Interventional Pain Management Interventional Pain Management In CancerIn Cancer

P N Jain, MD MNAMSP N Jain, MD MNAMSProfessor, Department Of Anaesthesia, Critical Care & Pain Professor, Department Of Anaesthesia, Critical Care & Pain

President, Indian Society for the study of painPresident, Indian Society for the study of painpnj5@hotmail.com pnj5@hotmail.com

Tata Memorial HospitalMumbai, India

Role Of Invasive Therapy In Cancer PainRole Of Invasive Therapy In Cancer Pain

Drug therapy remains the foundation of cancer pain Drug therapy remains the foundation of cancer pain management. (management. (IASP Update Vol VI,ISS 1998)IASP Update Vol VI,ISS 1998)

WHO ladder is effective in 70-90% patients. WHO ladder is effective in 70-90% patients. ((WHO validation WHO validation study for cancer pain relief 1987, study for cancer pain relief 1987, de Conno , Ann Oncol 1993)de Conno , Ann Oncol 1993)

10-30% patients (unresponsive or SAE with opioids)10-30% patients (unresponsive or SAE with opioids)No clear-cut consensus, when to use invasive therapy in No clear-cut consensus, when to use invasive therapy in cancer paincancer painRule of thumbRule of thumb: start with conservative, progress to low : start with conservative, progress to low risk to more invasive high risk procedure: justified in severe risk to more invasive high risk procedure: justified in severe refractory pain refractory pain

Indications For Invasive ProceduresIndications For Invasive Procedures

Unrelieved pain by WHO 3-step ladderUnrelieved pain by WHO 3-step ladderUnacceptable side effects with systemic therapiesUnacceptable side effects with systemic therapiesPain crisisPain crisisPatient’s desire to avoid systemic therapyPatient’s desire to avoid systemic therapy

Short life expectancyShort life expectancy

……Effect may persist only for several months. Effect may persist only for several months. But for someone with a terminal illness, this But for someone with a terminal illness, this can be a lifetimecan be a lifetime

Lancet 2001:358(9276(:139-143 J Pain Symptom Manage 2002;24:152-159

What Is Neurolysis ?What Is Neurolysis ?

A treatment to destroy the nerve A treatment to destroy the nerve

Cancer pain often stems from growing Cancer pain often stems from growing

tumors and injured tissue, so an effective tumors and injured tissue, so an effective

block for it may be a neurolytic procedureblock for it may be a neurolytic procedure

Chemicals – Alcohol and PhenolChemicals – Alcohol and Phenol

Radio-Frequency Ablation –focused amounts Radio-Frequency Ablation –focused amounts

of heatof heat

Tata Memorial Hospital Pain Clinic: 2006-2007Tata Memorial Hospital Pain Clinic: 2006-2007Neurolytic BlocksNeurolytic Blocks

20062006 20072007 ComplicationsComplications

CPBCPB 4343 3434 ARF ARF

Intercostal + ParavertebralIntercostal + Paravertebral 2020 1818 Transient LL weaknessTransient LL weakness

Subarachnoid phenolSubarachnoid phenol 7 7 0606 Incontinence Incontinence

Stellate ganglionStellate ganglion 44 1212 Hoarseness Hoarseness

GlossopharyngealGlossopharyngeal 44 0606 Facial palsy Facial palsy

Maxillary + MandibularMaxillary + Mandibular 33 0606 Hematoma Hematoma

Local steroid Inj.Local steroid Inj. 33 0303

Superior hypogastricSuperior hypogastric 22 0606 Acute abdomen Acute abdomen

Lumbar sympatheticLumbar sympathetic 22 0404

88/713 (12%) 88/713 (12%) 95/890 (10.7%)95/890 (10.7%)

““Experience gives the pain practitioner good Experience gives the pain practitioner good judgment… judgment…

bad judgment provides a wealth of bad judgment provides a wealth of experience”.experience”.

Neurolytic DrugsNeurolytic DrugsALCHOHOLALCHOHOL PHENOLPHENOL

Colourless Colourless water solublewater soluble

Very Viscous Very Viscous Insoluble in waterInsoluble in water

Absolute to 50%Absolute to 50% 6-10% 6-10% in saline, Hin saline, H22O, glycerine, O, glycerine, radiological dyesradiological dyes

Hypobaric Hypobaric (0.85 with respect to CSF)(0.85 with respect to CSF)

Hyperbaric Hyperbaric (1.1 with respect to CSF)(1.1 with respect to CSF)

Action:Action:Dehydration & sclerosis of nerve Dehydration & sclerosis of nerve fibres & demyelinationfibres & demyelination

Action:Action: protein denaturation (in vascular protein denaturation (in vascular structures Sp cord infarction)structures Sp cord infarction)IV phenol: arrhythmia,cardiac arrestIV phenol: arrhythmia,cardiac arrest

Longer Shelf LifeLonger Shelf Life Shelf Life -1 yearShelf Life -1 year

Longer duration of reliefLonger duration of reliefInexpensive drugsInexpensive drugsFrequent visits not requiredFrequent visits not requiredPatient can remain at homePatient can remain at homePain free or reduced Pain free or reduced medicationsmedications

Effect is unpredictableMay need hospitalization for Assessment / complications Skilled practitioner Imaging equipment Need to be repeated

Advantages Disadvantages

Neurolytic BlocksNeurolytic Blocks

Prerequisites for Neurolytic Block …Prerequisites for Neurolytic Block …

Technically demanding: Imaging modalities never pick up nerves, Technically demanding: Imaging modalities never pick up nerves,

Growth of the tumour, radiation fibrosis, Sx may distort the Growth of the tumour, radiation fibrosis, Sx may distort the

anatomy.anatomy.

Experience and Skill. Experience and Skill.

Careful selection of patients.Careful selection of patients.

Diagnostic block with LA is essential.Diagnostic block with LA is essential.

Anticipate and tackle complications ( Multidisciplinary Set up)Anticipate and tackle complications ( Multidisciplinary Set up)

Action unpredictable/ May be repeated/ Need follow up Action unpredictable/ May be repeated/ Need follow up

Weigh the risk versus the benefitWeigh the risk versus the benefit

Risk versus BenefitRisk versus Benefit

Benefit

Subarachnoid Block

Epidural Block

Coeliac Plexus Block

Risk

LR, HBLR, LB

HR, HBHR, LB

Stellate ganglion BlockPeripheral nerveblock

Types of Neurolytic BlocksTypes of Neurolytic Blocks

Autonomic Nerve BlocksAutonomic Nerve Blocks

Peripheral Nerve BlocksPeripheral Nerve Blocks

Neuraxial BlocksNeuraxial Blocks

Sympathetic BlocksSympathetic Blocks

TYPE OF BLOCK TYPE OF BLOCK SITE /CONDITION TREATEDSITE /CONDITION TREATED

Stellate ganglion Stellate ganglion Head or arm pain Head or arm pain

Celiac plexus (splanchnic Celiac plexus (splanchnic nerves) nerves)

upper abdominal pain (visceral origin) upper abdominal pain (visceral origin)

Lumbar sympathetic Lumbar sympathetic Lower limb pain Lower limb pain

Sup.Hypogastric plexus Sup.Hypogastric plexus Perineal, pelvic, and lower limb pain Perineal, pelvic, and lower limb pain

Ganglion Impar ( Walther) Ganglion Impar ( Walther) Perineal or Rectal pain Perineal or Rectal pain

Stellate Ganglion Stellate Ganglion BlockBlock

Neurolytic Coeliac Plexus Block (NCPB)Neurolytic Coeliac Plexus Block (NCPB)

Perhaps the most rewarding block Perhaps the most rewarding block CPB may improve bowel motility and may convert CPB may improve bowel motility and may convert bedridden patient into an ambulatory one (1)bedridden patient into an ambulatory one (1)CPB abolishes pain until death in 10-24% when employed CPB abolishes pain until death in 10-24% when employed alone. 80%-90% when used with other treatment options alone. 80%-90% when used with other treatment options (2)(2)Significant pain relief at 2 ,4,6 months and survival benefit Significant pain relief at 2 ,4,6 months and survival benefit in 137 unresectable pancreas cancer patients (3)in 137 unresectable pancreas cancer patients (3)Significant reduction in morphine consumption and VAS Significant reduction in morphine consumption and VAS score in the first month (4,5)score in the first month (4,5)

1. Br J Surg 1998;85:199-2011. Br J Surg 1998;85:199-201 2. Anesthesiology 1992:76:394 – 4102. Anesthesiology 1992:76:394 – 410

3. Ann Surg 1993;217:447-4573. Ann Surg 1993;217:447-457 4. Pain 1993;52:534-5404. Pain 1993;52:534-540 5. Pain 1996;64:597-6025. Pain 1996;64:597-602

Indications:Severe upper Abdominal pain (PS >7.0)Poor control on NSAID + opioidsLife expectancy > 3 months

Contraindications:Ascitis++, encased CP(CT scan)Multiple painscoagulation?Deny consent

Anterocrural Vs Retrocrural spread

Fluoroscopic imaging in CPBFluoroscopic imaging in CPB

De Cicco et al, Single-needle celiac plexus block,Anesthesiology:87;1997

Cephalad to celiac trunk

Caudad

NCPB reduced pain intensity and morphine consumption, NCPB reduced pain intensity and morphine consumption, improved performance status at one month improved performance status at one month

Journal of Pain and Palliative Care Pharmacotherapy.2005;19(3);15-20

Demographic DataDemographic DataAge (yrs)Age (yrs) CPB CPB

(n=48)(n=48)Morphine Morphine (n=50)(n=50)

Mean Mean SD SD 48.62 48.62 10.5010.50 50.90 50.90 10.0210.02

RangeRange 23-7323-73 32-7832-78

Sex RatioSex Ratio CPB CPB (n=48)(n=48)

MorphineMorphine (n=50)(n=50)

MaleMale 24 (50%)24 (50%) 30(60%)30(60%)FemaleFemale 24 (50%)24 (50%) 20(40%)20(40%)

4848 5050 PN Jain et al, Journal of Pain and Pall Care Pharmacotherapy Vol 19,N0 3 2005

CPBCPBn=48n=48

MorphineMorphine n=50n=50

PancreasPancreas 18 (37.5%)18 (37.5%) 18(36%)18(36%)Gall BladderGall Bladder 17 (34.5%)17 (34.5%) 21(42%)21(42%)

StomachStomach 8 (16.7%)8 (16.7%) 8(16%)8(16%)L 1/3 oesophagusL 1/3 oesophagus 3 (6.3%)3 (6.3%) 00Transverse ColonTransverse Colon 1 (2.1%)1 (2.1%) 00

Liver metastasisLiver metastasis 1 (2.1%)1 (2.1%) 3(6%)3(6%)

TotalTotal 4848 5050

DiseaseDisease

PN Jain et al, Journal of Pain and Pall Care Pharmacotherapy Vol:19,No 3 2005

What is the evidence on CPB?What is the evidence on CPB?

Author and yearAuthor and year(reference)(reference)

Type of Type of paperpaper

No. ofNo. ofpatientspatients

Type of Type of CancerCancer

GuidanceGuidance

Ischia (1992) Ischia (1992) RCTRCT 6161 PancreasPancreas FluoroscopyFluoroscopy

Lillemoe (1993) Lillemoe (1993) RCTRCT 137137 PancreasPancreas Intra-operative Intra-operative Neurolysis Neurolysis

Polati (1998) Polati (1998) RCTRCT 2424 PancreasPancreas FluoroscopyFluoroscopy

Gunaratnam(2001) Gunaratnam(2001) NRCTNRCT 5858 PancreasPancreas Endoscopic USGEndoscopic USG

Mercadante (2003) Mercadante (2003) RCTRCT 2222 PancreasPancreas FluoroscopyFluoroscopy

Wong (2004) Wong (2004) RCTRCT 100100 PancreasPancreas FluoroscopyFluoroscopy

Stefaniak (2005) Stefaniak (2005) NRCTNRCT 5959 PancreasPancreas ThoracoscopyThoracoscopy

Neurolytic celiac plexus block for pain control in unresectable pancreatic cancer (A systematic review)

RESULTS: Five RCTs involving 302 patients (NCPB, N = 147; control, N = 155)

CONCLUSIONS: In patients with unresectable pancreatic cancer, NCPB is associated with improved pain control, and reduced narcotic usage and constipation compared with standard treatment, albeit with minimal clinical significance. PMID: 17100960 [PubMed - indexed for MEDLINE]

Yan BM, Am J Gastroenterol. 2007 Feb;102(2):430-8.

Recent modalities of CPBRecent modalities of CPBUSG USG (Montero,1989)(Montero,1989) / CT guided / CT guided ((Herpels 1988Herpels 1988))EUS guided EUS guided ((Levy MJ 2003Levy MJ 2003))Trans-discal splanchicectomy Trans-discal splanchicectomy (Plancarte 2003)(Plancarte 2003)

Thoracoscopic splanchicectomy Thoracoscopic splanchicectomy (Worsey (Worsey 1993,Stefaniak 2005)1993,Stefaniak 2005)

Laparoscopic ablation Laparoscopic ablation (Strong 2006)(Strong 2006)

Radiofrequency ablation (Radiofrequency ablation (P Raj,2001P Raj,2001))

Peripheral Nerve BlocksPeripheral Nerve Blocks

Blockade has to be proximal to the source of IrritationBlockade has to be proximal to the source of Irritation

Sensory distribution overlap :blockade of the neighboring Sensory distribution overlap :blockade of the neighboring

segment recommendedsegment recommended

Many peripheral nerves are of mixed typesMany peripheral nerves are of mixed types

Diagnostic block with LA is essential: impact of concomitant Diagnostic block with LA is essential: impact of concomitant

motor deficitmotor deficit

Accuracy essential for good effect and to avoid damage of Accuracy essential for good effect and to avoid damage of

non targeted structuresnon targeted structures

Paravertebral Nerve BlockParavertebral Nerve Block

Subarachnoid and Epidural NeurolysisSubarachnoid and Epidural Neurolysis

Advantages:Advantages:Good resultsGood results

Ease of injection & repetitionEase of injection & repetition

No hospitalisationNo hospitalisation

Good duration of analgesiaGood duration of analgesia

Used in aged & debilitated Used in aged & debilitated

Low complication rateLow complication rate

Complications: Complications: Paresis Paresis

Bladder-bowel dysfunctionBladder-bowel dysfunction

Subarachnoid Versus Epidural NeurolysisSubarachnoid Versus Epidural Neurolysis

Verification of placement more specific (CSF Verification of placement more specific (CSF return) return)

More profound AnalgesiaMore profound Analgesia

Can be performed on an outpatient basisCan be performed on an outpatient basis

Precise control, proper positioning , minimum Precise control, proper positioning , minimum dose is possible with subarachnoid blockdose is possible with subarachnoid block

RRodriguez et al Surg Gynecol Obstet 1991:173(1):41 44)odriguez et al Surg Gynecol Obstet 1991:173(1):41 44)

Subarachnoid Phenol in GlycerineSubarachnoid Phenol in Glycerine(Dorsal Rhizotomy)(Dorsal Rhizotomy)

Subarachnoid Subarachnoid Absolute alcoholAbsolute alcohol

Superior Hypogastric Block

Plancarte R, Anesthesiology 1990 & Reg Anesth,1997

Ganglion ImparGanglion Impar

Plancarte R, Anesthesiology 1990

ConclusionsConclusions

Pain Physicians should consider nerve blocks when Pain Physicians should consider nerve blocks when

systemic analgesics are failing. systemic analgesics are failing. (Adjuvant therapy)(Adjuvant therapy)

Careful selection of patients Careful selection of patients

Benefits should outweigh the risksBenefits should outweigh the risks

Thorough knowledge of the limitations and side effectsThorough knowledge of the limitations and side effects

Need for randomized controlled clinical trialsNeed for randomized controlled clinical trials

Thanks