Anesthesiology Consultation for Localized Cancer Pain

Abed Rahman¹, Magdalena Anitescu², and Raed Rahman¹

¹Cancer Treatment Centers of America, Zion, IL, USA

²University of Chicago Medical Center, Chicago, IL, USA

Case study 139.1

A 54-year-old male with advanced pancreatic cancer reports severe epigastric pain radiating to his middle back, worsening over the last 2 months. His pain score is 9/10, and he describes it as aching and throbbing, with sharp intermittent episodes. He has tried oxycontin and oxycodone with minimal analgesia, and has noticed severe mental sluggishness. He was rotated to morphine immediate release and extended release with intolerable mental sedation and poor analgesic control. He feels his quality of life is poor and is being referred to a psychiatrist for anxiety and depression. He dislikes opioids and their side effects.

1. Which of the following pain management options is appropriate for this patient?

Rotating to another opioid; hydromorphone short and long acting
Start acetaminophen 500 mg every 8 hours for analgesia
Start amitryptyline 25 mg every evening for depression
Evaluate the patient for a celiac plexus block
Hold off on further pain management changes until the psychiatric evaluation is complete

Epigastric pain is common in patients with pancreatic cancer. If the adverse effects of opioids are intolerable or escalating doses are ineffective for analgesia, a celiac plexus block can be beneficial. Pancreatic cancer can cause severe pain in up to 70% of patients and can be difficult to treat. A celiac plexus block can be effective technique for reducing the pain severity for up to 1 year if a destructive neurolytic agent (95% alcohol or 6% phenol) is used. The celiac plexus innervates the distal esophagus, stomach, duodenum, liver, and pancreas. Rotating to hydromorphone and escalating doses will take days to weeks, and this patient is not interested in further opioids. The most common side effect is temporary pain or soreness at the injection site. Uncommon risks involve bleeding, infection, spinal block, epidural block, collapsed lung, and injection into blood vessels and surrounding organs. Patients should not have this block if they are allergic to any of the medications being injected, if the patient is on blood-thinning medications, if the patient has an active infection, or if the patient has poorly controlled diabetes or heart disease (Figures 139.1 and 139.2).

Figure 139.1 Celiac plexus block needle tip anterior to the L1 vertebral body prior to contrast being injected.

Figure 139.2 Celiac plexus block needle tip anterior to the L1 vertebral body after contrast was injected.

Case study 139.2

A 34-year-old female with colon carcinoma complains of moderate to severe abdominal pain, worsening over the last week. Her pain is located at her right upper quadrant with radiation to her right thoracic spine area. She is currently on methadone 10 mg every 12 hours and morphine immediate release 30 mg every 2 hours for pain control. An updated CT abdomen and pelvis study shows new metastatic lesions to her liver, with encroachment on the liver capsule.

1. Which of the following pain management options is indicated?

Rotate her morphine to codeine for improved analgesia
Start acetaminophen 1000 mg orally every 4 hours
Consult a palliative medicine specialist for hospice admission
Start Lyrica 150 mg orally four times daily
Start ibuprofen 800 mg orally every 8 hours

Starting an anti-inflammatory, non-opioid medication for liver capsular pain is appropriate. The type of pain described is primarily inflammatory in its nature and can be effectively controlled with a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs produce analgesia by inhibiting the enzyme cyclogenase, COX, and they reduce the production of peripheral and central prostaglandins. The two main isoforms are COX1 and COX2, which are involved in physiologic function and inflammation. Opioid rotation from a strong opioid (morphine) to a mild opioid (codeine) will not help with liver capsular pain. Acetaminophen is an analgesic for mild pain and has limited (if any) anti-inflammatory properties. The patient is having nociceptive visceral pain for a few days, and is not at the end of her life and thus requiring admission to a hospice program. The pain is not neuropathic; therefore, Lyrica would not be effective.

Case study 139.3

A 45-year-old male with locally advanced sarcoma to his right leg had an amputation of his right leg below the knee 2 months ago. He complains of sharp, burning, constant sensations to his right toes. He thought this was normal after surgery and would get better, but now he is refusing rehabilitation therapy due to the pains. He is married with children and is unable to work through the pains as a postal carrier, although he wants to get back to work as soon as possible.

1. How would you classify this patient’s pain?

Stump pain
Phantom limb pain
Central pain
Malingering
Postsurgical pain

Chronic pain following limb amputation may involve stump pain, phantom pain, or both. Phantom limb pain can result from loss of limb due to cancer, trauma, vascular disease, or infection. More than 50% of patients report phantom limb pain syndrome. Of those, up to 10% experience severe and debilitating pain, primarily neuropathic, often as burning, tingling, and numbness distal to the site to the amputation. Stump pain may be due to a neuroma formation several months after the amputation, and is pain at the site of the actual amputation. Central pain results from damage to the central nervous system and reorganization of the transmitting pathways. Malingering is exaggerating an illness for secondary gain. Postsurgical pain is acute and is present in the immediate postoperative period.

Case study 139.4

A 55-year-old female with a history of breast carcinoma started complaining of severe pelvic pain over the last 3 months. She had imaging of her abdomen and pelvis that showed new metastatic lesions to her cervix. She is undergoing chemotherapy and radiation therapy, with a minimal decrease in her pain severity. She has never taken opioids and refuses to take them. She is not able to tolerate lying on the radiology suite table for further radiation treatments. Her radiation oncologist refers her to the pain management service for assistance.

1. Which of the following pain management options is appropriate for this patient?

Evaluate the patient for a celiac plexus block
Evaluate her for a lidocaine infusion trial
Start duloxetine 30 mg twice daily
Start fentora 100 mcg every 6 hours, as needed, for severe pain
Evaluate the patient for a superior hypogastric plexus block

Superior hypogastric plexus blocks may be used for visceral pelvic pain that is refractory to medical management (Figures 139.3 and 139.4). The superior hypogastric plexus lies in the retroperitoneum and extends from the anterior aspect of L5 to the superior portion of the sacrum. Female pelvic pain can be adequately treated with this block. The superior hypogastric pelvic nerves innervate the lower abdomen and pelvic organs. A celiac plexus block would be useful in malignancies arising from upper abdominal viscera such as the esophagus, stomach, and liver. A lidocaine infusion and duloxetine are primarily for neuropathic pain conditions, and they have fewer efficacies in visceral nociceptive pain syndromes. This patient is opiate naïve and should not be started out on fentora, and her fear of taking opioids for analgesia should be further investigated. The most common side effect is temporary pain or soreness at the injection site. Uncommon risks involve bleeding, infection, spinal block, epidural block, collapsed lung, and injection into blood vessels and surrounding organs. Patients should not have this block if they are allergic to any of the medications being injected, if the patient is on blood-thinning medications, if the patient has an active infection, or if the patient has poorly controlled diabetes or heart disease.