Interventional Treatments of Cancer Pain

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Key points

  • Intrathecal drug delivery should be considered for patients with cancer experiencing opioid-related side effects or pain refractory to opioid dose escalation.

  • In cancer patients with painful vertebral compression fractures that have failed to improve with conservative treatment, vertebral augmentation is a safe and minimally invasive technique that improves both pain and function.

  • Neurolysis of the celiac plexus, superior hypogastric plexus, or ganglion impar is indicated in patients with cancer

Intrathecal drug delivery

Intrathecal drug delivery (IDD) entails the administration of drugs, typically opioids with or without adjunct medications, directly to the cerebrospinal fluid and to the central nervous system receptor sites via a subarachnoid catheter. The analgesic agent is delivered from an implanted device or, less commonly, an external pump. Because IDD allows the drug to largely bypass the systemic circulation, it results in minimal systemic side effects, yet superior analgesia, at a fraction of the

Vertebral augmentation

Osseous metastatic disease is common in patients with advanced cancer, and spine lesions are particularly common in patients with multiple myeloma as well as breast, prostate, renal cell, thyroid, and lung cancers. Spine lesions may lead to vertebral compression fractures (VCFs) that can cause debilitating pain and reduced function.

Although some patients improve with rest, analgesics, physical therapy, and bracing, pain can persist or be so severe that it compromises function. Open surgical

Neurolytic plexus blocks

Neurolysis of a sympathetic nervous system plexus, typically using dehydrated alcohol or phenol, is indicated for patients experiencing cancer-associated visceral pain. Pain relief typically lasts for months, and the procedure can be repeated if necessary. The celiac plexus, superior hypogastric plexus, and ganglion impar are the most common targets for the treatment of upper abdominal, pelvic, and perineal cancer pain, respectively. These procedures are summarized in Table 4.

Image-guided percutaneous tumor ablation

Painful bony metastatic disease is common in patients with cancer. While external beam radiation therapy remains the mainstay of treatment, approximately 20% to 30% of patients do not respond to radiation. Recent advances have been made in treating this population using image-guided tumor ablation. This technique involves percutaneous placement of a needle into painful bone metastases followed by thermal destruction using radiofrequency ablation (RFA) or cryoablation.41

Spinal Cord Stimulation

Spinal cord stimulation (SCS) for cancer pain is limited to case reports and one case series but has been used successfully for multiple types and locations of pain. There are reports of treating pain directly resulting from anal cancer, metastatic colon cancer, testicular cancer, and angiosarcoma, as well as post-thoracotomy and chemotherapy-induced peripheral neuropathy pain.46, 47, 48, 49, 50

Until recently, the frequent need for MRI in oncology has limited the use of SCS. However there are

Summary

Interventional treatments are indicated for the treatment of many different cancer pain syndromes. These approaches should be considered early in the treatment course and should complement pharmacologic and other symptom management techniques to improve patient comfort and function and permit full participation in the oncologic care plan. An understanding of proper patient selection, management of patient and referring physician expectations, knowledge of the procedural risks and benefits of

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    Disclosures: Dr J.E. Sindt has served as a consultant for Medtronic, Inc, Langhorne, PA. Dr S.E. Brogan has served as a speaker and consultant for Medtronic, Inc, Langhorne, PA.

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