Pain mechanisms involved and outcome in advanced cancer patients with possible indications for celiac plexus block and superior hypogastric plexus block

AIMS AND BACKGROUND: There is controversy about the role of neurolytic sympathetic blocks in advanced cancer, when pain syndromes may assume other characteristics, with a possible involvement of structures other than visceral. The aim of the present study was to assess the pain characteristics and the analgesic response of a consecutive sample of home care patients with pancreatic and pelvic pain, which would have possible indications for a celiac plexus block and a superior hypogastric block, respectively. METHODS: From January 1999 to December 1999, 400 consecutive advanced cancer patients were surveyed for a prospective longitudinal survey. We considered only patients who had pancreatic cancer or pelvic cancer with pain. RESULTS: Thirty-six patients were surveyed: 22 patients had pelvic cancers and 14 had pancreatic cancer. Patients with pelvic cancers showed a longer survival than those with pancreatic cancer (P = 0.019). Patients with pelvic cancers more frequently showed a neuropathic component associated with a visceral or somatic mechanism than patients with pain due to pancreatic cancer (P = 0.019). When the pain mechanism was taken into consideration, patients with pelvic cancers with a neuropathic component showed worse pain relief than patients with pain due to pancreatic cancer (P = 0.040). CONCLUSIONS: Sympathetic procedures for pain conditions due to pancreatic and pelvic cancers should be intended as adjuvant techniques to reduce the analgesic consumption, and not as a panacea, given that multiple pain mechanisms are often involved because progression of disease is able to change the underlying pain mechanisms. Pancreatic pain seems to maintain visceral characteristics amenable to sympathetic block more than pain due to pelvic cancer.     

基于循证医学的临床常用癌痛微创介入技术

癌痛严重影响肿瘤患者的生命质量,临床上仍有一部分患者药物治疗后未能获得满意的疼痛缓解。微创介入在其中发挥了重要意义。根据循证医学证据,建议使用腹腔神经丛或内脏神经阻滞治疗上腹部癌痛、上腹下丛阻滞治疗骨盆肿瘤所致内脏痛、经皮椎体成形或椎体后凸成形术治疗肿瘤所致椎体疼痛。肋间神经阻滞治疗胸壁癌痛、奇神经节及鞍区阻滞治疗骨盆肿瘤所致会阴部癌痛只有在临床研究中或是无有效缓解手段时作为一种体恤性治疗使用。     

Cancer pain management among underserved minority outpatients: perceived needs and barriers to optimal control

BACKGROUND: Minority patients with cancer are at risk for undertreatment of cancer-related pain. Most studies of patient-related barriers to pain control have surveyed primarily non-Hispanic Caucasian patients. The purpose of the current study was to explore barriers to optimal pain management among African-American and Hispanic patients with cancer through the use of structured patient interviews. Structured interviews allowed the authors to probe for previously unidentified barriers to pain management in these populations. METHODS: Thirty-one socioeconomically disadvantaged minority patients with cancer (14 African-American patients and 17 Hispanic patients) who had cancer-related pain completed structured interviews that assessed three main content areas: information and communication regarding cancer pain, treatment of cancer pain, and the meaning of cancer pain. RESULTS: The African-American and Hispanic patients reported severe pain and many concerns about pain management. The majority of patients in both ethnic groups expressed a belief in stoicism and concerns about possible addiction to opioid medications and the development of tolerance. The patients described their physicians as the most frequent and trusted source of information about cancer pain. However, patients also reported difficulties with communication and a reluctance to complain of pain. CONCLUSIONS: The reported barriers to pain management indicate that socioeconomically disadvantaged African-American and Hispanic patients can benefit from educational interventions on cancer pain that dispel myths about opioids and teach patients to communicate assertively about their pain with their physicians and nurses.     

Coeliac plexus block: utility of the anterior approach and the real time colour ultrasound guidance in cancer patient

AIMS: The aim of our study was to demonstrate the efficacy of ultrasound-guidance compared with computed tomography (CT) guidance for coeliac plexus block in cancer patients. METHODS: Coeliac plexus block (30 ml ethanol) was performed in 34 cancer patients (sex ratio: 10F, 24M), mean age: 54.8 years (range 26-67) under CT (n=21) and ultrasound-guidance (n=13). All patients had excruciating epigastric and generalized abdominal pain caused by cancer of the pancreas (n=13) or upper abdominal viscera (n=9) or a malignancy of extra-digestive origin (n=12). Feasibility and complication rates were analysed. RESULTS: Notable pain relief was obtained in 27 (79%) of the patients. The technical success rate was 100% for CT-guidance and 93% (13/14) for ultrasound guidance. There were six minor complications (17%): chemical peritonitis (n=2), orthostatic arterial hypotension (n=2) and transient left shoulder pain (n=2), no major complications occurred. The target route was transhepatic in 6/13 of the ultrasound cases and mean length was 6 cm (range 3-12 cm). Colour Doppler sonography improved visualization of the 21 Gauge Chiba needle when the needle shaft was vibrated. Echogenic foci were observed around the origin of the coeliac trunk and superior mesenteric artery in all cases. CT coeliac block was successfully performed after failure of ultrasound guidance in one patient. CONCLUSION: Ultrasound guidance is safe and effective and should be attempted for coeliac plexus block whenever possible.     

Invasive analgesia techniques for advanced cancer pain.

Because most cancer pain involves multiple anatomic sites, invasive techniques are intended to be analgesic adjuvants and not serve as the definitive treatment. These procedures often allow patients to reduce their dosages in their current drug regimens or to derive greater pain relief from their present doses in order to improve their quality of life. Medical care of the suffering pain patient requires a multimodality, multispecialty approach combining psychotherapy, social support, and pain management to provide the best possible quality of life or quality of dying.     

Morphine: Patient Knowledge and Attitudes in the Central Anatolia Part of Turkey

Background: In Muslim majority countries (MMC) opioid use for pain management is extremely low. The underlying factors contributing to this are not well defined. Aim: The aim of this study was to survey the attitudes of cancer patients towards morphine use for pain management in a MMC and identify the factors that influence patient decisions to accept or refuse morphine as treatment for cancer pain. Settings/participants: Patients were questioned whether they had pain or not, the severity and the medications for pain management. Questionsincluded what type of medication they thought morphine was, whether or not they would be willing to take morphine if recommended for pain management and the basis for their decision if they were against morphine use. Results: Four hundred and eighty-eight patients participated in the study. Some 50% of the patients whorefused morphine use and 36.8% of the patients who would prefer another drug, if possible, identified fear of addiction as the basis for their decision. Reservation of morphine for later in their disease was the case for 22.4% of the patients who refused morphine use. Only 13.7 % of the patients refusing morphine and 9.7% of the patients who preferred another drug, if possible, cited religious reasons as the basis for this decision. Conclusions: Identifying the underlying factors contributing to low opioid use for pain management in MMC is important. Once the underlying factors were identified, all efforts should be taken to overcome them as they are barriers to improving patient pain management.     

Adequacy of cancer pain management in a Japanese Cancer Hospital

BACKGROUND: Pain is one of the most frequent and deleterious symptoms in cancer patients. This study was carried out to investigate the adequacy of pain management at the National Cancer Center Hospital East, Japan. METHODS: The available data were obtained from 138 ambulatory cancer patients with pain. The data included pain severity, which patients reported using the Japanese version of the M. D. Anderson Symptom Inventory, along with such medical information as cancer and treatment information and currently prescribed analgesics. Adequacy of pain management was assessed using the Pain Management Index, which revealed whether prescribed analgesic drugs were congruent with pain severity. RESULTS: Physicians undertreated pain in 70% of patients. Patients with non-advanced cancer (local cancer or no evidence of any recurrent cancer) were more likely to receive inadequate treatment than those with advanced cancer [P = 0.009, odds ratio = 0.18, Exp (95% CI) lower = 0.05, higher = 0.64] in the exploratory logistic regression analysis. Additionally, we found significant differences among physicians in ability to manage cancer pain, unrelated to a physician's years of experience as an oncologist. CONCLUSIONS: This study suggests that cancer pain management is insufficient at the investigated institute. Remedial action should be taken, including increasing awareness of symptom management in medical staff and incorporating existing knowledge into routine clinical practice.     

Interventionelle Verfahren in der Tumorschmerztherapie

Background

Analgesics and antineuropathic substances are the mainstays of cancer pain management. Interventional procedures for the relief of cancer pain are only rarely applied.

Aim

In this review the indications for interventional pain management of cancer pain are presented.

Material and methods

In a systematic review PubMed and the Internet were searched for clinical trials and case reports documenting effects, adverse events and complications of specific interventional procedures used in the management of cancer pain.

Results

Based on the criteria of evidence-based medicine, there is no proof that the use of interventional procedures for cancer pain is necessary.

Discussion

The use of interventional procedures for cancer pain should be restricted to patients with individual indications. Interventional procedures have the potential to reduce adverse events but can also have additional severe complications.     

Supportive care in oncology

Pain management, nutritional support, and psychosocial support are fundamental services that enhance patients' ability to cope with their cancer and its therapy. The common goal of symptom prevention mandates that each of these supportive services be provided to all patients throughout their cancer experience. Comprehensive cancer pain management begins with identifying the origin of all of the patient's pains and treating each one specifically. Pain prevention can be achieved through around-the-clock opioid administration with as-needed supplements for breakthrough pain and dose titration. Common narcotic side effects such as constipation and nausea also must be prevented. Successful opioid analgesia requires that patient and family concerns regarding addiction and tolerance be dispelled at the outset. Cancer pain prevention can be further optimized with the use of appropriate coanalgesics in response to the pathophysiology of the patient's pains. Cognitive and behavioral therapies may also be useful adjuncts to reduce both pain and suffering. Procedure-oriented pain control should be considered when systemic pharmacologic therapy does not provide adequate pain relief or is associated with intolerable side effects. The only absolute contraindications for pain-relieving procedures are untreatable coagulopathy and a decrease in mental status not related to medical pain management. Useful neurodestructive techniques include radiofrequency lesioning, cryoanalgesia, and chemical neurolysis with agents such as phenol, alcohol, and hypertonic saline. The most beneficial pain-relieving procedures and percutaneous cordotomy, spinal narcotics, celiac and hypogastric plexus ablation, spinal neurolysis, and epidural injection of steroids and hypertonic saline. Procedure selection depends on the cause of the pain and the patient's prognosis. Common indications for pain-relieving procedures include unilateral pain below the shoulder, upper abdominal visceral pains, pelvic visceral pain, perineal pain, vertebral body metastasis, discogenic pain, and spinal stenosis. As results of well-conducted scientific trials begin to appear in the literature, the indications for these procedures will be better understood, resulting in their more appropriate use. Principles of nutritional support in patients with cancer include an awareness of the problem of malnutrition and its impact on performance status, quality of life, prognosis, and treatment; identification of those patients at risk; prophylactic versus therapeutic intervention; and analysis and management of the specific impediment(s) to adequate nutrient intake and absorption. The primary goals for nutritional support in cancer patients are prevention of weight loss and maintenance of adequate protein status. Appreciation of practical issues of nutritional support will enable the practicing physician to achieve these goals using primarily oral nutrition options.(ABSTRACT TRUNCATED AT 400 WORDS)     

Unequal quality of cancer pain management: disparity in perceived control and proposed solutions

Purpose/Objectives: To examine poverty-related and racial and ethnic disparity in cancer pain management. Data Sources: Published articles, conference proceedings, testimony, and clinical case studies. Data Synthesis: Disparity in the quality of cancer pain management exists resulting from interactions among patient, provider, and environmental factors. Irrespective of etiology, disparity results in inadequate management of cancer pain for vulnerable populations (poor patients, ethnic and racial group members, older adults) and is unacceptable in cancer care. Inadequate symptom management affects cancer treatment tolerance, exacerbating disparity in treatment outcomes and affecting end-of-life care. Conclusions: Evidence-based solutions include a systems approach, quality-improvement and quality-assurance processes that expose disparities and enforce evidence-based treatment per national guidelines, and statewide comprehensive cancer planning to target pain management outcomes. Implications for Nursing: Oncology nurses and interdisciplinary teams must be aware of disparities in cancer pain management for vulnerable groups, intervene to empower patients through customized educational approaches, and simultaneously implement systemwide strategies to ensure effective pain management and targeted monitoring for high-risk patients.     

局麻和腰麻下经尿道2 μm激光切除术治疗非浸润性膀胱癌的疗效对比研究

目的:对比分析局麻下经尿道2 μm激光切除术治疗非浸润性膀胱癌的疼痛和舒适度对疗效的影响。方法:150例男性非浸润性膀胱癌患者随机分为局麻组(n=75)及腰麻组(n=75),对比分析两组间术中操作疼痛评分、操作时间、出血量、并发症及术后1年复发率。结果:局麻组患者疼痛评分为3(2～5)分,腰麻组疼痛评分为2(1～3)分,局麻组患者疼痛评分高于腰麻组疼痛评分,差异有统计学意义(P＜0.05);局麻组与腰麻组间手术操作时间分别为(16.09±3.89) min、(15.88±3.84) min;出血量分别为(6.60±2.44) ml、(6.44±2.26) ml;术后1年复发率分别为13.33%、14.67%,差异均无统计学意义(P＞0.05),所有患者均无明显严重并发症。结论:局麻下经尿道2 μm激光切除术治疗非浸润性膀胱癌的疼痛程度较腰麻组稍重,但均能耐受, 疼痛并未影响手术疗效,对于较小肿瘤或肿瘤基底窄、有麻醉禁忌证等患者在门诊手术间行局麻下经尿道2 μm激光切除术是可行的选择。     

未能切除胰腺癌患者术中NCPB的临床意义

目的 研究术中腹腔神经丛阻滞对无法切除胰腺癌患者的镇痛疗效及并发症。方法 41例患者经腹行直视下的腹腔神经丛阻滞，每人次注射无水酒精20－50ml，同时行胆肠转流或／和胃肠转流，部分患者行区域动脉化疗。结果 腹腔神经丛阻滞后6个月内或已死亡者中有32例患者疼痛完全缓解，4例明显减轻，5例无明显效果。38例术中出现血压下降，15例术后腹泻，结论 术中直视下经腹行无水酒精腹腔神经丛阻滞对缓解未能切除胰腺癌患者的疼痛具有明显的镇痛效果。     

Using hypnosis with children for pain management

Although nurses are in a strategic position to use hypnosis to manage a child's cancer pain, many lack the knowledge, the skill, or the exposure to the clinical effectiveness of hypnosis. Hypnosis has been a potent analgesic and anesthetic agent for more than 100 years; it reduces a child's cancer pain and the pain associated with painful procedures. Nurses can use hypnosis to help children diminish pain and cope with lumbar punctures (LPs), bone marrow aspirations (BMAs), and nausea or vomiting from chemotherapy. This article's purpose is to discuss myths, contraindications, research, processes, and effectiveness of hypnosis as a strategy for managing the cancer pain of school-age children. Vignettes from the author's clinical practice illustrate concepts and procedures.     

Road map for pain management in pancreatic cancer: A review

Beside its poor prognosis and its late diagnosis, pancreatic cancer remains one of the most painful malignancies. Optimal management of pain in this cancer represents a real challenge for the oncologist whose objective is to ensure a better quality of life to his patients. We aimed in this paper to review all the treatment modalities incriminated in the management of pain in pancreatic cancer going from painkillers, chemotherapy, radiation therapy and interventional techniques to agents under investigation and alternative medicine. Although specific guidelines and recommendations for pain management in pancreatic cancer are still absent, we present all the possible pain treatments, with a progression from medical multimodal treatment to radiotherapy and chemotherapy then interventional techniques in case of resistance. In addition, alternative methods such as acupuncture and hypnosis can be added at any stage and seems to contribute to pain relief.     

硬膜外阻滞疗法对腰椎间盘突出症的疗效

目的探讨硬膜外阻滞治疗腰椎间盘突出症的疗效。方法在病变明显压痛点的上或下一个椎间隙行硬膜外穿刺，成功后置入导管，注入15～20ml复合镇痛液，通过药物的药理作用及液体自身的物理作用，减轻椎间盘神经压迫及组织黏连，缓解水肿，从而治疗因腰椎间盘突出而引发的不良症状。结果治疗76例，治愈28例，好转48例。每人治疗1疗程（3～4次，1周1次），平均随访14个月。结论硬膜外阻滞治疗腰椎间盘突出症具有疗效确切、缓解率高的优点。     

Pharmacologic Management of Painful Oncology Procedures in Pediatrics

Children with cancer often cite procedural pain as the most distressing part of their disease. Pharmacologic interventions that decrease the pain and anxiety of invasive procedures have been shown to be beneficial, particularly when these interventions are a routine part of every procedure. However, despite the known benefits of analgesia and sedation, guidelines for the management of pediatric pain and stress during oncology procedures have not been established. Thus, children may not be receiving optimal pain relief. Various drugs have been investigated in pediatric populations to provide local anesthesia, systemic analgesia, conscious sedation, deep sedation, and general anesthesia. These agents include lidocaine-prilocaine, amethocaine, lidocaine, methohexital, propofol, midazolam, meperidine, nitrous oxide, fentanyl, ketamine, and diazepam. Local anesthesia with lidocaine-prilocaine and amethocaine decreases pain from accessing centrally placed venous devices (ports) and venipuncture; however, neither, is sufficient as a sole intervention for bone marrow aspirations (BMA), bone marrow biopsies (BMB) or lumbar punctures (LP). Transient local skin reactions are common with the use of lidocaine-prilocaine and amethocaine. Deep sedation or general anesthesia can be achieved with a variety of agents and are ideal interventions if pain and movement are to be prevented during more invasive procedures such as LP, BMA, and BMB. Titration of doses and monitoring to detect early adverse effects increase the safety of these interventions. Systemic analgesia with fentanyl or nitrous oxide in combination with local anesthesia may be appropriate for older children more comfortable and familiar with these procedures; conscious sedation may also be an option for these children, but deep sedation and general anesthesia should always be made available if it is the child’s preferred method of pain relief.     

Enhancement of human papilloma virus type 16 E7 specific T cell responses by local invasive procedures in patients with (pre)malignant cervical neoplasia

It has been suggested that local invasive procedures may alter the natural course of (pre)malignant cervical disease. This could be due to partial excision of the lesions, or via induction of cellular immunity against human papillomavirus (HPV) by the local invasive procedures. We studied the influence of local invasive procedures on HPV-16 E7 specific immune responses in patients with different grades of cervical intra-epithelial neoplasia (CIN) and different stages of cervical cancer. Blood was obtained at intake and after invasive procedures from patients with CIN or cervical cancer. Antigen specific T-cell responses were measured by IFN-gamma ELISPOT analysis, after stimulation with recombinant HPV-16 E7 protein. As expected, HPV-16 E7 specific IFN-gamma T cell responses were more frequent in HPV-16 DNA positive patients compared with that in HPV-16 DNA negative patients (39/50 vs. 16/36, (p=0.006, chi2 test). After invasive procedures, a small number of HPV-16 DNA positive CIN patients, but a considerable proportion of HPV-16 DNA positive cervical cancer patients, showed an enhancement of T cell responses against HPV-16 E7. Induction of T cell reactivity was most pronounced in cervical cancer patients who had undergone previous invasive procedures. Both CD4+ and CD8+ T cells showed E7 specific IFN-gamma production upon in-vitro stimulation. Our study shows that invasive procedures may enhance HPV-specific cell-mediated immunity in a considerable number of patients with cervical cancer, but in only a minority of CIN patients. Our data indicate that invasive procedures should be considered as possible confounding factors when analyzing the effectiveness of therapeutic immunization studies, especially, when induction of HPV-specific immune responses is used as intermediate end-point.     

中国肿瘤患者围术期疼痛管理专家共识（2020版）

肿瘤切除术是绝大多数早中期实体肿瘤治疗的基础，肿瘤切除术后常伴随持续的疼痛。手术创伤和疼痛可引起炎症、下丘脑-垂体轴激活和交感系统过度反应发生。这些因素会影响肿瘤患者的免疫能力，导致免疫抑制。围术期有效的疼痛管理可以优化肿瘤患者的免疫功能，对肿瘤患者术后康复也具有重要意义。因此，中国抗癌协会肿瘤麻醉与镇痛专业委员会组织专家制定我国肿瘤患者围术期疼痛管理的专家共识，目的是为肿瘤患者术后急性疼痛管理提供基于证据的临床建议。本共识为学术性建议，仅限于指导肿瘤患者术后急性疼痛管理，不适用慢性疼痛或肿瘤导致的癌性疼痛。      

Pain experienced by lung cancer patients: a review of prevalence, causes and pathophysiology

BACKGROUND: Lung cancer is one of the commonest cancers to cause pain, but little is known regarding the extent of this complex problem in these patients. METHODS: Medline (1966-June 2002) and Cancerlit (1975-May 2002) were searched to identify studies of lung cancer patients' experience of pain, its prevalence, causes and underlying pathophysiology. RESULTS: Thirty-two studies were identified. Patients were recruited from diverse populations, and the prevalence varied according to study setting. Pain affected 27% of outpatients (range 8-85%), and 76% of patients cared for by palliative care services (range 63-88%). Pain was caused by cancer in 73% (range 44-87%), and cancer treatment in 11% (range 5-17%). Nociceptive pain was the major pathophysiological subtype in lung cancer pain, but neuropathic pain accounted for 30% (range 25-32%) of cases. CONCLUSIONS: The overall weighted mean pain prevalence of pain was 47% (range 6-100%). Cancer patients should be asked about pain at all stages of management. Those with pain should be investigated for disease progression and considered for referral for specialist management.