, bleeding and thromboembolic diseases, pain, depression, and fatigue, as well as pancreatic exocrine insufficiency and malnutrition. Metastatic spread is most often to the liver, peritoneum, or lungs. The presented overview aims to offer current therapeutic options across disciplines. In accordance with modern oncology, a multidisciplinary approach with a procedure tailored to the specific patient remains the gold standard.

Komplexe Schmerztherapie unter Einbeziehung eines Ischiadikus- und Saphenuskatheters in palliativer Situation bei ausgeprägter Metastasierung eines Bronchialkarzinoms

Hintergrund Kontinuierliche periphere Nervenblockaden (Continuous peripheral nerve blocks, CPNB) werden am häufigsten zur perioperativen Analgesie bei chirurgischen Eingriffen eingesetzt. Alternative Indikationen wie die Behandlung tumorbedingter Schmerzen sind die Ausnahme, gleichwohl das Verfahren auch hier effektiv eingesetzt werden kann.

Fallbericht Bei einer 59-jährigen Patientin mit Bronchialkarzinom konnte der durch Metastasierung in der Tibia verursachte starke Schmerz mittels 28-tägiger CPNB des N. ischiadicus und des N. saphenus bis zu ihrem Versterben effektiv behandelt werden. Neben der Schmerzreduktion auf ein Minimum wurde die vorhergehende opioidassoziierte Vigilanzminderung verringert, wodurch sich die Lebensqualität in der letzten Lebensphase steigern ließ.

Schlussfolgerungen CPNB können auch in der Palliativmedizin regional begrenzte Schmerzen effektiv behandeln. Aufgrund der notwendigen Versorgungsstrukturen wird es aber ein Verfahren bleiben, das nur für einzelne Palliativpatient*innen sinnvoll und indiziert ist.

Intrathecal neurolysis for the management of refractory pain in a patient with terminal oncological disease: case report

We report on the successful treatment of refractory cancer pain by intrathecal neurolysis using 96% absolute alcohol. A female patient with colorectal adenocarcinoma with metastases to the sacral bones, the patient had severe pain refractory to pharmacological and interventional treatment. Intrathecal neurolytic block at the L5-S1 intervertebral space was performed, she reported a significant improvement in her pain and decreased opioid use. The patient did not show deterioration of neurological functions after the procedure or associated complications, and outpatient treatment continued with a home medicine program. She remained comfortable until her death 6 weeks later. Considering that this is an accessible and cost-effective procedure, it could be a helpful alternative for the management of patients with refractory pain in the terminal stage.

Interventional Techniques to Management of Cancer-Related Pain: Clinical and Critical Aspects

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.

Pain Outcomes in Patients Undergoing CT-Guided Celiac Plexus Neurolysis for Intractable Abdominal Visceral Pain

The purpose of this study was to assess outcomes in patients who have undergone celiac plexus neurolysis (CPN) as treatment for refractory abdominal visceral pain at a tertiary care medical center. This study involved retrospective analysis of all patients who had undergone computed tomography (CT)-guided CPN over a 7-year period, as identified in the medical record. Cases were categorized into 1 of 3 groups-group 1: patients getting at least moderate improvement in pain but with improvements subsiding within 2 days; group 2: patients with some sustained pain relief but still requiring heavy doses of narcotics; group 3: patients with major or complete sustained reduction in pain where the narcotic dose was able to be reduced. One hundred thirty-eight cases were identified, 51 of which had no or insufficient follow-up, leaving 87 cases for analysis. Of the 87 cases, 31 (36%) were categorized as group 1, 21 (24%) as group 2, and 35 (40%) as group 3. There were no statistical differences in outcomes based on patient age, gender, time since diagnosis, or type of cancer. Documented postoperative complications were diarrhea (11 cases) and 1 case each of obtundation, hypotension, and presyncopal event. We conclude that patients undergoing CT-guided CPN for abdominal visceral pain achieve moderate or major short-term pain relief in a majority of cases. The procedure is safe with minimal complications.